Open Label - Personalized Therapeutic Neuromodulation for Anhedonic Depression

Study Overview
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Brief Summary
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This study will investigate the anti-anhedonic efficacy of a novel neurostimulation strategy termed accelerated intermittent theta burst stimulation (aiTBS) in participants with treatment resistant depression (TRD).

Detailed Description
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Repetitive transcranial magnetic stimulation (rTMS) is an established therapy for treatment-resistant depression. The approved method for treatment is 10Hz stimulation for 40 min over the left dorsolateral prefrontal cortex (L-DLPFC). This methodology has been effective in real world situations. The limitations of this approach include the duration of the treatment (approximately 40 minutes per treatment session, 5 days per week, for 4-8 weeks). Recently, the investigators have pursued modifying the treatment parameters to reduce treatment times with an accelerated treatment paradigm. This study aims to further study the accelerated protocol and examine changes in neuroimaging biomarkers.

Official Title
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Open Label - Personalized Therapeutic Neuromodulation for Anhedonic Depression

Conditions
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Treatment Resistant Depression

Intervention / Treatment
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* Device: Active TBS-DLPFC
* Device: TBS-DMPFC


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male or Female, between the ages of 18 and 80 at the time of screening. Able to read, understand, and provide written, dated informed consent prior to screening. Proficiency in English sufficient to complete questionnaires / follow instructions during fMRI assessments and aiTBS interventions. Stated willingness to comply with all study procedures, including availability for the duration of the study, and to communicate with study personnel about adverse events and other clinically important information. Currently diagnosed with Major Depressive Disorder (MDD) and meets criteria for a Major Depressive Episode, according to the criteria defined in the Diagnosis and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5). MADRS score of ≥20 at screening (Visit 1). TMS naive for one of the following areas: DLPCF or DMPFC The dose of the primary antidepressant medication (if applicable) must be stable for 6 weeks prior to baseline, and participant must agree to continue at this dose throughout the study period. In good general health, as evidenced by medical history. For females of reproductive potential: use of highly effective contraception for at least 1 month prior to screening and agreement to use such a method during study participation. Agreement to adhere to Lifestyle Considerations throughout study duration. Lifestyle Considerations: Abstain from becoming pregnant from the screening visit (Visit 1) until after the final study visit (Visit 10). Abstain from caffeine- or xanthine-containing products (e.g., coffee, tea, cola drinks, and chocolate) for 3 hours before the start of each dosing session until after the final TMS session. Abstain from alcohol for 24 hours before the start of each dosing session until after collection of the final MRI. Participants who use tobacco products will be instructed that use of cigarettes will not be allowed during the study. Exclusion Criteria: Pregnancy History of or current psychotic disorder or bipolar disorder Severe borderline personality disorder. Diagnosis of Intellectual Disability or Autism Spectrum Disorder Primary psychiatric condition other than MDD requiring treatment except stable comorbid anxiety disorder Current moderate or severe substance use disorder or demonstrating signs of acute substance withdrawal Urine screening test positive for illicit substances Acute suicide risk based on clinical judgement or a suicide attempt (as defined by the C-SSRS) within the past one year Any history of ECT (greater than 8 sessions) without meeting responder criteria Recent (within 4 weeks of any clinical effect) or concurrent use of rapid acting antidepressant agent (i.e., ketamine or a course of ECT) History of significant neurologic disease, including dementia, Parkinson's or Huntington's disease, brain tumor, seizure disorder, subdural hematoma, multiple sclerosis, or history of significant head trauma Untreated or insufficiently treated endocrine disorder. Contraindication to receiving rTMS (e.g., metal in head, history of seizure, known brain lesion) Contraindication to MRI (ferromagnetic metal in their body) Treatment with an investigational drug or other intervention within the study period Depth-adjusted aiTBS treatment dose > 65% maximum stimulator output (MSO) Unstable symptoms between screening and baseline as defined by a ≥ 30% change in MADRS score. Any other condition deemed by the PD to interfere with the study or increase risk to the participant

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Active TBS-DLPFC<br>The active group will receive theta-burst TMS DLPFC stimulation. | Device: Active TBS-DLPFC<br>* Participants will receive intermittent TBS to left DLPFC. The L-DLPFC will be targeted utilizing the Localite neuronavigation system. Stimulation intensity will be standardized at 90% of RMT and adjusted to the skull to cortical surface distance (see Nahas 2004). Stimulation will be delivered to the L-DLPFC using a MagPro TMS system (MagVenture, Denmark).<br>|
| Active Comparator: Active TBS-DMPFC<br>The active group will receive theta-burst TMS DMPFC stimulation. | Device: TBS-DMPFC<br>* Participants will receive intermittent TBS to DMPFC. The DMPFC will be targeted utilizing the Localite neuronavigation system. Stimulation intensity will be standardized at 90% of RMT and adjusted to the skull to cortical surface distance (see Nahas 2004). Stimulation will be delivered to the DMPFC using a MagPro TMS system (MagVenture, Denmark).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in clinician-administered MADRS from Baseline to Week 1 post-treatment-initiation | The Montgomery-Asberg Depression Rating Scale (MADRS) is a 10-item clinician-administered scale, designed to be particularly sensitive to antidepressant treatment effects in patients with major depression. Score range of 0-60. A higher score is indicative of more depression. | Baseline, 1-week post-treatment-initiation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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transcranial magnetic stimulation, theta burst