rTMS for Depressed Teens: A Sham-Controlled Trial, Part 1

Inclusion Criteria: * Diagnosis of unipolar major depressive disorder, in a current major depressive episode, without psychotic features * Pretreatment CDRS-R Raw score ≥ 40 * Age is at least 12 and less than 22 years * Ongoing, stable dose antidepressant therapy for at least 6 weeks to include the following antidepressants (with dosing range): * Celexa (citalopram hydrobromide) - 10 to 60mg * Cymbalta (duloxetine) - 40mg to 120mg * Desyrel (trazodone HCl) - 12.5mg to 150mg * Effexor (venlafaxine HCl) - 37.5mg to 300mg * Luvox (fluvoxamine maleate) - 25mg to 200mg * Lexapro (escitalopram oxalate) - 10mg to 40mg * Paxil (paroxetine HCl) - 10mg to 50mg * Pristiq (desvenlafaxine) - 50mg to 100mg * Prozac (fluoxetine HCl) - 10mg to 80mg * Remeron (mirtazapine) - 7.5mg to 45mg * Savella (milnacipran HCl) - 25mg to 200mg * Zoloft (sertraline HCl) - 25mg to 200mg * Subjects able to attend at least 31 study visits at study site. * Willing to provide informed assent (adolescent) and informed consent (family) Exclusion Criteria: * Subjects currently on stimulant, antipsychotic, bupropion or tricyclic antidepressant medications. * Prior rTMS, vagus nerve stimulation (VNS) or electroconvulsive therapy (ECT) * Contraindication to MRI * Contraindication to rTMS (history of neurological disorder such as seizures, increased intracranial pressure, brain surgery, or head trauma with loss of consciousness for \>15 minutes, history of stroke, family history of epilepsy, intracardiac lines, Anticoagulant, immune suppressive and/or chemotherapy, or those who received any of these therapies within 3 months before enrollment in the study Unstable medication conditions such as hematological or infectious (e.g., human immunodeficiency virus-HIV) disorders, implanted electronic device, metal in the head, or pregnancy) * History of schizophrenia, schizoaffective disorder, other \[non mood disorder\] psychosis, depression secondary to a medical condition, mental retardation, substance dependence or abuse within the past year (except nicotine), bipolar disorder, psychotic features in this or previous episodes, amnestic disorder, obsessive compulsive disorder, post-traumatic stress disorder, panic disorder * History of autoimmune, endocrine, viral, or vascular disorder. * Unstable cardiac disease, uncontrolled hypertension, or sleep apnea * Active suicidal intent or plan, or history of attempt within the past 6 months