Intensive TMS for Bipolar Depression

Inclusion Criteria:

• Bipolar depression (BP I and BP II) by Diagnostic and Statistical Manual 5 (DSM 5)criteria

• Age 18-70

• Right or left handed

• All genders

• Treatment resistant depression, as in they must have treatment resistant depressionwith 2 or more prior antidepressant trials that have failed to produce a response (> 50% reduction in symptoms) using ATHF criteria

• Able to provide informed consent to participate in the study

• Must be on a stable medication regimen, requiring at least one mood stabilizer

• Depression severity as represented by scoring at least 20 on Montgomery-AsbergDepression Rating Scale (MADRS)

Exclusion Criteria:

• No current substance abuse disorder for the past 6 months (previous substance abusenot exclusionary)

• Any psychotic disorder or current active psychotic symptoms (personality disordersnot exclusionary unless in the opinion of the referring psychiatrist it wouldjeopardize participation)

• No dementia or other major neurological disorders

• Not having depression as primary disorder

• No major medical illness, for example metastatic cancer, end stage renal disease

• Not able to verify contact information. Participants must be able to follow throughwith the study & must have verified contact information and at least one verifiedcontact

• Pregnancy. While there are no known risks to a fetus this is a new use of TMS, whichhas not been tested, thus pregnancy is exclusionary

• Score on Young Mania Rating Scale (YMRS) greater than 12 (patients with mixedfeatures have been shown not to respond well to TMS treatment)

• Rapid cycling Bipolar illness (patients with > 4 mood episodes within the past yearwill be excluded, as they have a higher risk of switch to mania)

• Any implants, conditions, or contraindications that would be deemed unsafe for TMSor MRI

• Currently using benzodiazepines (such as lorazepam) with a dose >1 mg per day orequivalent.