An Evaluation of Safety and Feasibility Using Repetitive Transcranial Magnetic Stimulation (rTMS) in Adolescents With Depression

High frequency rTMS applied to the left dorsolateral prefrontal cortex (L-DLPFC) has been shown to have an antidepressant effect. Initial studies comparing electroconvulsive therapy (ECT) and rTMS suggest that rTMS has been as effective as ECT in treating non-psychotic depression. Given the high degree of ongoing dysfunction in depressed adolescents despite optimization of treatment with antidepressant medications, new concerns regarding suicidal thoughts and behaviors in adolescents treated with antidepressant medications, and the more interventional nature of ECT, the use of rTMS as adjuvant therapy may be of significant clinical benefit. Thus far, research using rTMS to treat depression in adolescents has been limited. The primary aim of this study is to examine the safety and feasibility of using 10 Hz rTMS applied to the left dorsolateral prefrontal cortex (L-DLPFC) as adjuvant treatment for depression in adolescents.

Inclusion criteria

• Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of unipolar major depression without psychosis.
• Current or past history of lack of response to at least two adequate antidepressant trials selective serotonin re-uptake inhibitors (SSRI) operationally defined using the Antidepressant Treatment History Form (ATHF)
• Children's Depression Rating Scale-Revised (CDRS-R) score of 40 or higher at baseline
• At least six weeks of ongoing SSRI therapy at a stable dose.
• SSRI Medications will include:

• Citalopram (Celexa, Cipramil, Emocal, Sepram)
• Escitalopram oxalate (Lexapro, Cipralex, Esertia)
• Fluoxetine (Prozac, Fontex, Seromex, Seronil, Sarafem, Fluctin (EUR))
• Fluvoxamine maleate (Luvox, Faverin)
• Paroxetine (Paxil, Seroxat, Aropax, Deroxat)
• Sertraline (Zoloft, Lustral, Serlain)
• Age 13-18 years.
• Outpatient, inpatient, or partial hospitalization patients.
• Capable of providing informed assent/consent (in addition to parent/guardian consent).

Exclusion criteria

• Current Diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, mental retardation, pervasive developmental disorder, somatoform disorder, dissociative disorder, posttraumatic stress disorder, obsessive-compulsive disorder, eating disorders, antecedents of autism, and all personality disorders.
• Active substance dependence (except nicotine) in the past 12 months.
• Subjects with a history of head trauma, unprovoked seizure history, seizure disorder, or family history of treatment resistant epilepsy.
• Suspected pregnancy or pregnancy as confirmed by a urine pregnancy test at screening.
• History of failure to respond to ECT.
• Metal in the head (except in the mouth), implanted medication pump, cardiac pacemaker.
• Prior brain surgery.
• Risk for increased intracranial pressure such as brain tumor.
• Unable to obtain motor threshold in the subject or motor threshold too high, such that 120% MT cannot be obtained (i.e. >84% of device output).
• Significant change or increase in antidepressant medications within the last six weeks.
• Change in psychiatrist, psychologist, or therapist within the last four weeks.
• Suicide attempt within the past three months.
• Any suicide attempt or suicidal intent during the study will terminate involvement in this study.
• Subjects currently on stimulant, antipsychotic, atypical antidepressant or tricyclic antidepressant medications.
• Unstable medical or neurological conditions that may include hematological, infectious (such as Human immunodeficiency virus [HIV] positive patients) metabolic, or cardiovascular conditions that may preclude safe participation in trial.
• Subjects undergoing anticoagulant, immune suppressive and 1 or chemotherapy, or those who received any of these therapies </=3 months before enrollment in the study
• Subjects with intra-cardiac lines