Accelerated rTMS for Medication Resistant Major Depression.

Maximal therapeutic effects of rTMS treatment for Medication Resistant Depression

occur by 26–28 sessions of stimulation. For this reason, depression treatment in many clinics
consists of 30 daily stimulation sessions administered over 6 weeks. rTMS is usually offered in
an outpatient setting, meaning that patients are required to make 30 separate visits to the rTMS
clinic to complete a treatment. This time commitment may negatively influence treatment
acceptance or completion in some cases. There are also financial burdens. Up to now, there are
approximately 1000 rTMS centers around the world which means that outpatients usually have
to move to distant areas and pay for overnight. Most important, the slow rate of response makes
TMS not a suitable option for patients requiring rapid treatment.

Finding means of shortening the standard rTMS treatment period (Accelerated TMS)

-Reduces the time commitment required for standard rTMS.

-Offers the possibility of a much faster prognosis when predicting the treatment efficacy.

- May also results in faster symptom improvement, comparable to other acute treatments,
((ECT), lithium, ketamine and clozapine) with fewer side effects.

If safety and efficacy between accelerated vs standard TMS is not significant different ,
the only burden is the limited insurance coverage, since most insurance companies cover only
one treatment per day.

Typical Protocol for Treatment Resistant Major Depression

Protocol of Accelerated TMS for MRMD

Up to now, there is no standard protocol for aTMS for MRMD. The aim is to have the same at
least safety and efficacy with standard rTMS within the minimum time span.

Coil placement (left DLPFC), Coil type (figure eight), Coil positioning method (5cm rule),
Magnetic field intensity (100-120% of MT), Frequency (10 Hz), and stimulus train duration (4-5
sec) are the same as in standard rTMS protocol.

In order to consolidate the full course of treatments in few days, daily doses of standard rTMS
(3,000 pulses / session) are increased up to 10,000 pulses, administrated in multiple
consecutive sessions. There are:

-No differences in overall clinical response, including at the follow up assessment

-No differences in safety and tolerability.

-Possible more rapid improvement in accelerated treatment.