Alternative antidepressant deep transcranial magnetic stimulation protocols

Journal: Brain Stimulation, 11(3)-e2 (2018)

Authors: A Tendler, E Sisko, N Barnea-Ygael


The remission rate for patients with pharmacotherapy resistant depression who undergo standard deep repetitive transcranial stimulation (dTMS) is almost 50%. This protocol consists of twenty daily treatment utilizing high frequency (18Hz, 1980 pulses) stimulation to the left prefrontal cortex(L-PFC).


dTMS’s remission rate is second only to electroconvulsive therapy, which has significant cognitive side effects and poor durability. Nevertheless, alternative treatments for non-responders should be explored.


A literature review of PubMed for treatment resistant depression (TRD) and dTMS, as well as discussion among the authors for emerging techniques presented at meetings, to summarize all the current options as an infographic.


The only approach withdouble blinded placebo-controlled data shown to increase response and remission is treatment continuation beyond four weeks, in a twice a week schedule for twelve weeks. Alternative approaches include increasing the number of pulses in each treatment; increasing the number of treatments per day; increasing the treatment intensity (which also increases the risk for seizures); switching to intermittent theta burst and administering multiple daily treatments (accelerated iTBS); right PFC at low frequency; dorsomedial prefrontal –anterior cingulate cortex (dmPFC-ACC) stimulation at high frequency; bilateral insula stimulation at high frequency; or combination of these locations in sequence or simultaneously with a multifocal stimulator.


dTMSaffords highly treatment resistant depressed patients many non-invasive options. Identifications and testing of a-priori biomarkers to suggest the most effective treatment for the individual is essential to determine optimal courses of dTMS for TRD.