An agile, data-driven approach for target selection in rTMS therapy for anxiety symptoms: Proof of concept and preliminary data for two novel targets

Comparisons of Accelerated Continuous and Intermittent Theta Burst Stimulation for Treatment-Resistant Depression and Suicidal Ideation

BACKGROUND

Suicidal ideation is a substantial clinical challenge in treatment-resistant depression (TRD). Recent work demonstrated promising antidepressant effects in TRD patients with no or mild suicidal ideation using a specific protocol termed intermittent theta burst stimulation (iTBS). Here, we examined the clinical effects of accelerated schedules of iTBS and continuous TBS (cTBS) in patients with moderate to severe suicidal ideation.

METHODS

Patients with TRD and moderate to severe suicidal ideation (n = 44) were randomly assigned to receive accelerated iTBS or cTBS treatment. Treatments were delivered in 10 daily TBS sessions (1800 pulses/session) for 5 consecutive days (total of 90,000 pulses). Neuronavigation was employed to target accelerated iTBS and cTBS to the left and right dorsolateral prefrontal cortex (DLPFC), respectively. Clinical outcomes were evaluated in a 4-week follow-up period.

RESULTS

Accelerated cTBS was superior to iTBS in the management of suicidal ideation (pweek 1 = .027) and anxiety symptoms (pweek 1 = .01). Accelerated iTBS and cTBS were comparable in antidepressant effects (p < .001; accelerated cTBS: mean change at weeks 1, 3, 5 = 49.55%, 54.99%, 53.11%; accelerated iTBS: mean change at weeks 1, 3, 5 = 44.52%, 48.04%, 51.74%). No serious adverse events occurred during the trial. One patient withdrew due to hypomania. The most common adverse event was discomfort at the treatment site (22.73% in both groups).

CONCLUSIONS

These findings provide the first evidence that accelerated schedules of left DLPFC iTBS and right DLPFC cTBS are comparably effective in managing antidepressant symptoms and indicate that right DLPFC cTBS is potentially superior in reducing suicidal ideation and anxiety symptoms.

Personalized, parcel-guided rTMS for the treatment of major depressive disorder: Safety and proof of concept

BACKGROUND

Not all patients with major depressive disorder (MDD) benefit from the US Food and Drug Administration-approved use of repetitive transcranial magnetic stimulation (rTMS) at the dorsolateral prefrontal cortex. We may be undertreating depression with this one-size-fits-all rTMS strategy.

METHODS

We present a retrospective review of targeted and connectome-guided rTMS in 26 patients from Cingulum Health from 2020 to 2023 with MDD or MDD with associated symptoms. rTMS was conducted by identifying multiple cortical targets based on anomalies in individual functional connectivity networks as determined by machine learning connectomic software. Quality of life assessed by the EuroQol (EQ-5D) score and depression symptoms assessed by the Beck Depression Inventory (BDI) were administered prior to treatment, directly after, and at a follow-up consultation.

RESULTS

Of the 26 patients treated with rTMS, 16 (62%) attained remission after treatment. Of the 19 patients who completed follow-up assessments after an average interval of 2.6 months, 11 (58%) responded to treatment and 13 (68%) showed significant remission. Between patients classified with or without treatment-resistant depression, there was no difference in BDI improvement. Additionally, there was significant improvement in quality of life after treatment and during follow-up compared to baseline.

LIMITATIONS

This review is retrospective in nature, so there is no control group to assess the placebo effect on patient outcomes.

CONCLUSION

The personalized, connectome-guided approach of rTMS is safe and may be effective for depression. This personalized rTMS treatment allows for co-treatment of multiple disorders, such as the comorbidity of depression and anxiety.