TMS for OCD in a Patient with Remote Seizure History on Clomipramine and Lamotrigine
Yes, TMS can be recommended for this patient with treatment-resistant OCD, as the seizure risk remains very low (<1%) even with a remote seizure history, and both clomipramine and lamotrigine are compatible with TMS therapy. 1, 2
Risk-Benefit Analysis for This Specific Patient
The 20-year seizure-free interval on lamotrigine substantially reduces seizure risk, making TMS a reasonable option. 2 The overall seizure risk with TMS is less than 1%, comparable to most psychotropic medications, and seizures when they occur are typically self-limiting 2. Importantly:
- Lamotrigine does not contraindicate TMS and may actually provide neuroprotective effects through its glutamatergic modulation, as there are no documented drug interactions or safety concerns between lamotrigine and TMS 1
- The FDA-approved deep rTMS protocol for OCD does not list lamotrigine or other glutamatergic agents as contraindications 1
- TMS has been successfully used in patients with epilepsy and prior seizure histories without incident 2
Medication Compatibility Considerations
Both clomipramine and lamotrigine are compatible with TMS therapy, though clomipramine's seizure threshold-lowering effect requires acknowledgment. 3, 1
- Clomipramine lowers seizure threshold as a known tricyclic effect, but this patient's 20-year seizure-free status on lamotrigine suggests adequate seizure control 3
- There are no documented contraindications to combining TMS with either medication 1
- The combination of lamotrigine and TMS targets different mechanisms—lamotrigine modulates glutamatergic neurotransmission while TMS directly modulates neural circuitry through electromagnetic stimulation 1
Clinical Rationale for TMS in This Case
Deep rTMS is FDA-approved for treatment-resistant OCD and should be attempted before considering more invasive options like deep brain stimulation. 1, 4
- Deep rTMS demonstrates moderate therapeutic effect (effect size = 0.65) with 3-fold increased likelihood of treatment response compared to sham 1
- This patient appears to have treatment-resistant OCD given the use of clomipramine (typically reserved as second/third-line after SSRI failure) 1
- TMS appears in treatment algorithms alongside clomipramine for refractory cases 1
Practical Implementation Strategy
Use the FDA-approved bilateral DMPFC protocol with heightened monitoring given the seizure history. 5, 1
- Apply the 20-Hz protocol bilaterally over the left and right dorsomedial prefrontal cortex using a double-cone coil 5
- The FDA-approved TMS protocol includes individualized symptom provocation before each session 1
- Monitor closely during initial sessions, as the single reported seizure case occurred during the 7th session 5
Key Safety Precautions
Maintain current lamotrigine dosing and ensure therapeutic levels, as this provides seizure protection during TMS. 1, 6
- Continue monitoring for serotonergic effects given clomipramine's potent serotonergic properties, particularly when combined with TMS 1
- Avoid sleep deprivation and alcohol use, which increase seizure risk with TMS 2
- Have emergency protocols in place, though most TMS-related seizures are self-limiting and require only supportive care 2
Alternative Considerations if TMS is Declined
If the patient or treating physician remains concerned about seizure risk despite the favorable risk-benefit profile, alternative augmentation strategies include 1:
- Antipsychotic augmentation with risperidone or aripiprazole (strongest evidence, approximately one-third response rate)
- N-acetylcysteine or memantine as glutamatergic agents
- Intensified CBT with exposure and response prevention
However, the benefits of treating refractory OCD with TMS likely outweigh the minimal seizure risk in this well-controlled patient, especially given the significant morbidity associated with untreated treatment-resistant OCD. 2, 1