Tracking Brain Biomarkers and Renormalization Associated With Antidepressant Transcranial Magnetic Stimulation Therapy
Conditions: Major Depressive Disorder
Sponsor: Medical University of South Carolina

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PROTOCOL TITLE: 
Tracking Brain Biomarkers and Renormalization Associated with Antidepressant TMS Therapy 
 
PRINCIPAL INVESTIGATOR: 
Andrew Manett, MD 
 
 

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1.0 Objectives / Specific Aims 
 
Study Aim: Quantify the phenotypic-related brain states of MDD patients compared to healthy individuals 
using a novel INSCAPE neuroimaging method and identify dynamic biomarkers that can track brain recovery 
of MDD patients over an antidepressant course of TMS therapy.  
 
In this study, we plan to apply our novel “Individualized Network-based Single-frame Coactivation Pattern 
Estimation” (INSCAPE) method in 20 patients with Major Depressive Disorders (MDD) and 20 healthy controls to 
identify MDD-related brain states. We will then track changes in MDD-related brain states while MDD patients are 
undergoing 6 weeks of transcranial magnetic stimulation (TMS) therapy. Three separate neuroimaging visits will be 
conducted at the MUSC 30 Bee Street imaging center before, during, and after 30 sessions of the standard-of-care 
TMS treatment from the MUSC Brain Stimulation Service (~6 weeks in total). Additionally, healthy participants will 
undergo 3 times of MRI scanning with a 3-week interval between each two MRI sessions. 
 
Hypothesis: INSCAPE method can identify MDD specific brain states and track brain circuits recovery during TMS 
therapy. We intend to establish INSCAPE as an effective neuroimaging technique to track antidepressant response 
in MDD patients undergoing 6 weeks of TMS therapy. We hypothesize that a) our INSCAPE method will be able to 
quantify phenotypic differences between MDD patients before TMS therapy and compared to healthy individuals. 
We further hypothesize that we can b) track the renormalization of brain state during the course of TMS treatment, 
as patients transition from “depressed brain states” to more “healthy” brain states. Lastly, we c) identify whether 
baseline brain state dynamic measures can predict response to TMS based on behavioral measures of response to 
TMS treatment. 
 
2.0 Background 
 
Major depressive disorder (MDD) is a prevalent psychiatric disorder characterized by impairments in affect, behavior, 
and cognition. Individuals with MDD persistently suffer from feelings of sadness and worthlessness and experience 
less enjoyment in social interactions (1-3). Over 21 million adults have had at least one major depressive episode, 
which leads to job absenteeism and reduces productivity, and has been one of the highest causes of disability 
worldwide that creates a tremendous economic burden in society (3-5). Aside from conventional antidepressant 
medications, transcranial magnetic stimulation (TMS) has emerged as an effective second-line intervention for 
medication-resistant depression (6, 7). Although TMS delivered to the left dorsolateral prefrontal cortex (dlPFC) is 
used clinically for the treatment of depression, it remains limited by large heterogeneity in clinical response between 
patients (8). One factor contributing to this wide range of individual response rates is a limited understanding of the 
changes induced in neural circuits that drive TMS response. Thus, investigating the functional circuits underlying 
depression at the individual level can help lead to more effective treatments for depression. 
 
Resting-state functional magnetic resonance imaging (rs-fMRI) is a promising technique for assessing functional 
connectivity (FC) between brain regions that exhibit spontaneous synchronous fluctuations (9). Our previous rs-fMRI 
studies have revealed depressive-related functional connectivity (FC) changes in the default mode network (DMN) 
track with the severity of depression symptoms, including the anterior cingulate cortex, angular gyrus, and inferior 
parietal lobe (3, 10). Additionally, recent rs-fMRI advances have enabled the delineation of the spatial configuration 
of networks at the individual level (11). This individual-level analysis, rather than group-based averaging, has led to 
the discovery of new subnetworks in individuals that were missed in the group-average maps (12) and achieved 
higher accuracy in predicting phenotypes and disease symptoms based on functional measures (13). Therefore, 
exploring subnetworks of DMN at the individual level may help discover new biomarkers for depression treatment. 
 
An advancement in rs-fMRI is a novel dynamic analytic approach which examines absolute coactivation patterns of 
BOLD signal across the brain at each time point (14). Using this method, we have already found brain states of 
psychiatric phenotypes in schizophrenia and psychotic experience patients, which can track with psychotic symptom 
severity (15). Based on this, our group has further developed a new method of detecting robust, dynamic brain states 
at the individual level, called INSCAPE – Individualized Network-based Single-frame Coactivation Pattern 
Estimation. INSCAPE can detect phenotypic differences amongst different individuals based on brain state (16). Our 

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findings indicated that the occurrence rate of brain states related to brain laterality could predict language 
lateralization derived from a semantic decision task and distinguish genders and handedness. Additionally, we also 
found a brain state that can track longitudinal brain recovery from stroke over six months – the occurrence rate of 
this brain state continuously reduced to the normal level during inter-hemispheric communication restoration. Thus, 
INSCAPE is a novel and advanced method that can allow us to begin understanding functional brain state changes 
that occur over the course of antidepressant treatment track recovery. 
 
Ultimately, this study begins to optimize antidepressant treatments by identifying individual differences in brain 
states amongst patients. These individual differences likely play a large role in response rate, as well as network 
restoration in MDD patients. Thus, if successful, neuroimaging can become an additional tool that can be used before 
undergoing TMS treatment to better predict and improve treatment outcomes. 
 
 
3.0 Intervention to be studied (if applicable) 
 
This study is a neuroimaging study, thus, there is no intervention need to be managed for this study. Although, 
participants will be patients receiving the standard-of-care TMS therapy as part of their normal treatment plan in the 
MUSC Brain Stimulation Service, this intervention is not part of the study procedures. 
 
4.0 Study Endpoints (if applicable) 
 
Primary Outcome: Dynamic brain states changes relative to MDD. 
 
The main outcomes of this study are neuroimaging related dynamic parameters derived from our INSCAPE approach, 
including occurrence rate, dwell time, transition matrix, etc. These outcomes will be compared between depression 
patients and healthy individuals. Moreover, we will also estimate the renormalization of brain states by quantifying 
the continuous changes of functional imaging measures as patients improve over the course of TMS treatment, moving 
towards the level of healthy controls. Lastly, the psychiatric-related imaging measures at baseline will then be verified 
whether they can predict symptom improvement and response to TMS therapy. 
 
5.0 Inclusion and Exclusion Criteria/ Study Population 
 
Twenty patients with MDD receiving standard-of-care TMS treatment at the MUSC Brain Stimulation Service will 
be recruited to participate in this prospective neuroimaging study. No preference will be given based on race, gender, 
or ethnicity. Pregnant females and children under the age of 18 will be excluded for safety reasons. No vulnerable 
populations or special classes of subjects will be considered for participation.  
 
Major Depression Disorder (MDD) Patients 
 
Inclusion Criteria  
• 
Age 18-65  
 
• 
Have the capacity and ability to provide one’s own consent in English and sign 
the informed consent document.  
 
• 
DSM-IV diagnosis of MDD 
 
Exclusion Criteria 
• 
Unable to speak English. 
• 
Contraindicated for MRI. 

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• 
Any current or recent untreated medical, neurological, or psychiatric conditions 
other than MDD that would preclude candidacy for TMS.  
• 
Metal implant devices in the head, heart, or neck. 
• 
History of brain surgery. 
• 
History of cortisol medication use or electroconvulsive therapy. 
• 
History of myocardial infarction or arrhythmia, bradycardia. 
• 
Personal history of recent head injury, concussion, or self-report of moderate to 
severe traumatic brain injury.  
• 
Individuals suffering from frequent/severe headaches. 
• 
Moderate to severe alcohol or substance use disorder.  
• 
Pregnancy 
 
Healthy Individuals: 
Additionally, 20 demographic-matched healthy individuals will also be recruited as a control group. 
 
Inclusion Criteria  
• 
Age 18-65  
 
• 
Have the capacity and ability to provide one’s own consent in English and sign 
the informed consent document.  
 
Exclusion Criteria 
• 
Unable to speak English. 
• 
Contraindicated for MRI. 
• 
Any current or recent untreated medical, neurological, or psychiatric conditions 
• 
Metal implant devices in the head, heart, or neck. 
• 
History of brain surgery. 
• 
History of cortisol medication use or electroconvulsive therapy. 
• 
Comorbidity with other psychiatric/neurological illnesses or personality disorders 
• 
History of myocardial infarction or arrhythmia, bradycardia. 
• 
Personal history of recent head injury, concussion, or self-report of moderate to 
severe traumatic brain injury.  

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• 
Individuals suffering from frequent/severe headaches. 
• 
Moderate to severe alcohol or substance use disorder.  
• 
Pregnancy 
 
6.0 Number of Subjects 
 
We will enroll 40 total participants into this study (n=20 patients with depression and n=20 healthy adults) for this 
study. 
 
7.0 Setting 
 
Volunteers with Major Depressive Disorder who are candidates for TMS will be consented and educated about the 
study in a private screening area at either the MUSC Brain Stimulation Service or the MUSC 30 Bee Center for 
Biomedical Imaging, whatever is most convenient for the participant. Healthy volunteers will be consented at MUSC 
30 Bee Street Center for Biomedical Imaging. 
 
All neuroimaging conducted in this study, for both healthy volunteers and depressed volunteers, will be completed at 
the MUSC 30 Bee Street Center for Biomedical Imaging.  
 
Depressed volunteers will complete the additional standardized mood assessments at the MUSC Brain Stimulation 
Service during their scheduled standard-of-care TMS treatment visits at the MUSC Brain Stimulation Service. 
Depressed volunteers will receive standard-of-care TMS treatment at the MUSC Brain Stimulation Service.  
 
8.0 Recruitment Methods 
 
The Brain Stimulation Service will be recruiting depressed volunteers who are seen in consultation for clinical 
services. Patients who are found to be appropriate candidates for TMS for MDD will be offered to be screened for 
enrollment into the study protocol by clinical care team members prior to being contacted by members of the study 
team. Healthy participants will be recruited from the MUSC community (students and staff) as well as general 
population from the greater Charleston region. We will recruit via flyers around campus and word of mouth.  
 
9.0 Consent Process 
 
Consent procedures will be conducted in a private, quiet room at the MUSC 30 Bee Street Center for Biomedical 
Imaging or within the MUSC Brain Stimulation Service. Approved study personnel will walk through the consent 
procedures with the participant. Furthermore, after the consenting procedures, the consent form will be printed and 
provided to all participants to independently review to ensure understanding, including describing the laboratory 
measures, study duration, and equipment and materials. The study team will describe confidentiality/privacy 
measures, participant right to withdraw, risks/benefits, and that $50 compensation will be paid using Clincards. In 
addition, participants will be prompted to ask questions throughout consenting to further ensure understanding. After 
signing the consent form, they will also be offered a hard copy. 
 
10.0  Study Design / Methods 
 
1. 
Study Overview: After determining eligibility and interest, written informed consent will be obtained from 
participants at the MUSC Center for Biomedical Imaging. Enrolled MDD patients (n=20) will be involved 
in neuroimaging before, during, and after 30 sessions of the standard-of-care TMS treatment MUSC brain 
stimulation service (~6 weeks in total). For each neuroimaging visit, participants will be placed in the MRI 
scanner and undergo four runs of resting-state fMRI (6 min/run). During the scanning, participants will be 

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asked to stay still in the scanner. Additionally, enrolled healthy control participants (n=20) will undergo 3 
sessions of MRI scanning over a 6-week interval (Baseline, week 3, week 6). Upon completion of the 30 
minutes neuroimaging visit, participants will be compensated $50. A timeline and group assignment 
overview are demonstrated in Figure 1. 
 
 
Figure 1. Study Overview. 
 
2. 
Recruitment, Screening, and Consent Procedures: MDD patients will be recruited from the Brain 
Stimulation Service at MUSC by the clinical care team. Patients who are found to be appropriate candidates 
for TMS for MDD will be offered to be screened for enrollment into the study protocol.  
 
Healthy participants will be recruited from the MUSC community (students and staff) as well as general 
population from the greater Charleston region. We will recruit via flyers around campus and word of mouth. 
If interested in learning more about the study, potential subjects will be phone screened and educated 
regarding the study’s details. If interested in participating in the study, they will be consented and enrolled 
into the study’s protocol. After consent, the participant will complete a demographics and intake form. 
 
3. 
Pregnancy Test Procedures: If participants are individuals of childbearing potential, they will be provided 
with a pregnancy test strip. After completing the pregnancy test, participants with negative results will be 
asked to continue to the remaining study procedures, whereas those with a positive result will be debriefed 
and released.  
 
4. 
Neuroimaging Procedures: All MRI imaging will be performed using a Siemens 3.0 T Prisma scanner 
equipped with a 32-channel head coil. All MRI scan visits will be held at the MUSC Center for Biomedical 
Imaging (CBI; see the Facilities and Resources section). Each MRI scan session will include a high-resolution 
T1-weighted structural scan (whole brain sagittal acquisition, 224 slices, TR=2530ms, TE=3.65ms, 
TI=1100ms, 1mm thick slices, FOV=256, 256x176, flip angle = 7 degrees.), followed by four runs of resting-
state fMRI scans using a gradient-echo echo-planar pulse sequence (TR = 2000 ms, TE = 36 ms, FA = 80°, 
2.2 × 2.2 × 2.2-mm voxels).  
 
5. 
Depression/Anxiety Assessments: MDD participants will complete several standardized assessments 
performed prior to starting TMS treatment, and repeated on weekly intervals. The assessments to be 
performed are the Beck Depression Inventory II (BDI-II), Hamilton Anxiety Rating Scale (HAM-A),  
Hamilton Depression Rating Scale (HAM-D), and Patient Health Questionnaire 9 (PHQ-9). These 
assessments will be used to describe more accurately clinical changes in depression over the course of TMS, 
and will be used alongside the collected MRI data to potentially identify changes to the brain associated with 
clinical improvement or lack thereof.  
 
12.0 Data Management  
 
All data will be stored in the Redcap database as well as in paper documentation. Information about the participant 
(including their identifiable private information) may have all their identifiers removed and used for future research 

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studies or distributed to other researchers for future research without additional informed consent. After participation, 
RedCAP data will be downloaded in excel format to the secure MUSC server. Paper documentation will be stored 
in locked cabinet within a locked office of the study team. In terms of publication, data will be published in aggregate 
form, so individual participants will not be identifiable in the final manuscript. No identifying information will be 
published. 
 
Most of the data collected in this study are imaging data. These data will be collected from the 3T MRI scanner at 
30 Bee Street. All imaging data will be automatically transferred to and stored on a password-protected, encrypted 
secure server that limits data access to personnel directly involved with the study. The data will be analyzed using 
standard imaging analysis software packages (such as FSL and SPM) and lab developed programs (such as INSCAP 
and Individual Parcellation).  
 
If desired, participants may request a deidentified CD of their imaging data the day the scan occurs, so they may 
have it for their records, free of cost. Additionally, if any incidental findings occur during the scan, research staff 
and PI will follow the Center for Biomedical Imaging incidental finding procedures and have the scan read by a CBI 
affiliated neurologist or neuroradiologist for report. 
 
Confidentiality and Quality Control: All study personnel will complete Social-Behavioral-Educational research CITI 
training, and also complete in-lab training regarding data security practices. Study personnel will be trained in the 
IRB protocol. The investigator, and co-investigators will be available to monitor data collection to ensure quality, 
confidentiality, and adherence to the IRB protocol. 
 
The study’s procedures will take place at the MUSC 30 Bee Street Neuroimaging Center. Regarding documentation, 
participant names will appear only on the IRB-approved Consent and HIPAA.  
 
13.0 Provisions to Monitor the Data to Ensure the Safety of Subjects 
 
There are three areas in which safeguards to protect subjects from undue risk require discussion. These Include: 1) 
procedures used to obtain informed consent, 2) procedures used to ensure confidentiality of the subject data, and 3) 
procedures used to minimize possible risks associated with the laboratory procedures. Regarding informed consent, 
participants are fully advised on the research procedures to be used, the amount of time required of them, the possible 
risks and benefits of the procedures, their right to refuse participation in the study without prejudice, their right to 
terminate participation at any moment without prejudice, and the name and telephone number of the principal 
investigator. All subjects will be required to have capacity to consent. Regarding confidentiality, subjects are 
informed that the information they provide will be kept strictly confidential, with access limited to the research staff. 
Participation in the study will be treated as confidential, as will all records. The identity of subjects will be protected 
with alphanumeric codes. All data will be kept in locked file cabinets file cabinets or on secure servers designed for 
use and access by study team only.  
 
The PI and Co-Is of this study will meet every two months, for the duration of this project and review all the data 
related to this project. 
 
We do not anticipate any adverse events to occur in this study, however the experienced research team has a long-
standing record of recording and reporting unanticipated adverse events to the IRB. We will report any adverse event 
within 48 hours to the IRB. 
 
14.0 Withdrawal of Subjects 
 
Participants will be informed during consenting that they are free to withdraw from the study at any time. They will 
be informed that they are not obligated to participate once the study is initiated and in particular will be reminded 
prior to neuroimaging that they may discontinue the experiment at any point. Resting-state fMRI has been a very 
safe procedure and we do not anticipate subject withdrawal due to fMRI side effects.  

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15.0 Risks to Subjects 
 
Magnetic Resonance Imaging (MRI): 
MRI tests are non-invasive and painless. There are no known risks or side effects associated with conventional MRI 
procedures except to those people who have electrically, magnetically, or mechanically activated implants (such as 
cardiac pacemakers) or to those who have clips on blood vessels in their brain. However, an MRI may cause 
participants to feel claustrophobic (uncomfortable in a small space) or anxious from the noises made by the machine. 
 
Unknown Risks: 
There is always the possibility of other risks for a relatively new image processing technique. The Study team will 
let the participant know if they learn anything that might make the participant change their mind about participating 
in the study.  
 
Loss of Confidentiality: 
There is a risk of a loss of confidentiality of personal information. Subjects are informed that the information they 
provide, as well as participation in the study, will be kept strictly confidential, with access limited to the research 
staff. The identity of subjects in databases will be protected with alphanumeric codes. All data will be kept in locked 
file cabinets or on secure servers designed for use and access by Study Team members only. 
 
16.0 Potential Benefits to Subjects or Others 
 
There will be no direct benefit to the participant in the study. Data from this study, however, will benefit society by 
improving the understanding of the functional neurocircuitry underlying depression and whether there are MDD-
related dynamic brain states that can track clinical antidepressant TMS treatment. MRI is an FDA-approved 
diagnostic tool.  
 
17.0 Sharing of Results with Subjects 
 
There is no plan to inform subjects of the results of the study, but they can always contact the research staff and ask. 
If there are significant new findings during the course of the study, they will be notified. 
 
If desired, participants may request a deidentified CD of their imaging data the day the scan occurs, so they may have 
it for their records, free of cost.  
18.0 Drugs or Devices  
 
There is no plan to use any drugs or devices in this study. 
 
 
 

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