Accelerated Transcranial Magnetic Stimulation (aTBS) to Treat Depression
Condition: Depression
MeSH terms: Depression; Depressive Disorder
Study type: Interventional

Summary: 
      The primary aims of this study are to investigate the efficacy of L DLPFC accelerated TMS
      (aTMS) in patients with depression in Singapore and to assess the whether a 1-week course of
      treatment is as effective as a 4-week course of non-accelerated treatment and if additional
      aTMS or different aTMS treatments will be more efficacious in non-responders to initial aTMS
      treatment.
    

Detailed description: 
      Repetitive transcranial magnetic stimulation (TMS) is a technique for stimulating brain
      activity using transient magnetic field to induce an electrical current in the brain
      producing firing of focal groups of brain cells. TMS is beginning to emerge in routine
      clinical practice as a treatment for depression. The predominant hypothesis is that depressed
      patients benefit from left sided high-frequency TMS (LHF-TMS) over the left dorsolateral
      prefrontal cortex (DLPFC)(1). A major limitation of rTMS is the large amount of time taken
      for a standard protocol (38 minutes a day for 20-30 working days). The optimal type and
      duration of TMS is still uncertain , as is the optimal strategy for continuing or changing
      type of rTMS if there is poor initial response.(1) One potential strategy to improve the
      acceptability of rTMS is to compress or accelerate the administration of rTMS (aTMS) by
      administering multiple sessions of rTMS over a shorter period of time to have equivalent
      efficacy in shorter period of time. Various studies of aTMS (2-9) have been safely conducted
      with anywhere from 2 (3) to 10 (2) sessions of rTMS a day for a total of 9 (5) - 20 (4, 7)
      sessions of TMS over 2 (2) to 9 (8) days. These studies showed that aTMS was safe and
      efficacious, with no significant side effects reported and a high level of patient
      acceptability and significant improvements in subjects' depression after the aTMS. However,
      there is no data on whether subjects who do not response to aTMS will benefit from more of
      the same TMS or from changing the mode of rTMS. The only study investigating this issue
      investigated normal rTMS, not aTMS, and did not find a significant difference in response to
      different forms of rTMS in initial non-responders (10). Our own observations and some
      preliminary evidence suggest that there may be a delayed response to TMS in some patients
      (11, 12). Thus, instead of the usual practice of giving 4-6 weeks stimulation (every weekday)
      and assessing for response at the end of the stimulation period, the same outcome may be
      achieved by giving a shorter period of stimulation (eg 1 weeks), waiting 2-4 weeks, then
      assessing response and the need for further TMS treatment. Further, giving more than 1
      treatment per day has been shown to be effective (13) and may lead to more efficient
      treatment, i.e. fewer days to response and less requirement for patient attendance at the
      treatment centre (2-9).

      This pilot study will contribute to existing knowledge by being possibly the first group in
      South East Asia to investigate the immediate and delayed efficacy of aTMS in the local
      population (i.e. in an Asian setting) as well as whether continuing or changing the type of
      rTMS is more efficacious in subjects who do not respond to initial aTMS.
    

Intervention name(s): Accelerated repetitive transcranial magnetic stimulation
Intervention type(s): Device
Intervention description(s): Subjects will be given accelerated left sided rTMS and randomized to more of the same accelerated rTMS if not meeting remission criteria for depression or a different type of rTMS on the right side
Allocation: Randomized
Intervention model: Sequential Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: rTMS, depression, accelerated