Accelerated iTBS for Major Depression

Istanbul University - Cerrahpasa35 enrolled

Overview

Major depressive disorder (MDD) is a common and disabling psychiatric condition, and many patients do not achieve adequate response to standard antidepressant treatments. Accelerated intermittent theta burst stimulation (iTBS) is a promising neuromodulation approach that may provide rapid antidepressant effects. This prospective interventional study aims to evaluate the clinical effectiveness of accelerated bilateral dorsomedial prefrontal cortex iTBS in patients with MDD and to investigate treatment-related changes in neurobiological biomarkers, including cortisol, ACTH, BDNF, IL-1β, IL-6, TNF-α, and CRP. Associations between biomarker changes and treatment response will also be examined.

Major depressive disorder (MDD) is a highly prevalent and disabling psychiatric disorder. A substantial proportion of patients do not achieve sufficient improvement with conventional antidepressant treatments, resulting in treatment-resistant or difficult-to-treat depression. Noninvasive neuromodulation approaches such as transcranial magnetic stimulation (TMS) have emerged as effective alternatives for these patients. Accelerated intermittent theta burst stimulation (iTBS), delivered in multiple daily sessions over a short period, may provide faster clinical improvement compared with conventional protocols. This prospective single-arm interventional study aims to evaluate the clinical efficacy and biological correlates of accelerated bilateral dorsomedial prefrontal cortex (DMPFC) iTBS in adults with MDD who have shown inadequate response to at least one adequate antidepressant treatment trial. Participants aged 18 to 65 years will receive accelerated bilateral DMPFC iTBS for five consecutive days, with four sessions per day (20 total sessions). Participants demonstrating partial clinical improvement without remission after 20 sessions may receive an additional 10 sessions according to clinical evaluation. Clinical assessments will be performed at baseline, during treatment, at the end of treatment, and at one-month follow-up. Outcome measures include Hamilton Depression Rating Scale (HAM-D), Beck Depression Inventory, Beck Anxiety Inventory, suicidal ideation measures, self-rated depressive symptom scales, and Clinical Global Impression ratings. Blood samples will be collected at baseline and after treatment to evaluate neurobiological biomarkers, including cortisol, adrenocorticotropic hormone (ACTH), brain-derived neurotrophic factor (BDNF), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). The primary objective is to determine treatment response based on reduction in depressive symptom severity. Secondary objectives are to examine biomarker changes associated with treatment, identify predictors of response, and explore the relationship between early symptom improvement and final clinical outcomes.

Interventions

Accelerated Intermittent Theta Burst Stimulation (iTBS)DEVICE

Accelerated intermittent theta burst stimulation (iTBS) is administered bilaterally to the dorsomedial prefrontal cortex using a double-cone coil, targeting the stimulation site based on anatomical landmarks. Treatment is delivered over five consecutive days with four sessions per day (total of 20 sessions). Each session consists of 600 pulses per hemisphere (1200 pulses total) at an intensity of 120% of the individual motor threshold. Participants with partial response may receive an additional 10 sessions.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 65 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Age between 18 and 65 years * Diagnosis of Major Depressive Disorder according to DSM-5 criteria * Inadequate response to at least one adequate antidepressant treatment trial * Hamilton Depression Rating Scale (HAM-D) score ≥14 at baseline * Stable dose of antidepressant medication for at least 4 weeks prior to study entry * Ability to provide written informed consent Exclusion Criteria: * History of bipolar disorder, schizophrenia, schizoaffective disorder, or psychotic depression * Current substance use disorder * Neurological disorders that may affect brain function (e.g., epilepsy, multiple sclerosis, dementia, Parkinson's disease) * History of epileptic seizures * Severe head trauma * Presence of metal implants in the head or neck region * Cochlear implants * Cardiac pacemaker or implanted electronic devices * History of deep brain stimulation or vagus nerve stimulation * Previous neurosurgical procedures * Pregnancy or breastfeeding * Use of medications that may significantly affect neuroendocrine or inflammatory markers (e.g., corticosteroids, immunomodulators) * Endocrine disorders affecting the hypothalamic-pituitary-adrenal axis (e.g., Cushing's syndrome, Addison's disease, thyroid disorders) * Autoimmune diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis, Hashimoto thyroiditis) * Recent surgery or acute infection * Active suicidal crisis, severe agitation, or inability to comply with study procedures

Outcomes

Primary Outcomes

Change in Hamilton Depression Rating Scale (HAM-D) Score

Change in depressive symptom severity measured by the 17-item Hamilton Depression Rating Scale (HAM-D-17). Scores range from 0 to 53, with higher scores indicating greater depression severity.

Time frame: Baseline, within 3 days after completion of treatment and 1-month follow-up

Secondary Outcomes

Treatment Response Rate Based on HAM-D

Proportion of participants achieving ≥50% reduction in HAM-D score from baseline.

Time frame: within 3 days after completion of treatment

Remission Rate Based on HAM-D

Proportion of participants achieving remission defined as HAM-D score ≤7.

Time frame: Within 3 days after completion of treatment

Sustained Treatment Response at 1-Month Follow-Up

Proportion of participants maintaining ≥50% reduction in HAM-D score at 1-month follow-up.

Time frame: 1 month after treatment completion

Sustained Remission at 1-Month Follow-Up

Proportion of participants maintaining remission, defined as HAM-D score ≤7, at 1-month follow-up.

Time frame: 1 month after treatment completion

Change in Serum Cortisol and ACTH Levels

Change in serum cortisol and adrenocorticotropic hormone (ACTH) levels following treatment.

Time frame: Baseline, within 3 days after completion of treatment and 1-month follow-up

Change in Serum BDNF Levels

Change in serum brain-derived neurotrophic factor (BDNF) levels following treatment.

Time frame: Baseline, within 3 days after completion of treatment, and 1-month follow-up

Change in Inflammatory Biomarkers

Change in serum IL-1β, IL-6, TNF-α, and C-reactive protein (CRP) levels following treatment.

Time frame: Baseline, within 3 days after completion of treatment, and 1-month follow-up

Change in Beck Depression Inventory (BDI) Score

Change in depressive symptom severity measured by the Beck Depression Inventory(BDI). Scores range from 0 to 63, with higher scores indicating greater depressive symptom severity.

Time frame: Baseline, within 3 days after completion of treatment, and 1-month follow-up

Change in Beck Anxiety Inventory (BAI) Score

Change in anxiety symptom severity measured by the Beck Anxiety Inventory (BAI). Scores range from 0 to 63, with higher scores indicating greater anxiety severity.

Time frame: Baseline, end of treatment, and 1-month follow-up

Change in Clinical Global Impression (CGI) Score

The scale includes three clinician-rated dimensions assessing illness severity (1-7), clinical improvement (1-7), and side effect severity (1-4).

Time frame: Baseline, within 3 days after completion of treatment and 1-month follow-up

Accelerated iTBS for Major Depression

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes

Central Contacts