Linear Asymmetric rTMS in Adolescent Treatment-Resistant Depression: Tolerability of Treatment Durations Ranging From Ten Days to One Day

Study Overview
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Brief Summary
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This is a pilot interventional study to investigate the acceptability, tolerability, and side effect profile for varying numbers of treatment sessions/day of a new rTMS treatment in adolescents with treatment-resistant depression (TRD). Conventional rTMS has been limited to sinusoidal biphasic electromagnetic pulses. In contrast, the First Dawn rTMS system by NeuroQore can sustain a repetitive linear asymmetric pulse. In addition, identification of rTMS treatment sites in adolescents with TRD most often relies on anatomic landmarks, but the First Dawn rTMS system utilizes personal fMRI data in a novel algorithm to determine where to apply the rTMS in each patient. Based on adult data in healthy volunteers and patients with TRD, the investigators propose that the First Dawn rTMS system will be acceptable and well-tolerated by adolescents and will have minimal side effects. Please see https://clinicaltrials.gov/ct2/show/NCT02667041 for details on the completed pilot study in adults. The investigators aim to investigate acceptability, tolerability, and side effects in groups of patients receiving treatment in numbers of sessions/day that are gradually accelerated over the course of the study. Results will be used to inform the development of a randomized controlled trial.

Detailed Description
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The 18 patients will be placed into 6 sub-groups sequentially as they are enrolled. All patients will receive a maximum of 30,000 pulses in their treatment course, as tolerated. The first group will receive daily sessions, similar to standard rTMS treatment. Each of the remaining groups will be set to receive more frequent sessions/day in decreasing numbers of days on a graduated schedule while holding the total number of pulses for each patient's treatment course at 30,000 pulses. in addition, the investigators will recruit one healthy volunteer to test fMRI server data transfer and analysis. This healthy volunteer will not receive rTMS. Primary Objectives The primary objectives of this study are to assess: 1) the feasibility of enrollment (number of patients who enroll divided by the number of patients approached), 2) study retention (number of patients completing the study divided by the number enrolled), and 3) AE/SE profile of the treatment at each protocol level and 4) patient experience in the study across the sample and within the sub-groups. Secondary Objectives The secondary objectives of this study are to: 1) evaluate daily changes in symptoms of depression and mental status; 2) evaluate fMRI changes in the LDLPFC after treatment; 3) evaluate post-treatment and 3-month changes in depression symptoms, global function, mental status, verbal memory.

Official Title
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Dose-Response Study of Linear Asymmetric rTMS in Adolescent Treatment-Resistant Depression: Tolerability of Treatment Durations Ranging From Ten Days to One Day

Conditions
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Treatment Resistant Depression

Intervention / Treatment
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* Device: Linear Asymmetric rTMS System


Participation Criteria
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Eligibility Criteria
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Inclusion: Meets criteria for DSM-5 MDD, as determined by a structured psychiatric interview. Meets criteria for TRD: failed two adequate courses of antidepressant medication OR failed adequate course of medication AND one course of psychotherapy. Score of > 40 on Child Depression Rating Scale-Revised OR score of > 20 on Child Depression Inventory-2. Fluent in speaking and reading English. Exclusion: Positive pregnancy test. Current or past: bipolar disorder, psychotic disorder, autism spectrum disorder, intellectual disability, substance use disorder, conduct disorder, as determined by a structured psychiatric interview. Medical illness that could lower the seizure threshold, e.g., epilepsy from any cause. Medications that could lower the seizure threshold or affect brain function. Psychotropic medications changed in two weeks prior to enrollment. Fails the TMS safety screening questionnaire. Fails fMRI screening process. Left-handed (may indicate different cortical lateralization which could affect outcomes). Involuntarily committed to the hospital.

Ages Eligible for Study
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Minimum Age: 15 Years
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Interventional Model Description: rTMS
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Adolescents<br>Device: First Dawn rTMS System used in 18 patients divided into groups of 3. Each group will receive a different and gradually increasing frequency of treatment sessions/day (1-10) over a decreasing number of days (10-1). The total number of pulses for all levels will be 30,000. The use of each level will be dependent on tolerability and safety of the previous lower level, i.e., if one level is not tolerated well by a group, progression to the next level will not occur. | Device: Linear Asymmetric rTMS System<br>* Linear Asymmetric rTMS System<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient Enrollment Rate | Number of patients who give consent divided by the number who are approached. | Through study completion, an average of 10 months | 
| Patient Completion Rate | Number of patients who complete the study divided by the number of patients who enroll in the study. | Through study completion, an average of 10 months | 
| Side Effects Profile | Measured with the rTMS Side Effect Questionnaire | Through study completion, an average of 10 months | 
| Patient Experience | Measured with the Multi-Care Institute for Research and Innovation Research Participant Satisfaction Questionnaire | Through study completion, an average of 10 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in self-reported MDD symptoms | Measured with the Child Depression Inventory-2.(CDI-2) | Change from baseline score to score at 3 months | 
| Change in clinician-rated MDD symptoms | Measured with the Child Depression Rating Scale-Revised (CDRS-R) | Change from baseline score to score at 3 months | 
| Change in function | Measured with the Children's Global Assessment Scale (C-GAS) | Change from baseline score to score at 3 months | 
| Change in mental status | Measured with the Mini-Mental State Examination (MMSE) | Change from baseline score to score at 3 months | 
| Change in short-term verbal memory | Measured with the Hopkins Verbal Learning Test-Revised (HLVT-R) | Change from baseline score to score at 3 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Major Depressive Disorder, Repetitive Transcranial Magnetic Stimulation (rTMS), Treatment-Resistant Depression, Adolescents