High Dose Accelerated ITBS for Depression

Inclusion Criteria:

1. are outpatients

2. are voluntary and competent to consent to treatment

3. have a Mini-International Neuropsychiatric Interview (MINI) confirmed diagnosis ofMDD, single or recurrent

4. are between the ages of 18 and 65

5. have failed to achieve a clinical response to an adequate dose of an antidepressantbased on an Antidepressant Treatment History Form (ATHF) score for thatantidepressant trial of > 3 in the current episode OR have been unable to tolerateat least 2 separate trials of antidepressants of inadequate dose and duration (ATHFscore of 1 or 2 on those 2 separate antidepressants)

6. have a score > 18 on the HRSD-17 item

7. have had no increase or initiation of any psychotropic medication in the 4 weeksprior to screening

8. able to adhere to the treatment schedule

9. Pass the TMS adult safety screening (TASS) questionnaire

10. have normal thyroid functioning based on pre-study blood work.

Exclusion Criteria:

1. have a Mini-International Neuropsychiatric Interview (MINI) confirmed diagnosis ofsubstance dependence or abuse within the last 3 months

2. have a concomitant major unstable medical illness, cardiac pacemaker or implantedmedication pump

3. have active suicidal intent

4. are pregnant

5. have a lifetime Mini-International Neuropsychiatric Interview (MINI) diagnosis ofbipolar I or II disorder, schizophrenia, schizoaffective disorder, schizophreniformdisorder, delusional disorder, or current psychotic symptoms

6. have a MINI diagnosis of obsessive compulsive disorder, post-traumatic stressdisorder (current or within the last year), anxiety disorder (generalized anxietydisorder, social anxiety disorder, panic disorder), or dysthymia, that is assessedby a study investigator to be primary and causing greater impairment than MDD

7. have a diagnosis of any personality disorder, and assessed by a study investigatorto be primary and causing greater impairment than MDD

8. have failed a course of ECT in the current episode or previous episode

9. have received rTMS for any previous indication due to the potential compromise ofsubject blinding

10. have any significant neurological disorder or insult including, but not limited to:any condition likely to be associated with increased intracranial pressure, spaceoccupying brain lesion, any history of seizure except those therapeutically inducedby ECT or a febrile seizure of infancy, cerebral aneurysm, Parkinson's disease,Huntington's chorea, multiple sclerosis, significant head trauma with loss ofconsciousness for greater than 5 minutes

11. have an intracranial implant (e.g., aneurysm clips, shunts, stimulators, cochlearimplants, or electrodes) or any other metal object within or near the head,excluding the mouth, that cannot be safely removed

12. if participating in psychotherapy, must have been in stable treatment for at least 3months prior to entry into the study, with no anticipation of change in thefrequency of therapeutic sessions, or the therapeutic focus over the duration of thestudy

13. clinically significant laboratory abnormality, in the opinion of the one of theprincipal investigators or study physicians

14. currently take more than lorazepam 2 mg daily (or equivalent) or any dose of ananticonvulsant due to the potential to limit rTMS efficacy

15. non-correctable clinically significant sensory impairment (i.e., cannot hear wellenough to cooperate with interview).