Comparing Uni- and Bi-lateral TBS in Major Depression

  • End date
    Sep 28, 2023
  • participants needed
  • sponsor
    The Royal Ottawa Mental Health Centre
Updated on 28 June 2022


Repetitive transcranial magnetic stimulation (rTMS) is a Health Canada approved treatment for major depression. Theta burst stimulation (TBS) is a very promising new treatment for major depression that allows a 15-fold reduction in duration of daily sessions. However, no large scale naturalistic study has assessed the superiority of bilateral TBS in comparison with unilateral left TBS. In fact, no TBS study thus far has included both unipolar and bipolar depression, or other psychiatric comorbidities such as anxiety. Maintenance has yet to be studied with TBS, along with an effective maintenance protocol to prevent relapse. Our study aims to explore and address these gaps.


Repetitive transcranial magnetic stimulation (rTMS) is a Health Canada approved treatment for major depression. Typical treatments involve 30 to 45 minutes daily session delivered over 4 to 6 weeks. Recent technical advances allowed the development of theta burst stimulation (TBS), a novel rTMS paradigm which reduces daily sessions to 3 to 4 minutes while maintaining the same clinical efficacy. However, it remains to be determined if applying TBS to both sides of the frontal cortex (i.e. bilateral TBS) is more efficient than delivering it to only one side (i.e. unilateral TBS). In addition, it is difficult to predict treatment response as there is a lack of tools to identify potential responders early on in the treatment phase. Finally, the effects of rTMS are known to last up to 12 months after the treatment. To avoid relapse, a maintenance phase is typically introduced after treatment in which treatment sessions are delivered at a gradually decreasing rate. This study proposes to bridge these gaps by conducting a randomized double-blinded naturalistic superiority trial in which the efficacy of bilateral and unilateral TBS will be compared in individuals with a diagnosis of major depressive episodes. Neurobiological markers of response will be assessed at different time points. In people that respond to treatment, a 6-month maintenance phase will be conducted using a flexible schedule.

The study has four primary aims:

  1. To compare the efficacy of bilateral and unilateral TBS on symptoms of depression, as well as rates of remission and response
  2. To investigate how unilateral and bilateral TBS modulates brain activity in the dorsolateral prefrontal cortex (DLPFC) using interleaved TMS-EEG
  3. To investigate neural predictors of the clinical response to TBS.
  4. To compare the efficacy of a flexible schedule of maintenance on a period of 6 months on symptoms of depression and rate of relapse.

TREATMENT PHASE TBS treatment will be administered 5 days/week (Monday to Friday) over a first phase of 4 weeks (20 sessions). If remission is achieved (Hamilton Rating Scale for Depression-17 scorescore ≤ 8), treatment will cease and the patient will move on to the maintenance phase. Non-remitters will receive a second phase of treatment, consisting of an additional 2 weeks (10 sessions, for a total of 30). After 6 weeks, all responders may move on to the maintenance phase.

MAINTENANCE PHASE The maintenance phase will be of 6 months duration from the end of the randomized treatment. For each TBS condition, responders will be assigned to a flexible maintenance protocol based on symptom emergence. In the flexible protocol, participants will receive a fixed 2x/week schedule for the month 1. For month 2 and 3, a brief weekly assessment (Hamilton Rating Scale for Depression-17 score) will be conducted in which it will be determined if they will receive 0, 1 or 2 sessions in the week. For month 4 and 5, a bimonthly assessment (Hamilton Rating Scale for Depression-17 score) will be conducted in which it will be determined if they will receive 0, 1 or 2 sessions over the two weeks. For month 6, one brief assessment (Hamilton Rating Scale for Depression-17 score) will be conducted in which it will be determined if they will receive 0, 1 or 2 sessions in the month.

Condition Major Depressive Episode
Treatment Theta Burst Stimulation
Clinical Study IdentifierNCT04142996
SponsorThe Royal Ottawa Mental Health Centre
Last Modified on28 June 2022


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Inclusion Criteria

voluntary and competent to consent to study
female or male aged 18 years old or older
can speak and read English and/or French
primary and/or predominant diagnosis of major depressive episode without psychotic features (confirmed by a Mini-International Neuropsychiatric Interview)
depressive symptoms have not improved after ≥ 1 but ≤ 7 adequate dose of antidepressant trial in the current depressive episode
moderate symptoms in the current depressive episode as indexed by a score of at least 15 at the 17-item Hamilton Rating Scale for Depression (HRSD-17)
have been referred to rTMS treatment by their treating physician, and took a free and informed decision to follow this treatment
are able to adhere to treatment schedule
have received a stable medication (including prescribed cannabis) or psychotherapy regiment for at least four weeks prior to entering the trial
have an education-adjusted score of ≥ 24 at the Mini-Mental State Evaluation (MMSE) if are aged ≥ 65

Exclusion Criteria

current or past (< 3 months) substance (excluding caffeine or nicotine) or alcohol abuse/dependence, as defined in DSM-5 criteria
current use of illegal substances or recreational cannabis
have a concomitant major unstable medical or neurologic illness (e.g. uncontrolled diabetes or renal dysfunction)
significant laboratory test abnormalities (e.g. thyroid dysfunctions)
acute suicidality or threat to life from self-neglect
are pregnant or breastfeeding, or thinking of becoming pregnant during course of treatment
have a specific contraindication for TMS (e.g., personal history of epilepsy or seizure, metallic head implant, pacemaker)
unwilling to maintain current antidepressant regiment
are taking more than 1 mg of lorazepam or equivalent
any other condition that, in the opinion of the investigators, would adversely affect the participant's ability to complete the study
have failed a course of ECT within the current depressive episode due to the lower likelihood of response to rTMS
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