title: Hypomanic shift observed during rTMS treatment of patients with unipolar depressive disorder: four case reports.
abstract: OBJECTIVE
  Repetitive transcranial magnetic stimulation (rTMS) can enhance the excitement of the brain through adjusting the biological activities of the cerebral cortex and has wide biological effects, making it one basic mechanism of therapy for depression. In the treatment of unipolar depressive disorder, almost in every treatment method, hypomanic and manic shifts can be observed. There is still a lack of data regarding manic and hypomanic symptoms triggered by rTMS applications.
  
  
  METHODS
  We describe four cases with unipolar depression in which high-frequency rTMS over the left dorsolateral prefrontal cortex applied as an add-on antidepressive strategy may have induced a hypomanic episode.
  
  
  RESULTS
  In these cases, 25 Hz rTMS combined with antidepressants may have contributed to the occurrence of hypomanic symptoms.
  
  
  CONCLUSIONS
  Using an intensive methodology of rTMS may induce hypomanic or manic symptoms.
authors.affiliation: NPIstanbul Hospital, Uskudar University, Alemdag Cad, Siteyolu Sk, No:27, Istanbul, Umraniye 34675, Turkey. gokben.hizlisayar@uskudar.edu.tr.
authors.forename: Eylem
authors.initials: E
authors.lastname: Ozten
authors.forename: Gokben Hizli
authors.initials: GH
authors.lastname: Sayar
authors.forename: Oguz
authors.initials: O
authors.lastname: Karamustafalioglu