Accelerated TMS for treatment-resistant Depression

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Accelerated TMS

Objective: New antidepressant treatments are needed that are effective, rapid-acting, safe, and tolerable. Intermittent theta-burst stimulation (iTBS) is a noninvasive brain stimulation treatment that has been approved by the U.S. Food and Drug Administration for treatment-resistant depression. Recent methodological advances suggest that the currentiTBS protocol might be improved through 1) treating patients with multiple sessions per day at optimally spaced intervals, 2)applying a higher overall pulse dose of stimulation, and 3)precision targeting of the left dorsolateral prefrontal cortex(DLPFC) to the subgenual anterior cingulate cortex (sgACC)circuit. The authors examined the feasibility, tolerability, and preliminary efficacy of Stanford Accelerated IntelligentNeuromodulation Therapy (SAINT), an accelerated, high-dose resting-state functional connectivity MRI (fcMRI)–guided iTBS protocol for treatment-resistant depression.

Methods: Twenty-two participants with treatment-resistant depression received open-label SAINT. fcMRI was used to individually target the region of the left DLPFC most anti-correlated with sgACC in each participant. Fifty iTBS sessions(1,800 pulses per session, 50-minute intersession interval)were delivered as 10 daily sessions over 5 consecutive days at 90% resting motor threshold (adjusted for cortical depth). Neuropsychological testing was conducted before and after SAINT

Results: One participant withdrew, leaving a sample size of 21. Nineteen of 21 participants (90.5%) met remission criteria(defined as a score, of 11 on the Montgomery-Åsberg Depression Rating Scale). In the intent-to-treat analysis, 19 of 22 participants (86.4%) met the remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects.

Conclusions: SAINT, an accelerated, high-dose, iTBS protocol with fcMRI-guided targeting, was well-tolerated and safe. Double-blinded sham-controlled trials are needed to confirm the remission rate observed in this initial study.

For the full article go to https://ajp.psychiatryonline.org/toc/ajp/177/8 pages 647-734