Giant cell arteritis (GCA), a form of large vessel vasculitis, carries the risk of irreversible loss of vision due to involvement of arteries supplying optic nerve, retina and choroid. As such, timely diagnosis of GCA is crucial. The study examines the presenting symptoms among suspected GCA patients with both positive and negative biopsy results and the association of computed tomography angiography (CTA) findings of the suspected GCA patients with superficial temporal artery (STA) biopsy results.

A retrospective study involving 22 patients who underwent STA biopsy and CTA at Kingston Health Science Center. The CTA images of the patients were analyzed for the following imaging signs: blurred STA wall, perivascular enhancement, presence of stenosis or occlusion of STA and calcification. The association between imaging signs and STA biopsy results was assessed using odds ratios (ORs). Additionally, the final alternative diagnosis for the patients with negative biopsy results was also investigated.

There was a strong association between the presence of two CTA imaging findings : blurred STA wall and perivascular enhancement, and positive STA biopsy results (OR: 29, p: 0.001). Suspected GCA patients with negative STA biopsy results had no single unifying alternative diagnosis.

This study provides evidence for the potential role of CTA in the initial assessment of suspected GCA patients.

Repetitive negative thinking (RNT) in major depressive disorder (MDD) involves a persistent focus on negative self-related experiences. Resting-state fMRI shows that the functional connectivity (FC) between the anterior insula and the superior temporal sulcus is associated with RNT intensity. This study examines how insular FC patterns differ between resting state and RNT induction in MDD and healthy control (HC) participants.

Forty-one individuals with MDD and 28 HCs (total n = 69) underwent resting-state and RNT-induction fMRI scans. Seed-to-whole brain analysis using insular subregions as seeds was performed.

No diagnosis-by-run interaction effects were observed across insular subregions. MDD participants showed greater FC between the bilateral anterior, middle, and posterior insular regions and the cerebellum (z = 4.31–6.15). During RNT induction, both MDD and HC participants demonstrated increased FC between bilateral anterior/middle insula and prefrontal cortices, parietal lobes, posterior cingulate cortex (PCC), and medial temporal gyrus, encompassing the STS (z = 4.47–8.31). In exploratory correlation analyses, higher trait RNT was associated with increased FC between the right dorsal anterior/middle insula and the PCC, middle temporal gyrus, and orbital frontal gyrus in MDD participants (z = 4.31–6.15). Greater state RNT was linked to increased FC in similar insular regions, as well as the bilateral angular gyrus and right middle temporal gyrus (z = 4.47–8.31).

Hyperconnectivity in insula subregions during active rumination, especially involving the default mode network and salience network, supports theories of heightened self-focused and negative emotional processing in depression. These findings emphasize the neural basis of RNT when actively elicited in MDD.

Schizophrenia (SCZ) and Autism Spectrum Disorder (ASD) are complex neurodevelopmental disorders with overlapping cognitive, social, and behavioral symptoms. Although each has distinct diagnostic criteria, shared traits such as impaired social cognition, communication difficulties, and atypical behaviors, often blur the distinction between them. This overlap is particularly challenging in cases of very early onset psychosis (before age 13), where symptoms like social withdrawal, unusual behaviors, and communication difficulties closely mirror those of ASD, complicating accurate diagnosis.

This study aims to explore the diagnostic challenges of distinguishing between ASD and early psychosis through a comprehensive review of published literature and a case report.

A bibliographic review was conducted using articles from PubMed, focusing on the terms “Autism Spectrum Disorder”, “Early Psychosis”, and “Early Onset Schizophrenia”. Additionally, a case report was presented to illustrate the complexities in differentiating these overlapping conditions.

This study highlights the difficulty of distinguishing ASD from early psychosis due to overlapping symptoms, particularly in young patients. ASD is typically characterized by persistent social communication difficulties and repetitive behaviors, while early psychosis involves hallucinations, delusions, and disorganized thinking. However, some children with ASD may also exhibit psychotic-like symptoms, such as paranoia or unusual perceptual experiences, mimicking early-onset schizophrenia. These findings underscore the importance of comprehensive diagnostic assessments that include developmental history, symptom trajectory, and family background. Increasing evidence shows that ASD and early psychosis share genetic, neurobiological, and environmental risk factors, supporting the idea of a neurodevelopmental continuum where both conditions may be viewed as different points along a shared spectrum of neurodevelopmental disruption.

This work calls for a more integrated approach to diagnosing ASD and early psychosis, especially in cases of very early onset. A continuum model suggests these disorders may represent points along a spectrum of neurodevelopmental disorders rather than entirely separate entities. Future research should prioritize long-term studies to identify specific markers, such as genetic, brain imaging, and cognitive profiles, that can better differentiate between ASD and early psychosis and guide more targeted, personalized interventions.

None Declared

Suicide involves not only patients but also families and communities, causing long-lasting effects on those who “survive”. The term “second victim” is used to define people who experience significant distress after a patient suicide (PS). For mental health professionals, PS could be considered an “occupational hazard”.

To assess the impact of patient death on psychiatric trainees and early career psychiatrists (ECPs), comparing PS to other causes of death.

Participants completed a socio-demographic section and a section about the experience of PS. Impact of event scale–revised version (IES-R) based on the last 7 days and the 7 days after the most recent patient death, Suicide Knowledge and Skills Questionnaire (SKSQ), the Impact of a Patient’s Suicide on Professional and Personal Lives Scale and the Maslach Burnout Inventory (MBI) were administered.

110 subjects were recruited from 23 European and 1 Asian countries. The mean age was 31.9 (SD=4.7). Most were trainees (66.4%, n=73), worked in a psychiatric ward (61.8%, n=68), and in general adult psychiatry (83.6%, n=92). Patient death was experienced by 51.8 % (n=57) of the participants. 17.3% (n=19) experienced a PS, 12.7% (n=14) experienced multiple PS, 13.6% (n=15) had patients who died both by suicide and other medical conditions, and 8.2% (n=9) had patients who died from other medical conditions. The most reported feelings were sadness, regret, guilt, helplessness and frustration. Among participants who experienced at least one PS, 89.7% (n=35) developed symptoms. The most common were increased awareness of risk (40.4%; n=19), low mood (34.0%; n=16), anxiety (32.6%; n=15) and lack of concentration (26.1%; n=12). 6.5% (n=3) experienced suicidal thoughts/passive death wishes, and 6.5% (n=3) received individual psychotherapy treatment for their symptomatology. Having experienced a patient loss influenced clinical practice in 33.3% (n=19) of the sample, with 10.5% (n=6) reporting the affliction of the ability to carry out clinical duties. 12.7% (n=14) considered changing careers, 10.5% (n=6) took sick leave, 57.8% (n=33) received helpful support from colleagues. However, 52.3% (n=30) felt they needed additional support. According to the total score of IES-R scored on the 7 days after the most recent patient death, 22.9% (n=11) of the sample who experienced at least one PS had a score indicating a risk of PTSD, compared to 22.2% (n=2) of participants who experienced other type of patient death. No difference in all scales was observed in those experienced PS rather than any other kind of patient death (p>0.05).

Our results confirm that PS affects the mental health of ECPs and psychiatric trainees, and impacts their daily lives. A larger sample should be collected to strengthen our results and better characterize the impact of these events.

None Declared

A 26-year-old man presented with his first-episode psychosis (FEP) following a 15-month period marked by a progressive sense of estrangement from his surroundings, ideas of reference, persistent anxiety, difficulty focusing, and social withdrawal. Two years prior, he began stimulant treatment for suspected attention-deficit/hyperactivity disorder (ADHD), though he discontinued the medication shortly after, as he perceived no improvement. Over the past year, he became increasingly distant from friends and eventually resigned from his job. About three months before hospitalization, he began experiencing first-rank symptoms of schizophrenia. This case will serve as a starting point to discuss the complexities of diagnosing the prodromal phase of FEP.

This clinical review aims to examine the phenomenology of the prodromal phase of FEP and address the diagnostic challenges posed by symptom similarities between this phase and neurodevelopmental conditions like ADHD.

A literature review was conducted using the PubMed database, covering studies from the past 20 years. Studies were selected if they included phenomenological descriptions of the prodromal phase in FEP and/ or examined the impact of neurodevelopmental conditions on the emergence of psychosis.

The review identified several key phenomenological markers characterizing the prodromal phase of FEP, which can aid in distinguishing it from other psychiatric conditions. The prodromal phase of FEP is frequently marked by subtle but progressive alterations in cognition, perception, and affect, including experiences such as derealization-depersonalization, ideas of reference, paranoid ideation, and social withdrawal. Evidence suggests that prodromal symptoms intensify over time, evolving from vague unease to specific disruptions in reality testing. Although ADHD and the prodromal phase of a FEP may share some overlapping characteristics - particularly when symptoms are assessed in a cross-sectional manner - ADHD symptoms are generally regarded as stable traits that persist consistently into adulthood.

This case underscores the need for careful differential diagnosis, especially when evaluating individuals in high-risk age groups for psychosis who present with subtle symptoms that do not clearly fit a single diagnostic category. In such cases, clinicians should avoid premature conclusions and instead adopt a longitudinal and comprehensive approach, considering whether genetic, neurodevelopmental, or social risk factors may be contributing to the presentation. A phenomenological perspective can help clinicians detect subtle yet significant shifts in perception, cognition, and affect, enhancing diagnostic accuracy and enabling timely intervention.

None Declared

Delayed perinatal grief occurs when the grieving process for a lost baby is reactivated after the birth of a healthy child. This case presents a 39-year-old mother who, after losing her first baby at 36 weeks due to Patau syndrome, experienced delayed grief following the birth of a full-term baby two years later. Despite receiving one psychological consultation at the time of the loss, the lack of follow-up contributed to the reactivation of her grief postpartum, presenting with sadness and anxiety.

• - To describe the process of delayed perinatal grief in a mother who lost a baby due to Patau syndrome.

• - To evaluate the psychological impact of the lack of follow-up after the loss on the subsequent development of reactivated grief.

• - To propose therapeutic interventions for the management of mothers experiencing delayed perinatal grief.

We present the case of a 39-year-old mother who lost a baby at 36 weeks of gestation due to Patau syndrome. Following the loss, she received a single psychological consultation with no further follow-up. Two years later, she gave birth to a healthy baby at 40 weeks, and six weeks after delivery, she was referred to psychiatry due to symptoms of profound sadness and anxiety, consistent with delayed perinatal grief. The patient was evaluated by the psychiatry team and began treatment with psychological intervention and pharmacological management when necessary.

The psychiatric intervention led to a gradual improvement in symptoms of sadness and anxiety. The patient responded favorably to psychological treatment, incorporating cognitive-behavioral therapy techniques to manage grief. However, feelings of sadness persisted on dates related to the previous loss. Ongoing emotional support was crucial for the recovery process.

Delayed perinatal grief can reactivate after the birth of a new child, especially in cases where the original loss was not adequately followed up. Proper psychological support is essential to help mothers process their grief and prevent long-term emotional complications.

None Declared

Social isolation (SI) is defined as the lack of social contact or support. Older adults have a higher risk of social isolation because of the changes in health and social relationships that can occur during ageing. Several studies have shown that SI is independently associated with poorer physical and mental health and worsened quality of life. However, limited evidence is available on SI predictors in old public housing populations.

To assess the risk of SI and dependency in Basic and Instrumental Activities of Daily Living (BADL; IADL) in a sample of older people living alone in public housing. To identify predictors of SI, namely whether ADL dependency is one of them.

As part of the ongoing “Porto Importa-se” project, this study included a sub-sample of older persons aged 70 years and over living alone in public housing communities in Porto City, Portugal. All participants were assessed with a comprehensive multidimensional assessment protocol, which encompassed the Barthel and Lawton Indexes (BADLs and IADLs dependency) and the Lubben Social Network Scale-6 (SI risk). Loneliness was measured with a categorical question. A multiple logistic regression model was performed to identify predictive factors for SI. Odds Ratio (OR) and its 95% Confidence Interval (95%CI) were calculated. A p<0.05 was considered statistically significant.

The final sample (n=716) was namely female (84%), with an average age of 80.4 years (SD=6.2). Around 36% presented a risk of SI, and 24% reported feeling lonely almost always to always. About 53% had moderate dependency on IADLs, and 11% dependency on BADLs. The proportion of participants dependent on BADLs and at risk of SI is more than double the proportion of cases considered not to be at risk (17%v.s.8%; p<0.001). Similarly, the proportion of cases considered to be severely dependent on IADLs and at risk of SI is about four times higher than the proportion of cases considered not to be at risk (13%v.s.3%; p<0.001). Based on the logistic regression model, severe dependence on IADLs (OR=5.16, 95%CI[2.37;11.24], p<0.001) and loneliness (OR=2.87, 95%CI[2.02;4.09], p<0.001) were significant predictors of the risk of SI. The model has a modest explanatory power (Nagelkerke R2=0.126).

The rate of SI found in this study aligns with the results reported in other studies with similar objectives. The identification of loneliness and dependence in ADL as predictors of SI also complies with previous studies. These results reinforce the importance of monitoring elderly people who find themselves alone and dependent on the fulfilment of their ADLs more closely.

This work was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020)

None Declared

Major depressive disorder (MDD) is a very common and debilitating disorder. MDD accounts for 4.3% of the global burden of disease, is among the largest single causes of disability worldwide, and is an important cause of premature death. Depression expands its negative influence in all aspects of life, being estimate that 12 billion productive workdays are lost every year to depression and anxiety.

On top of that, non-response to first line pharmacological and psychotherapeutic treatments are substantial, with treatment-resistant depression (TRD) affecting approximately one third of these patients. These patients are thus candidates for non-invasive neuromodulation procedures such as repetitive transcranial magnetic stimulation (TMS), included in all major treatment guidelines.

With this work we intend to present a descriptive analysis of the efficacy of the intermittent theta burst TMS (iTBS) protocol in patients with TRD who underwent this treatment at Hospital de Magalhães Lemos, Porto, since July 2022.

We conducted an analysis of sociodemographic characteristics of patients who underwent treatment with iTBS. The primary outcome was the Beck’s Depression Inventory (BDI) score difference between the first and last sessions. Secondary outcome included the Montgomery-Asberg Depression Rating Scale (MADRS) applied to a smaller cluster of patients.

Since July 2022, more than 50 cycles of iTBS treatment have been performed.

More than 60% of the TRD patients enrolled scored positive changes with the treatment, on BDI. Improvements exceeded non-response in both sexes, irrespective of disease duration, and in nearly all age groups – except for the single patient under 25 years old. Positive changes were also observed with the MADRS, with more than 70% of this cluster of TRD patients scoring positive changes, including the patient under 25 years old who score non-response with BDI.

iTBS was also applied to a small number of patients diagnosed with treatment-resistant bipolar major depression, in whom positive changes outweighed non-response.

All iTBS cycles were performed without major adverse effects being reported.

TMs, represented here by the iTBS protocol, is safe and effective in improving depressive symptoms when first line treatments are not. The positive effects extend to patients diagnosed with BD, despite the small number of patients present in our patient pool.

Combined with the logistical ease of its use, not requiring general anaesthesia or induction of seizures like electroconvulsive therapy, TMS presents itself as an important alternative in the treatment of TRD.

None Declared

Electroconvulsive Therapy (ECT) is a proven treatment for treatment-resistant depression (TRD), especially in elderly patients. Managing depression in this population is challenging due to comorbidities and medication intolerance. Research suggests that factors like melancholic features and early symptom improvement predict a positive response to ECT. ECT offers rapid and sustained antidepressant effects.

To present the case of a 74-year-old woman with TRD who successfully underwent ECT after failing multiple medications.

A literature review was conducted on ECT for TRD in elderly patients. The clinical case is detailed, focusing on treatment, ECT application, and outcomes.

The patient had a history of severe depressive episodes. Previous hospitalizations were managed with tricyclic antidepressants, lithium, and olanzapine. However, lithium was discontinued after discharge due to subclinical hypothyroidism and renal function impairment. Although the patient remained stable for a time, her mood progressively worsened, leading to a marked decline in daily functioning and eventual admission to the psychiatric unit. Upon admission, the patient presented with severe depression, including loss of functionality, self-neglect, and passive suicidal ideation, hyporeactive state, significant vegetative symptoms, and moderate-to-severe anxiety. Given the lack of response to a comprehensive pharmacological regimen, ECT was initiated. The patient underwent six sessions of ECT, with initial improvements observed after the first session. By the third session, she showed marked improvements in mood, energy, and anxiety levels. By the end of the ECT course, she had regained full functionality and emotional stability.

This case underscores the effectiveness of ECT in managing psychotic depression in elderly patients when pharmacological treatments are ineffective or poorly tolerated. The patient’s rapid response aligns with previous findings suggesting that early symptom improvement predicts favorable ECT outcomes. Additionally, the presence of melancholic features may have contributed to the success of ECT, as described in the literature. Given the patient’s history of lithium intolerance and multiple pharmacological failures, ECT emerged as the most viable treatment option. ECT also demonstrated long-term benefits.

This case also highlights the importance of considering ECT earlier in the treatment process for elderly patients and demonstrates the crucial role of ECT in achieving rapid and sustained recovery in elderly patients with psychotic depression resistant to pharmacological treatments. Early intervention with ECT was essential for the patient’s full functional recovery, reinforcing its value as a therapeutic option in severe, treatment-resistant cases.

None Declared

The widespread use of mobile devices, particularly among young people, extends beyond entertainment to education and professional purposes. However, excessive smartphone use has led to health issues such as headaches, poor concentration, sleep problems, and anxiety. A condition called nomophobia, or the fear of being without a mobile phone, has emerged, though it’s not officially recognized as a psychiatric disorder. In adults, 20% experience mild nomophobia, 50% moderate, and 20% severe symptoms, which can be measured using the Nomophobia Questionnaire (NMP-Q). Smartphone overuse is also linked to psychopathological issues like insomnia and anxiety.

The aim of this study is to evaluate the impact of nomophobia in insomnia and anxiety.

Non-systematic review of the literature regarding nomophobia and anxiety and insomnia. The research was carried out through the PubMed® database, using the terms “nomophobia”, “nomophobia and anxiety” and “nomophobia and insomnia”.

The included studies highlight that nomophobia is associated with higher anxiety levels in most individuals as well as a substantial correlation between nomophobia symptoms and insomnia.

Nomophobia is increasing due to technological advancements and widespread access. Overuse of mobile phones is linked to psychopathologic symptoms, like anxiety and insomnia. Raising awareness and helping young adults manage their phone use is essential for promoting health and well-being as digital technologies become an integral part of daily life.

None Declared

Treatment resistance affects 20-60% of patients, leading to substantial personal and economic impact. Repetitive transcranial magnetic stimulation (rTMS) is effective, with theta burst stimulation (TBS) providing similar benefits more efficiently.

To assess high-dose TBS effectiveness and to explore how demographic and clinical factors influence treatment outcomes.

Accelerated high-dose (30 sessions) cTBS and iTBS was administered targeting the right and left dorsolateral prefrontal cortex (DLPFC) respectively (3600 pulses per session), with MRI-guided neuronavigation. Pre- and post-treatment HAM-D and HAM-A scores were analyzed with mixed-effects models. Response and remission rates were further examined using generalized linear models (GLM). All analyses were conducted using the R Studio.

The study included a total of 101 participants, of whom 89 had data available for HAM-D (56 [38.8–65] years; 69.7% females), and 82 had data available for HAM-A (56 [39–65] years; 70.7% females). 29.2% achieved HAM-D remission, 22% achieved HAM-A remission, with response rates of 46.1% for depression and 50% for anxiety.

Mixed-effects models showed a highly significant reduction in both HAM-D and HAM-A scores after TMS treatment (HAM-D: β = -12, p = 2.2e−15; HAM-A: β = -14.484, p = 1.1×10−14) (Fig. 1). For HAM-D, family history was associated with reduced treatment effectiveness (β = 5.302, p = 0.011). Sex also influenced HAM-D scores, with males showing a greater response than females (p = 0.018), although this trend was only marginally significant for HAM-A (p = 0.073).

Fig. 1. Pre- and post-treatment scores on the HAM-D and HAM-A showing significant reductions following rTMS.

The GLM analysis for HAM-D and HAM-A remission did not reveal statistically significant overall results. However, specific predictors were significantly associated with treatment response. A family history of mental health conditions was linked to a lower likelihood of response, based on HAM-D (OR = 0.058, p = 0.016) and HAM-A (OR = 0.074, p = 0.049). Age was a significant predictor for response on both HAM-D (OR = 1.1, p = 0.048) and HAM-A (OR = 1.115, p = 0.032) (Fig. 2). Additionally, regarding employment status individuals identified as “Housekeeper” or “Retired” had reduced likelihood of positive response (p < 0.05).

Figure 2. Influence of age on HAMA and HAM-D response outcomes in patients undergoing TMS treatment.

Image:

Image 2:

High-dose accelerated bilateral TBS using the Sevilla Protocol significantly reduced depression and anxiety symptoms in treatment-resistant patients, with notable response and remission rates. Family history, age, and certain employment statuses significantly influenced treatment response, suggesting that TBS may benefit from tailored approaches. Larger, balanced samples are needed to confirm these findings and improve prediction models.

None Declared

Psychotic depression, a severe subtype of major depressive disorder with delusions or hallucinations, increases suicide risk due to distressing symptoms and hopelessness. Suicide attempts in psychotic depression can be severe and violent. Combining antidepressants and antipsychotics shows promise in reducing suicidal ideation and improving prognosis. This case presents a patient with a severe suicide attempt and self-harm in the context of psychotic depression, highlighting successful treatment with a combination of antidepressants and antipsychotics.

To present a case study of a patient with a depressive episode that progressed to psychotic features.

A comprehensive literature search was conducted to identify relevant studies on the treatment of depression with psychotic features. A case report was then developed, detailing the patient’s clinical presentation, diagnosis, and treatment regimen.

A 53-year-old male was hospitalized following a serious suicide attempt. The patient had a history of a recent work-related accident, leading to a depressive episode that progressed to psychotic features, including delusions of guilt and economic ruin, attempted suicide using a firearm, leading to significant self-inflicted injuries. Emergency surgical intervention was required for tendon and arterial damage. Psychiatrically, the patient exhibited profound hopelessness, delusional guilt, and active suicidal ideation. Following hospital admission, the patient was treated with a combination of sertraline, olanzapine, and mirtazapine, which resulted in significant improvement in mood, a reduction of delusions, and cessation of suicidal ideation over a three-weeks period. The patient returned to social activities and expressed interest in resuming his professional responsibilities, with no recurrence of psychotic symptoms or suicide attempts.

This case illustrates the severity of suicidal behavior in psychotic depression and the critical importance of combining antidepressants with antipsychotics for effective management. Research has consistently shown that psychotic depression carries a heightened risk of severe suicide attempts due to the intensity of delusions and hopelessness. Antidepressant-antipsychotic combinations, particularly those involving selective serotonin reuptake inhibitors (SSRIs) like sertraline, and atypical antipsychotics such as olanzapine, have demonstrated efficacy in reducing both depressive and psychotic symptoms, thereby mitigating suicide risk. In this case, the patient’s marked improvement and remission of psychotic features underscore the role of combined pharmacotherapy in stabilizing mood and preventing future suicidal behavior.

None Declared

Bipolar affective disorder (BD) affects approximately 2% of the population. It’s an incapacitating condition that significantly impairs quality of life and functional capacity; depressive episodes in BD are highly debilitating and carry major suicide risk and treatment-resistant bipolar depression has been reported in about one-quarter of patients with bipolar disorders. Non-invasive neuromodulation procedures, such as repetitive transcranial magnetic stimulation (TMS), being an approved treatment for treatment-resistant unipolar depression, can also be an option for bipolar depression.

with this work we intend to assess the efficacy and outcomes of the intermittent theta burst TMS (iTBS) protocol in patients with bipolar depression, who underwent this treatment at Hospital de Magalhães Lemos, Porto, since July 2022. We also conducted a literature review on the subject.

analysis of clinical and sociodemographic characteristics of the 4 patients who underwent treatment and of the treatment outcomes using Beck’s Depression Inventory (BDI) score difference between first and last sessions and Montgomery-Asberg Depression Rating Scale (MADRS) as the secondary outcome, the last applied to only 2 of the patients. A computerized search was performed on PubMed, for articles published in the last 10 years, using the key-words “bipolar depression”, “bipolar depressive episode” and “tms”.

since July 2022, 4 patients with bipolar depression were submitted to iTBS treatment, 3 women and 1 man. Of these, 3 had a diagnosis of bipolar type 1 disorder and 1 of bipolar type 2. One of the women had a comorbid diagnosis of dementia and was not able to answer BDI. All 4 of these patients were referred to this treatment after failure to reach sustained symptomatic remission with at least two different treatment trials, at adequate therapeutic doses. We found positive changes in BDI in all 3 patients that completed this questionnaire and in MADRS in the 2 that answered. One of the patients had an elevated mood and an increase in energy levels following treatment but did not meet criteria for hypomanic/manic episode. No major side effects were reported.

Our results and literature review suggest that TMS, in our study iTBS protocol, may well be an effective treatment for bipolar depression, with some studies showing even higher response rates for bipolar depression when compared with unipolar depression, suggesting that bipolar disorder is more likely a better biological target. Furthermore, the low side effect profile of TMS and the fact that it is a minimally invasive procedure, makes it even more appealing as a treatment option. Risk of psychomotor agitation and hypomania/mania must be closely monitored in these cases.

None Declared