Background: 30-50% of patients with Major Depressive Disorder (MDD) do not respond adequately despite two or more antidepressant treatments with proper dosage and timing of administration, configuring a condition of Treatment-Resistant Depression (TRD). Repetitive Transcranial Magnetic Stimulation (rTMS) is a neuromodulation technique that uses a magnetic field to stimulate focal cortical brain regions and it has been approved by the FDA for the treatment of TRD. Accelerated rTMS (arTMS) protocols involve multiple daily sessions of rTMS and they have been shown to be equally effective and safe compared to rTMS protocols, with reduced administration time and potentially faster antidepressant efficacy.
Objectives: The main aim of this study is to identify MDD endophenotypes/biotypes predictive of response to accelerated treatment of rTMS to better characterize the clinical correlates of response in patients with TRD.
Eligibility: Subjects between 18 and 65 years suffering from TRD in stable psychopharmacological treatment for at least one month.
Design: This clinical trial includes three phases: 1) a screening phase; a rTMS continued treatment phase; and a follow-up.
In order to be enrolled, participants will be screened with:
* Medical history to assess the existence of the inclusion criteria and exclude any medical conditions that could contraindicate treatment with arTMS * Questionnaires
After being enrolled, baseline data will be collected. In particular, participants will be administered:
* Questionnaires * Functional MRI * Cognitive tasks * Eye examination with Electroretinography (ERG) * Blood sampling * Salivary cortisol sampling
Repetitive TMS will be delivered during 5 outpatient treatment days (4 times/die).
After treatment patients will be contacted by telephone on a weekly basis for the first 3 weeks, to carry out an assessment of the clinical condition.
A follow-up visit, in the clinic, will be carried out after 21 days from the last stimulation (Friday), with the administration of psychometric scales.
Blood samples will be taken on the first day of stimulation and the day after the last stimulation.
Salivary cortisol sampling will be taken before the start of the stimulation protocol, after the first stimulation day and immediately after the last stimulation session foreseen by the protocol.
fMRI will be performed during baseline and at the end of treatment. ERG will be performed before the start of the stimulation protocol, after the first stimulation and immediately after the last stimulation session foreseen by the protocol. Patients will undergo ERG again during the follow-up visit at 21 days.
Treatment includes:
* rTMS: A brief electrical current passes through the coil placed on the head. At each day, participants will receive four rTMS sessions (36 min), with a 55 min interval between sessions. * MRIs: Patients will undergo two MRI sessions lasting 45 min. Blood pressure and respiratory rate will be recorded before the examination. During fMRI, patients will be asked to perform tasks. * Eye examination with Electroretinography (ERG) * Blood and salivary sampling. * Screening tests and questionnaires.
Current diagnosis of Major Depressive Disorder (MDD), based on the Diagnostic and Statistical Manual of Mental Disorder - Fifth Edition (DSM-5);
Subjects without clinical response to at least two antidepressant treatments administered at adequate dosage and duration during the current episode;
Stable psychopharmacological treatment for at least one month.
Co-morbidity with organic diseases that could interfere with magnetic stimulation safety (epilepsy, brain lesions or diseases, previous neurosurgery, metal grafts, cardiac devices) based on applied procedure guidelines;
Diagnosis of Substance or Alcohol Use Disorder (DSM-5) in the past 6 months;
Substances of abuse or alcohol acute intoxication or abstinence;
Co-morbidity with significant organic or neurological diseases;
Single group
Accelerated Repetitive Transcranial Magnetic Stimulation
DevicerTMS is a non-invasive brain stimulation technique. It will be used a MagPro R30 with the Cool-B-70 figure-of-eight coil (MagVenture, Falun, Denmark).
Changes in psychometric test indicator of depression - MADRS
Montgomery Asberg Depression rating scale (MADRS - 10 items - score 0-60) to measure relevance of mood, concentration, physical and sleep symptoms
Changes in psychometric test indicator of depression - HAM-D 21
Hamilton Depression Scale (HAM-D - 21 items - score 0-69) to assess relevance and pervasiveness of depressive symptoms
Changes in neuroplasticity - structural RM and fMRI (physiological parameter)
Functional MRI (which requires a preliminary structural MRI) produces images of the brain both in a "resting state" and when it is engaged in producing movements, sensations or when concentrated in activities involving emotional and cognitive responses. It is based on the ability to capture the signals emitted by hydrogen atoms when they are subjected to a magnetic field.
Changes in neuroplasticity - DTI (physiological parameter)
Diffusion Tensor Imaging (DTI) techniques to assess the integrity of white matter tracts between brain regions. DTI data, accompanied by fMRI studies, in subjects with MDD are indicative of reduced functional connectivity between cortical and subcortical structures. It is based on the principle of Brownian motion of water molecules, the signal is directly proportional to the integrity of the myelin sheath.
Cognitive Performance Using the THINC-it Tool
THINC-it (an acronym), include nclude the Spotter task (Choice Reaction Time), Symbol Check task(1-back test),Trails task(Trails Making Test B), and Codebreaker task (Digit Symbol Substitution Test).Z-value indicates the performance result (higher z higher performance)
Trait scales - TEMPS-A-brief Italian Version
Temperament Evaluation of Memphis, Pisa and San Diego Autoquestionnaire brief version (TEMPS-A-brief Italian Version - subscales' score: cyclothymic 0-12; depressive 0-8; irritable 0-8; hyperthymic: 0-8; anxious 0-3): a 39 items scale to investigate temperamental traits
Trait scales - BIS-11
Barratt Impulsiveness Scale, Version 11 (BIS-11, 30 item - score 30-120) to evaluate temperamental impulsive traits. BIS-11 consists in 3 subscale: "Attentional Impulsivity", "Motor Impulsivity" and "Nonplanning Impulsivity"
Trait scales - CTQ-28 items
Childhood Trauma Questionnaire (CTQ-28 items - score 0-112) to evaluate childhood and adolescence abuses and trauma
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