Accelerated Repetitive Transcranial Magnetic Stimulation to Treat Major Depression: The Past, Present, and Future

Abstract

Repetitive transcranial magnetic stimulation (rTMS) is an effective and evidence-based therapy for treatment-resistant major depressive disorder. A conventional course of rTMS applies 20-30 daily sessions over 4-6 weeks. The schedule of rTMS delivery can be accelerated by applying multiple stimulation sessions per day, which reduces the duration of a treatment course with a predefined number of sessions. Accelerated rTMS reduces time demands, improves clinical efficiency, and potentially induces faster onset of antidepressant effects. However, considerable heterogeneity exists across study designs. Stimulation protocols vary in parameters such as the stimulation target, frequency, intensity, number of pulses applied per session or over a course of treatment, and duration of intersession intervals. In this article, clinician-researchers and neuroscientists who have extensive research experience in accelerated rTMS synthesize a consensus based on two decades of investigation and development, from early studies ("Past") to contemporaneous theta burst stimulation, a time-efficient form of rTMS gaining acceptance in clinical settings ("Present"). We propose descriptive nomenclature for accelerated rTMS, recommend avenues to optimize therapeutic and efficiency potential, and suggest using neuroimaging and electrophysiological biomarkers to individualize treatment protocols ("Future"). Overall, empirical studies show that accelerated rTMS protocols are well tolerated and not associated with serious adverse effects. Importantly, the antidepressant efficacy of accelerated rTMS appears comparable to conventional, once daily rTMS protocols. Whether accelerated rTMS induces antidepressant effects more quickly remains uncertain. On present evidence, treatment protocols incorporating high pulse dose and multiple treatments per day show promise and improved efficacy.

Optimization Strategies of Transcranial Magnetic Stimulation in Major Depressive Disorder

“… 6 Furthermore, daily multiple treatment sessions of accelerated rTMS can reduce the overall treatment duration, enhance clinical efficiency, and expedite the onset of antidepressant effects. 7 Notably, 4 sessions per day of accelerated rTMS were found to be more effective than intranasal esketamine. 8 …”

“…In rTMS, HF-rTMS is an U.S. Food and Drug Administration (FDA)-approved technique for the treatment of treatment-resistant depression (TRD). 5 Bilateral rTMS 6 and accelerated rTMS 7 are promising techniques for treating MDD. A meta-analysis reported that bilateral rTMS is a potentially effective treatment for MDD, offering clinically significant benefits over standard antidepressant medications and unilateral rTMS.…”

Repetitive transcranial magnetic stimulation in the treatment of middle-aged and elderly major depressive disorder: A randomized controlled trial

“…[ 5 , 6 ] A recent study found that treatment regimens combining high pulse doses and multiple daily treatments of rTMS showed improved efficacy for MDD. [ 7 ] rTMS has also been proved to be an effective and safe a treatment for elderly patients with MDD. [ 8 ]…”

A Pilot Trial of Stepwise Implementation of Virtual Reality Mindfulness and Accelerated Transcranial Magnetic Stimulation Treatments for Dysphoria in Neuropsychiatric Disorders

“…There is also building evidence for efficacy in PTSD and some chronic pain conditions [10,11]. "Accelerated TMS" is a potential major advancement in the field [12]. The standard protocol of TMS for depression involves one daily session distributed over six weeks [13,14], while accelerated protocols use multiple treatments per day in an attempt to accelerate response.…”