Optimizing Treatment: Case Series of a Time-Efficient Accelerated Intermittent Theta Burst Stimulation Protocol for Depression and Call for a Protocol Consensus in Clinical Trials

Treatment-resistant depression (TRD), characterized by frequent relapses, diminished quality of life, and increased mortality, affects approximately 50% of patients with depression and often necessitates poly-pharmacological treatments. 1 Intermittent theta burst stimulation (iTBS), a newer form of repetitive transcranial magnetic stimulation was developed in 2005, has received the U.S. Food and Drug Administration (FDA) approval as an augmentation strategy for depression in 2019. 2,3Consequently, researchers are particularly engaged in exploring the efficacy and optimal techniques of accelerated, intensive or prolonged iTBS (piTBS) protocols, which are proposed to provide options in more severe forms of TRD.While the Stanford Neuromodulation Therapy (SNT) 4 protocol is a prominent FDA-cleared example, various studies have documented piTBS 5 which consists of once a daily session for roughly 4 to 6 weeks, and accelerated protocols (accelerated iTBS [aiTBS]) involving multiple daily sessions within relatively shorter time period (few days to 2 weeks). 6-8Despite iTBS's FDA approval for TRD, its clinical applicability is constrained by its 6-week duration, 3 prompting investigations into accelerating TBS delivery.These investigations focus on optimizing minimal treatment duration, total pulse number, and magnetic intensity to enhance efficacy and treatment adherence.A significant challenge in this area is the absence of standardized stimulation parameters across various research groups, contributing to this shortfall.Addressing the standardization issue has recently become a prominent topic