Depression is one of the leading causes of disability worldwide. Common treatments like antidepressant medications and talk therapy work well for some people, but many others do not improve, even after trying multiple treatments.
This study will investigate two alternative treatment options for people whose depression has not responded to standard treatments: repetitive transcranial magnetic stimulation (rTMS), a non-invasive form of brain stimulation, and ketamine, a fast-acting medication. It can be difficult to decide between these interventions in clinical practice, and selecting between them often comes down to patient preference and trial and error. This study is working to optimize the selection approach: using biological and behavioral markers to match each person to identify biomarkers that may predict response to rTMS or ketamine. Investigators believe that differences in how individuals respond to rTMS versus ketamine are partly explained by differences in how their brains are organized, and that these differences can be measured and used to guide intervention decisions. This is an early-stage pilot study designed to test whether this biomarker-based approach is practical and acceptable to patients. Investigators will evaluate how well a combination of brain imaging and clinical data can predict, at the individual level, who is likely to respond to rTMS versus ketamine. The ultimate goal is to develop a reliable, scalable tool that helps clinicians make faster and more informed intervention decisions, reducing the time people with treatment-resistant depression spend searching for an antidepressant that works.
Provision of signed and dated informed consent form
Adults of all genders aged 18-70 at the time of screening
Diagnosis of Major Depressive Disorder (by DSM-5 criteria)
Depressive symptoms of at least moderate severity (GRID HDRS-17 score >= 14 or as determined by a study clinician)
Imminent risk of suicide
Presence of primary psychiatric diagnosis other than MDD (e.g., post-traumatic stress disorder, obsessive-compulsive disorder, MDD with psychotic features, primary psychotic illness, bipolar I or II disorder)
History of epilepsy or a history of seizures that would influence the participant's risk for TMS-evoked seizures; history of any condition / concurrent medication that could notably lower seizure threshold in the estimation of a study clinician
Met criteria for any clinically significant substance use disorder (by DSM-V criteria) with active substance misuse in the 6 months prior to screening
Parallel
TMS
DevicerTMS will be administered as intermittent theta burst simulation (iTBS) delivered to the left dorsolateral prefrontal cortex with an accelerated intervention protocol (up to 5 consecutive days of 10 hourly rTMS sessions).
Ketamine
DrugKetamine is a dissociative anesthetic with rapid-acting antidepressant properties. It will be administered in 6 total sessions (3 days x 2 weeks), each comprising a single subanesthetic dose of ketamine (0.5 mg/kg) delivered intravenously over 40 minutes.
Change from Baseline to 2-Week Post-Intervention Score in Hamilton Depression Rating Scale (HDRS) Score
Change in depressive symptoms from pre- to post-intervention, as measured by mean percent change in score on the GRID 17-item Hamilton Depression Rating Scale (HDRS-17), in participants receiving rTMS vs. ketamine. The GRID HDRS-17 has a minimum score of 0 and maximum score of 52, with higher scores indicating greater depression severity.
Change from Baseline to Post-Intervention on a Visual Analog Scale of the Antidepressant Selection Approach
Ratings on a visual analog scale assessing whether the study visits (including MRI scans and clinical assessments) are tolerable and perceived to be an acceptable component of future intervention protocols. The scale will be scored from -10 to +10, with higher scores indicating higher acceptability. Secondary outcome analyses will use a one-sample t-test to evaluate whether visual analog scores are significantly greater than zero.
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Weill Medical College of Cornell University
Lead sponsor
Icahn School of Medicine at Mount Sinai
Collaborator
National Institute of Mental Health (NIMH)
Collaborator
