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Repetitive transcranial magnetic stimulation (rTMS) is a recently developed noninvasive brain stimulation method for the treatment of psychiatric and neurological disorders. Although, its exact mechanism of action is still not clear, current evidence points toward its role in causing long-term inhibition and excitation of neurons in certain brain areas. As evidence steadily grows in favor of rTMS as a therapeutic tool; there is a need to develop standardized protocols for its administration. There have been no reports of any serious side effects with rTMS, though its use is restricted in those having magnetic implants or recent adverse neurological or cardiac event. Of all the psychiatric indications of rTMS, the evidence is most robust for treatment of refractory unipolar depression. This paper reviews contemporary literature highlighting the evolution of rTMS as a diagnostic and therapeutic tool, especially in the management of treatment-resistant depression.

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Valproate (VPA)-induced hyperammonemic encephalopathy is an unusual, but serious, adverse effect of divalproex sodium (DVPX) treatment and if untreated can lead to raised intracranial pressure, seizures, coma, and eventually death. It can, however, be reversed if an early diagnosis is made. It is therefore extremely important to recognize it and discontinue DVPX treatment. Our patient developed sudden deterioration of sensorium, drowsiness, lethargy, and later severe comatose state after few days of starting DVPX with high levels of serum ammonia despite therapeutic levels of VPA and normal liver function test. He responded to hemodialysis, cerebral decongestants, and other intensive supportive measures.

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