Accelerated Intermittent Theta Burst in Treatment-Naive Adolescents

This single-site open-label clinical trial aims to test the safety and efficacy of precision accelerated intermittent theta burst stimulation (paiTBS) in treatment-naive adolescents with major depressive disorder (MDD) who remain antidepressant-free throughout the treatment. The paiTBS protocol, or a truncated version (5 or 10 applications per day to a customized target within the left dorsolateral prefrontal cortex [L-DLPFC] identified with fMRI for five consecutive days), in combination with MNS software will be delivered to each adolescent participant. Changes in depressive symptoms will be measured at baseline and two follow up visits. Additionally, parents and adolescents will answer questions regarding their preference for paiTBS as a first-line treatment option for MDD.

The hypothesis is that adolescent participants receiving paiTBS or the truncated version will demonstrate similar response and remission rates that are comparable to aiTBS trials in adults (80-90%) as measured by the Childhood Depression Rating Scale (CDRS) and Hamilton Depression Rating Scale.

The primary objective of this study is to determine the efficacy of active paiTBS in reducing symptoms of depression as measured by the CDRS at the one-month follow up time point.

The study will enroll approximately 40 participants and employ a two-arm design with 20 participants per arm. The target population is adolescents of all genders and ethnicities who are between 13 and 20 years of age with a diagnosis of MDD experiencing their first major depressive episode who have not received a full course of prior treatment and who are otherwise in good general health. Participants must be without contraindications to Magnetic Resonance Imaging (MRI) or transcranial magnetic stimulation (TMS) and must be able to attend all study visits.

This study will deliver paiTBS via a MagPro X100 edition (MagVenture, Skovlunde, Denmark) TMS device equipped with a Cool-B65 A/P coil. The stimulation paradigm consists of 5 or 10 daily sessions (25 or 50 total over 5-days) of paiTBS (3-pulse 50-Hz bursts at 5-Hz for 2-second trains, with trains every 10 seconds), delivered with 50-minute inter-session intervals (10-minute sessions, 50-minutes in between sessions). Stimulation will be delivered at 90% of the resting motor threshold (with depth correction to account for the distance between the scalp and cortex).

Inclusion criteria

• Male or Female, between the ages of 13 and 20 at the time of screening.
• Able to read, understand, and provide written, dated assent and/or consent prior to screening. Proficiency in English sufficient to complete questionnaires and follow instructions during aiTBS interventions. Stated willingness to comply with all study procedures, including availability for the duration of the study, and to communicate with study personnel about adverse events and other clinically important information.
• Diagnosed with Major Depressive Disorder (MDD) with a current Major Depressive Episode (MDE), according to the criteria defined in the Diagnosis and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5).
• No prior major depressive episodes (MDEs) as determined by MINI-KID
• CDRS-R score of ≥40 at screening (Visit 1).
• Treatment-naive as determined by the ATHF (no adequate antidepressant trials prior to screening defined as fewer than 12 weeks of antidepressant medication in the past 2 years and fewer than 10 psychotherapy sessions for depression in the past year; willingness to taper medications and stop psychotherapy if recently started and within the window defined above.)
• TMS naive.
• Access to ongoing psychiatric care before and after completion of the study.
• In good general health, as evidenced by medical history.
• Agreement to adhere to Lifestyle Considerations throughout study duration.

Exclusion criteria

• Pregnancy
• High-risk for suicide or active suicidal ideation as determined by clinical interview
• The presence or diagnosis of prominent anxiety disorder, or dysthymia (>4 on SAPAS; >16 on GAD-7)
• Current severe insomnia (must sleep a minimum of 5 hours each night before stimulation)
• Current mania or psychosis
• Bipolar Affective Disorder and/or primary psychotic disorders.
• Autism Spectrum disorder or Intellectual Disability
• A diagnosis of obsessive-compulsive disorder (OCD)
• Current moderate or severe substance use disorder or demonstrating signs of acute substance withdrawal.
• Urine screening test positive for illicit substances.
• Any history of ECT (greater than 8 sessions) without meeting responder criteria
• Recent (during the current depressive episode) or concurrent use of a rapid acting antidepressant agent (i.e., ketamine or a course of ECT).
• History of significant neurologic disease, including dementia, Parkinson's or Huntington's disease, brain tumor, unexpected seizure/epilepsy disorder, subdural hematoma, multiple sclerosis, or history of significant head trauma.
• Untreated or insufficiently treated endocrine disorder.
• Contraindications to receiving rTMS (e.g., metal in head, history of seizure, known brain lesion)
• Contraindications to MRI (ferromagnetic metal in their body).
• Any current or past history of any physical condition which in the investigator's opinion might put the subject at risk or interfere with study results interpretation.
• Depth-adjusted aiTBS treatment dose > 65% maximum stimulator output (MSO)
• Treatment with another investigational drug or other intervention within the study period.
• Any other condition deemed by the PI to interfere with the study or increase risk to the participant.