| Paper authors: | Michelle Goodman, Alisson Trevizol, Gerasimos Konstantinou, David Boivin-Lafleur, Ram Brender, Jonathan Downar, Tyler Kaster, Yuliya Knyahnytska, Fidel Vila-Rodriguez, Daphne Voineskos, Zafiris Daskalakis, Daniel Blumberger |
| Year of paper publication: | 2025 |
| Post authors: | Alice Erchov, Sarah Kesler, Fidel Vila-Rodriguez |
| Download the research article: | Goodman et al. (2025) Extended course accelerated intermittent theta burst stimulation as a substitute for depressed patients needing electroconvulsive therapy |
Introduction
For people with very severe treatment-resistant depression, electroconvulsive therapy (ECT) remains as the most effective treatment option to offer rapid improvement. However, ECT use remains limited due to misconceptions about its safety, accessibility, and, recently, the COVID-19 pandemic. Alternatively, repetitive transcranial magnetic stimulation (rTMS) is relatively more accessible and effective in treatment-resistant depression, but it’s protocols take longer (i.e., weeks), on average. While new accelerated protocols (called “iTBS”) are emerging, it is unclear whether they are effective for the same degree of depressive severity, short timeframe, and/or have lasting improvements, when compared to ECT.
Methods
There were 172 patients with severe treatment-resistant depression who completed an accelerated iTBS protocol. Every treatment day included eight 3.5 minute treatment sessions, delivered 50 mins apart from one another.
- Acute phase: 5x treatment days a week (every weekday), until either:
- (A) participants’ depression symptoms fell below clinical levels (i.e., remission), or
- (B) 10 treatment days
- Tapering phase (part 1): 2x treatment days a week, for 2 weeks
- Tapering phase (part 2): 1x treatment day a week, for 2 weeks
- Relapse prevention: Patients who had their symptoms improve by at least 50% (responded) by the end of the tapering phase then moved onto relapse prevention
Results
Response = symptoms improve (i.e., are less severe) by at least 50% compared to when participants started
Remission = symptoms fall below a “clinically-relevant” severity (i.e., are so low that it is likely no longer enough to classify as depression)
- By the end of the acute phase, participants saw an average 29% improvement in their depressive symptoms, compared to the start of the study
- 25% responded, and 16% achieved remission from depression
- By the end of the tapering phase, participants saw an average 43% improvement in depressive symptoms, compared to the start of the study
- 50% responded, and 35% achieved remission from depression
- By the end of the relapse prevention phase, participants saw an average of 60% improvement in depressive symptoms, compared to the start of the study
- Of the 61 patients who made it to the end of this phase (all either responded or achieved remission from depression), 49% ended as responders and 17% ended as remitters
- This meant that, of the people who ended tapering phase as either responders or remitters, 34% had relapsed at least partially
- On average, participants rated the treatment pain as a 2/10. The most common iTBS side effects were headaches (38%), dizziness (8%), and nausea (7%).
Conclusion
Accelerated iTBS appears to be generally safe, effective, and well-tolerated – leading to meaningful improvements in people with severe depression who would have otherwise received ECT. However, the results of an accelerated protocol suggests that 10 days of treatments do not achieve the same level of efficacy that ECT does in such a short time frame. Thus, while iTBS can be safely and effectively delivered over a relatively short period, ECT remains a gold-standard option for those with severe and treatment-resistant depression requiring a rapid response.