Accelerated TBS in Late Life Depression

Inclusion Criteria: 1. Are voluntary and competent to consent to treatment 2. are an outpatient 3. are ≥60 years old 4. have a Mini-International Neuropsychiatric Interview (MINI 6.0) confirmed diagnosis of major depressive disorder (MDD), with a current major depressive episode (MDE) 5. have failed to achieve a clinical response to an adequate dose of an antidepressant based on an Antidepressant Treatment History Form (ATHF) score of \> 3 in the current episode or have failed to tolerate two separate trials of an antidepressant 6. have a score \> 18 on the Montgomery-Asberg Depression Rating Scale (MADRS) 7. have had no increase or initiation of any antidepressant or antipsychotic medication in the 4 weeks prior to screening 8. Pass the TMS adult safety screening (TASS) questionnaire Exclusion Criteria: 1. have a history of substance dependence or abuse within the last 3 months 2. have a concomitant major unstable medical illness as determined by one of the study physicians 3. have active suicidal intent 4. have a lifetime MINI diagnosis of bipolar I or II disorder, or primary psychotic disorder 5. have current psychotic symptoms 6. have a 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), or dysthymia, assessed by a study investigator to be primary. One of these comorbidities will not be exclusionary if they are not deemed to be primary. 7. have a diagnosis of any personality disorder as assessed by a study investigator to be primary and causing greater impairment than MDD 8. have presumed or probable dementia or clinical evidence of dementia as assessed by a Short Blessed Test score of greater than 10. 9. did not respond to a course of electroconvulsive therapy (ECT) in the current depressive episode 10. have received rTMS in the current episode, patients who have had rTMS in a previous episode would be eligible 11. have a history of a primary seizure disorder or a seizure associated with an intracranial lesion. 12. 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 13. have a implanted electronic device that is currently function such as a defibrillator 14. currently take more than lorazepam 2 mg daily (or equivalent) or any dose of an anticonvulsant 15. 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 16. non-correctable clinically significant sensory impairment (i.e., cannot hear well enough to cooperate with interview).