Nathan Bakker1, Saba Shahab2, Peter Giacobbe3, Daniel M Blumberger4, Zafiris J Daskalakis4, Sidney H Kennedy5, Jonathan Downar6. 1. MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8. 2. MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Faculty of Arts and Sciences, University of Toronto, 100 St. George Street, Toronto, Ontario, Canada M5S 3G3. 3. MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8. 4. Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8; Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada. 5. Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8. 6. MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8; Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada. Electronic address: jonathan.downar@uhn.ca.
Abstract
BACKGROUND: Conventional rTMS protocols for major depression commonly employ stimulation sessions lasting >30 min. However, recent studies have sought to improve costs, capacities, and outcomes by employing briefer protocols such as theta burst stimulation (iTBS). OBJECTIVE: To compare safety, effectiveness, and outcome predictors for DMPFC-rTMS with 10 Hz (30 min) versus iTBS (6 min) protocols, in a large, naturalistic, retrospective case series. METHODS: A chart review identified 185 patients with a medication-resistant major depressive episode who underwent 20-30 sessions of DMPFC-rTMS (10 Hz, n = 98; iTBS, n = 87) at a single Canadian clinic from 2011 to 2014. RESULTS: Clinical characteristics of 10 Hz and iTBS patients did not differ prior to treatment, aside from significantly higher age in iTBS patients. A total 7912 runs of DMPFC-rTMS (10 Hz, 4274; iTBS, 3638) were administered, without any seizures or other serious adverse events, and no significant differences in rates of premature discontinuation between groups. Dichotomous outcomes did not differ significantly between groups (Response/remission rates: Beck Depression Inventory-II: 10 Hz, 40.6%/29.2%; iTBS, 43.0%/31.0%. 17-item Hamilton Rating Scale for Depression: 10 Hz, 50.6%/38.5%; iTBS, 48.5%/27.9%). On continuous outcomes, there was no significant difference between groups in pre-treatment or post-treatment scores, or percent improvement on either measure. Mixed-effects modeling revealed no significant group-by-time interaction on either measure. CONCLUSIONS: Both 10 Hz and iTBS DMPFC-rTMS appear safe and tolerable at 120% resting motor threshold. The effectiveness of 6 min iTBS and 30 min 10 Hz protocols appears comparable. Randomized trials comparing 10 Hz to iTBS may be warranted.
BACKGROUND: Conventional rTMS protocols for major depression commonly employ stimulation sessions lasting >30 min. However, recent studies have sought to improve costs, capacities, and outcomes by employing briefer protocols such as theta burst stimulation (iTBS). OBJECTIVE: To compare safety, effectiveness, and outcome predictors for DMPFC-rTMS with 10 Hz (30 min) versus iTBS (6 min) protocols, in a large, naturalistic, retrospective case series. METHODS: A chart review identified 185 patients with a medication-resistant major depressive episode who underwent 20-30 sessions of DMPFC-rTMS (10 Hz, n = 98; iTBS, n = 87) at a single Canadian clinic from 2011 to 2014. RESULTS: Clinical characteristics of 10 Hz and iTBSpatients did not differ prior to treatment, aside from significantly higher age in iTBSpatients. A total 7912 runs of DMPFC-rTMS (10 Hz, 4274; iTBS, 3638) were administered, without any seizures or other serious adverse events, and no significant differences in rates of premature discontinuation between groups. Dichotomous outcomes did not differ significantly between groups (Response/remission rates: Beck Depression Inventory-II: 10 Hz, 40.6%/29.2%; iTBS, 43.0%/31.0%. 17-item Hamilton Rating Scale for Depression: 10 Hz, 50.6%/38.5%; iTBS, 48.5%/27.9%). On continuous outcomes, there was no significant difference between groups in pre-treatment or post-treatment scores, or percent improvement on either measure. Mixed-effects modeling revealed no significant group-by-time interaction on either measure. CONCLUSIONS: Both 10 Hz and iTBS DMPFC-rTMS appear safe and tolerable at 120% resting motor threshold. The effectiveness of 6 min iTBS and 30 min 10 Hz protocols appears comparable. Randomized trials comparing 10 Hz to iTBS may be warranted.
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