Sequential l-PFC, DMPFC-ACC, Accelerated Intermittent Theta Burst DTMS For Highly-Suicidal Treatment-Resistant Depression Patients

Authors: A Tendler, E Sisko, N Rodriguez, S Corbett-Methot, J Sutton-DeBord, J Brown, N Williams

Introduction
Depressed, suicidal patients who failed pharmacologic and brain stimulation protocols have significant hopelessness about future treatment, making a four-week treatment protocol particularly challenging. We treated this challenging population with accelerated intermittent theta burst (iTBS) to the left PFC (L-PFC) and dorsomedial prefrontal cortex-anterior cingulate cortex (dmPFC-ACC), two regions associated with antidepressant deep rTMS(dTMS) response.
Methods
Seven severely depressed, suicidal patients, who failed pharmacotherapy and a course of dTMS, were given 108,000 pulses over three to four days. dTMS was administered at 30-50HZ in 3 pulse bursts, 10 bursts over two seconds (5HZ), followed by a five second interval, for 60 cycles (1800P over 7 minutes) with the H1 coil over the L-PFC at 90% resting hand MT followed by the H7 over the dmPFC-ACC at 90% resting foot MT. After 15-minutes from the end of H1 treatment, the cycle was repeated 10 times per day for three days. Progress was assessed with the SSI, IDS, and CGI-S at baseline and later time points. Significance was evaluated with paired t-tests.
Results
90%MT sequential dual-target accelerated iTBS was well tolerated with headaches, jaw movements and scalp discomfort as adverse events. By day ten, suicidality decreased in 7/7 patients (Mean % decrease SSI¼21.97% ± SD¼25.61). The five patients’ depression responded and the two were non-responders by IDS-SR30 (Mean % decrease IDS-SR30¼56.02% ± SD¼21.96) and CGI-S criteria (Mean decrease CGI-S¼3.57 ± SD¼2.23). The two non-responders only tolerated 80%MT iTBS.
Conclusions
Accelerated sequential L-PFC, dmPFC-ACC 90%MT iTBS appears safe and helpful for suicidal patients. Controlled studies are warranted.

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