Comparisons of Accelerated Continuous and Intermittent Theta-burst Stimulation for Treatment-Resistant Depression and Suicidal Ideation

Background Suicidal ideation is a substantial clinical challenge in treatment-resistant depression (TRD). Recent work demonstrated promising antidepressant effects in TRD patients with no or mild suicidal ideation using a specific protocol termed intermittent theta burst stimulation (iTBS). Here, the author examined the clinical effects of accelerated schedules of iTBS and continuous TBS (cTBS) in patients with moderate to severe suicidal ideation. Methods TRD patients (n=44) with moderate to severe suicidal ideation were randomized to receive accelerated iTBS or cTBS treatment. These were delivered in ten daily TBS sessions (1800 pulses/session) for five consecutive days (total of 90,000 pulses). Neuronavigation was employed to target accelerated iTBS and cTBS to the left and right dorsolateral prefrontal cortex (DLPFC) respectively. Clinical outcomes were evaluated in a four-week follow-up period. Results Accelerated cTBS was superior to iTBS in the management of suicidal ideation (Pweek1 = 0.027) and anxiety symptoms (Pweek1 = 0.01). Accelerated iTBS and cTBS were comparable in antidepressant effects (P < 0.001; Meana-cTBS at week 1, 3, 5 = 49.55%, 54.99%, 53.11%; Meana-iTBS at week 1, 3, 5 = 44.52%, 48.04%, 51.74%). No severe adverse events occurred during the trial. One patient withdrew due to hypomania. The most common adverse event was discomfort at the treatment site (22.73% in both groups). Conclusions These findings provide the first evidence that accelerated schedules of left-DLPFC iTBS and right-DLPFC cTBS are comparably effective in managing antidepressant symptoms and indicate that right-DLPFC cTBS is potentially superior in reducing suicidal ideation and anxiety symptoms.