Deep rTMS for Treatment-Resistant Late-life Depression

Inclusion Criteria: * outpatients * voluntary and competent to consent to treatment * SCID for DSM-IV confirmed diagnosis of major depressive disorder, single or recurrent * between the ages of 60 and 85 * failed to achieve a clinical response to an adequate dose of an antidepressant based on an ATHF score of ≥ 3 in the current episode OR have been unable to tolerate at least 2 separate trials of antidepressants of inadequate dose and duration (ATHF 1 or 2) * a score of ≥ 22 on the HDRS-24 * no increase or initiation of any psychotropic medication in the 4 weeks prior to screening * able to adhere to the treatment schedule * pass the TMS safety screening questionnaire * have normal thyroid functioning based on pre-study blood work Exclusion Criteria: * history of DSM-IV substance dependence or abuse within the last 3 months * concomitant major unstable medical illness, cardiac pacemaker or implanted medication pump * acutely suicidal * pregnant * lifetime SCID diagnosis of Bipolar I or II disorder, schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, or current psychotic symptoms * SCID diagnosis of obsessive compulsive disorder, post-traumatic stress disorder (current or within the last year), anxiety disorder (generalized anxiety disorder, social anxiety disorder, panic disorder) assessed by a study investigator to be primary and causing greater impairment than MDD * SCID diagnosis of any personality disorder and assessed by a study investigator to be primary and causing greater impairment than MDD * have presumed or probably dementia, as defined by Mini Mental Status Exam (MMSE)\<26 and clinical evidence of dementia * failed a course of ECT within the current depressive episode * a significant neurological disorder or insult, including, but no limited to: any condition likely to be associated with increased intracranial pressure, space occupying brain lesion, any history of seizure except those therapeutically induced by ECT, cerebral aneurysm, Parkinson's disease, Huntington's chorea, multiple sclerosis, significant head trauma with loss of consciousness for greater than or equal to 5 minutes * on a dose of Buprioprion greater than 300mg per day * have an intracranial implant(e.g., aneurysm clips, shunts, stimulators, cochlear implants, or electrodes) or any other metal object within or near the head, excluding the mouth, that cannot be safely removed * if participating in psychotherapy, must have been in stable treatment for at least 3 months prior to entry into the study, with no anticipation of change in the frequency of therapeutic sessions , or the therapeutic focus over the duration of the study * clinically significant laboratory abnormality, in the opinion of the investigator * currently (or in the last 4 weeks) take more than lorazepam 2 mg daily (or equivalent) or any dose of an anticonvulsant due to the potential to limit rTMS efficacy * inability to communicate in English * non-correctable clinically significant sensory impairment (i.e cannot hear well enough to cooperate with interview)