title: rTMS of the dorsomedial prefrontal cortex for major depression: safety, tolerability, effectiveness, and outcome predictors for 10 Hz versus intermittent theta-burst stimulation.
abstract: BACKGROUND
  Conventional rTMS protocols for major depression commonly employ stimulation sessions lasting >30 min. However, recent studies have sought to improve costs, capacities, and outcomes by employing briefer protocols such as theta burst stimulation (iTBS).
  
  
  OBJECTIVE
  To compare safety, effectiveness, and outcome predictors for DMPFC-rTMS with 10 Hz (30 min) versus iTBS (6 min) protocols, in a large, naturalistic, retrospective case series.
  
  
  METHODS
  A chart review identified 185 patients with a medication-resistant major depressive episode who underwent 20-30 sessions of DMPFC-rTMS (10 Hz, n = 98; iTBS, n = 87) at a single Canadian clinic from 2011 to 2014.
  
  
  RESULTS
  Clinical characteristics of 10 Hz and iTBS patients did not differ prior to treatment, aside from significantly higher age in iTBS patients. A total 7912 runs of DMPFC-rTMS (10 Hz, 4274; iTBS, 3638) were administered, without any seizures or other serious adverse events, and no significant differences in rates of premature discontinuation between groups. Dichotomous outcomes did not differ significantly between groups (Response/remission rates: Beck Depression Inventory-II: 10 Hz, 40.6%/29.2%; iTBS, 43.0%/31.0%. 17-item Hamilton Rating Scale for Depression: 10 Hz, 50.6%/38.5%; iTBS, 48.5%/27.9%). On continuous outcomes, there was no significant difference between groups in pre-treatment or post-treatment scores, or percent improvement on either measure. Mixed-effects modeling revealed no significant group-by-time interaction on either measure.
  
  
  CONCLUSIONS
  Both 10 Hz and iTBS DMPFC-rTMS appear safe and tolerable at 120% resting motor threshold. The effectiveness of 6 min iTBS and 30 min 10 Hz protocols appears comparable. Randomized trials comparing 10 Hz to iTBS may be warranted.
authors.affiliation: MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8.
authors.forename: Nathan
authors.initials: N
authors.lastname: Bakker
authors.affiliation: MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Faculty of Arts and Sciences, University of Toronto, 100 St. George Street, Toronto, Ontario, Canada M5S 3G3.
authors.forename: Saba
authors.initials: S
authors.lastname: Shahab
authors.affiliation: MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8.
authors.forename: Peter
authors.initials: P
authors.lastname: Giacobbe
authors.affiliation: Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8; Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Blumberger
authors.affiliation: Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8; Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
authors.forename: Zafiris J
authors.initials: ZJ
authors.lastname: Daskalakis
authors.affiliation: Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8.
authors.forename: Sidney H
authors.initials: SH
authors.lastname: Kennedy
authors.affiliation: MRI-Guided rTMS Clinic, Department of Psychiatry, University Health Network, 399 Bathurst Street, Room 7M-415, Toronto, Ontario, Canada M5T 2S8; Department of Psychiatry, University of Toronto, 250 College Street, Floor 8, Toronto, Ontario, Canada M5T 1R8; Institute of Medical Science, University of Toronto, Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8; Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada. Electronic address: jonathan.downar@uhn.ca.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Downar
mesh_terms: D000328:Adult; D003865:Major Depressive Disorder / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010555:Personality Inventory; D017397:Prefrontal Cortex / Q000502:physiology*; D011569:Psychiatric Status Rating Scales; D012189:Retrospective Studies; D013826:Theta Rhythm; D050781:Transcranial Magnetic Stimulation / Q000009:adverse effects*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Bipolar; Case series; Chart review; Depression; Dorsomedial; Predictor; Theta burst stimulation; rTMS