| Paper authors: | Michelle S. Goodman, Alisson P. Trevizol, Gerasimos N. Konstantinou, David Boivin-Lafleur, Ram Brender, Jonathan Downar, Tyler S. Kaster, Yuliya Knyahnytska, Fidel Vila-Rodriguez, Daphne Voineskos, Zafiris J. Daskalakis, Daniel M. Blumberger |
| Year of paper publication: | 2025 |
| Post authors: | Caleb Pozdnikoff, Sarah Kesler, Fidel Vila-Rodriguez |
| Check out the full research article: | Goodman et al. (2025) Extended course accelerated intermittent theta burst stimulation as a substitute for depressed patients needing electroconvulsive therapy |
Introduction
Electroconvulsive therapy (ECT) is known for being one of the most effective treatments for depression. Despite its effectiveness, it is associated with negative perceptions among the public and the potential for cognitive side effects. In comparison, repetitive transcranial magnetic stimulation (rTMS) is a less invasive treatment for depression that, unlike ECT, does not require anesthesia or triggering a seizure. Also, it is not associated with these same cognitive side effects. If ECT and rTMS are both used to treat depression, could healthcare providers use rTMS as a replacement for ECT?
This study uses accelerated rTMS as a substitute treatment for ECT. The researchers used an extended course of accelerated rTMS, meaning that the patients received 2 weeks of treatment with 8 treatments per day. The type of rTMS that patients received was intermittent theta burst stimulation (iTBS). The iTBS treatment only takes about 3 minutes to complete.
The study took place when the COVID-19 pandemic was placing limitations on access to ECT. Researchers wanted to determine if accelerated iTBS was a suitable alternative. The goal of the researchers was to establish a safe and effective substitute treatment (iTBS) for patients with the most severe depression. To do this, researchers recruited participants who would normally have been referred to ECT treatment and gave them accelerated iTBS instead.
For more information about ECT, visit our article about it here.
Methods
There were 155 people that completed the two weeks of accelerated iTBS treatment. After the two weeks of accelerated treatment, patients were asked to do 2 days of treatment (8 treatments daily) per week for 2 weeks, then 1 day per week for 2 weeks. This phase was termed the tapering phase. If participants benefitted from the treatment, they were offered to join the symptom-response phase. In the symptom-response phase, treatments were scheduled based on symptom re-emergence and clinician judgment, and lasted up to 6 months. The tapering phase and the symptom-response phase were designed to keep the treatment effective for as long as possible.
Each patient filled out questionnaires that monitored their depressive symptoms, anxiety, and suicidal ideation. This data was used to determine the proportion of patients who achieved significant reductions/disappearance of depressive symptoms.
Results
- The extended accelerated iTBS protocol was well-tolerated in patients with severe depression.
- The initial 10-day acute phase resulted in fewer people improving in depressive symptoms (a low response rate).
- However, extending the course with the 4-week tapering phase substantially increased the number of people who experienced an improvement (a higher response rate).
- The protocol also demonstrated the feasibility and potential benefit of using the symptom-response approach to maintain symptom improvement for up to six months.
Conclusion
The extended course of iTBS was found to be safe and well-tolerated for patients suffering from severe depression who would otherwise have required ECT. Implementing this alternative led to meaningful clinical outcomes for patients. Although the initial 10-day acute phase had limited remission rates, extending the treatment with a 4-week tapering phase substantially improved outcomes. However, further research is needed to determine if rTMS is an adequate substitute compared to the improvement rates that ECT provides. The study demonstrated the possibility and potential benefits of using a symptom-based approach to scheduling TMS appointments to maintain the benefits of treatment for up to six months.