TMS Use in Psychosis and MDD with Psychotic Features
TMS should NOT be used in patients with active psychosis or MDD with psychotic features, as psychosis represents a true contraindication to TMS therapy. 1
Primary Contraindication: Active Psychosis
Psychosis is a contraindication to TMS treatment, similar to how stimulants are contraindicated in patients with schizophrenia, psychosis NOS, or manic episodes with psychosis due to psychotomimetic effects. 1
The American Academy of Child and Adolescent Psychiatry explicitly states that stimulants should not be used in patients with an Axis I diagnosis of schizophrenia, psychosis NOS, or manic episodes with psychosis, and this principle extends to other neuromodulatory treatments like TMS. 1
Evidence from MDD with Psychotic Features
Patients with MDD and psychotic features respond dramatically better to ECT than to TMS, with statistically significant differences (chi² = 9.2, p < 0.01). 2
In contrast, patients with non-psychotic MDD responded similarly to both TMS and ECT, suggesting TMS efficacy is limited to non-psychotic presentations. 2
One case series specifically documented that a patient with psychotic depression yielded no response to rTMS and required subsequent modified ECT for treatment. 3
Risk of Inducing Psychotic Symptoms
TMS can precipitate psychotic symptoms even in previously non-psychotic patients. A case report documented a 55-year-old male with MDD and no history of psychosis who developed mania with psychotic symptoms during TMS treatment. 4
Another case documented development of severe delusions during rTMS treatment in a patient with recurrent, non-psychotic major depression who had never experienced psychotic symptoms before. 5
These psychotic symptoms are thought to occur due to increased dopaminergic activity after rTMS treatment, which can trigger psychosis in vulnerable individuals. 5
Clinical Decision Algorithm
For patients with MDD:
- Screen for psychotic features (delusions, hallucinations, disorganized thought) before initiating TMS
- If psychotic features present: Use ECT or antipsychotic medications with antidepressants instead of TMS 2, 3
- If non-psychotic: TMS is appropriate and shows similar efficacy to ECT 2
For patients with primary psychotic disorders:
- Use antipsychotic medications, psychological therapy, and psychosocial interventions as first-line treatment 1, 6
- TMS is not indicated and may worsen symptoms 1, 5
Important Caveats
Monitor all TMS patients for emergence of psychotic symptoms during treatment, as this can occur even without prior psychotic history. 4, 5
If psychotic symptoms emerge during TMS, immediately discontinue TMS and initiate antipsychotic medication, which typically leads to rapid symptom resolution. 4, 5
The 2022 Molecular Psychiatry consensus guidelines acknowledge that MDD with psychotic features should be considered within treatment-resistant depression definitions, but this does not change the contraindication to TMS for active psychotic symptoms. 1