New York, New York 10065

  • Major Depressive Disorder


Repetitive transcranial magnetic stimulation (rTMS) is a treatment for depression. The investigators are continuing to learn how to optimize outcomes from rTMS treatment. The purpose of this research project is to use brain network connectivity patterns as measured by resting state functional magnetic resonance imaging (fMRI) to confirm a way to optimize the use of rTMS to treat depression. In addition, the study aims to gain a better understanding of how rTMS influences brain networks.

Study summary:

Major depressive disorder (MDD) is a leading cause of global disability, and approximately 30% of MDD patients are resistant to antidepressant pharmacotherapy. Repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC) is an FDA-cleared intervention with proven efficacy in treatment-resistant depression, but only 30-40% of these patients achieve remission after a single course. Other studies have shown that rTMS targeting the dorsomedial prefrontal cortex (DMPFC) is comparably effective, but biomarkers for informing target site selection do not exist. Diagnostic heterogeneity has been an obstacle to biomarker discovery efforts. Recently, we developed and validated an approach to diagnose four novel MDD subtypes or "biotypes' defined by resting state functional connectivity (RSFC) patterns and predicting differing antidepressant responses at the individual level to rTMS. This pivotal trial will test a novel, biotype-guided treatment selection strategy motivated by the hypothesis that an individual patient's likelihood of responding to left DLFPC vs.DMPFC rTMS is determined in part by individual differences in 1) the degree to which their symptoms are driven by dysfunction in specific cerebral network targets comprising Valence Systems; and 2) the degree to which dysfunction in those targets can be modulated by stimulating the left DLPFC or DMPFC. Subjects (N=348; 174 from this site) will be randomized to receive a) biotype-guided rTMS targeting the DMPFC or left DLPFC; b) to a disconfirmation arm receiving rTMS targeting the opposite site; and c) to a third arm receiving FDA-cleared, standard-of-care rTMS targeting the left DLFPC, regardless of biotype. The dosage and method of delivery of rTMS for all arms are as follows: intermittent theta burst stimulation (iTBS) will be delivered at 120% of the resting motor threshold. It will be administered in triplet 50 Hz bursts, repeated at 5 Hz with a duty cycle of 2 s on and 8 s off, for a total of 600 pulses per session and a total duration of 3 min 9 s. All patients will be assessed before and after treatment on a battery of fMRI, behavioral, and clinical assessments. The primary goal is to confirm the efficacy of a novel RSFC biomarker-guided approach to differential treatment selection in treatment resistant depression.


Inclusion Criteria: - Age 22 to 65 years - Major Depressive Disorder (by M.I.N.I., Diagnostic Statistical Manual V (DSM-V criteria); Verification by evaluation by licensed study psychiatrist or psychologist - At least moderately severe depression (17-item Hamilton Depression Rating Scale greater than or equal to 18) - Failure to respond in the current episode to at least 1 antidepressant medication at an adequate dose and duration as measured by a modified Antidepressant Treatment History Form - Off antidepressants OR on a stable dose of antidepressants for greater than or equal to four weeks with plans to remain on this stable dose during the study - Any and all medication intended to treat depression or reduce symptoms of depression must be discontinued or maintained at the same daily dose for ≥ 4 weeks prior to enrollment and for the duration of the study - Capacity to consent - Written consent to allow communication between members of the research team and the patient's outpatient clinician(s) (psychiatrist, psychotherapist, nurse practitioner, primary care physician, or equivalent) as needed to ensure safety - Ability to safely participate in MRI - Fluent in English Exclusion Criteria: - Imminent risk of suicide (based on the Columbia-Suicide Severity Rating Scale) - Current depressive episode greater than or equal to 2 years duration - Presence of primary psychiatric diagnoses other than MDD and/or comorbid generalized anxiety disorder (GAD) or phobia (e.g., post-traumatic stress disorder; obsessive-compulsive disorder; MDD w psychotic features; primary psychotic illness; Bipolar I or II) - Evidence of cognitive impairment (MMSE score falling greater than or equal to 1 SD below the mean score for his or her age and education) - Have met criteria for any significant substance use disorder within the past six months - Recent onset (within 8 weeks of screening) psychotherapy, including, but not limited to: any form of treatment, aid, or therapy that has intensively and extensively examined the patient's psychological history, including, but not limited to: cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, and family-focused therapy - Prior exposure to any form of TMS during the current depressive episode. - Participated in any clinical trial with an investigational drug or device within the past 6 weeks prior to screening - History of neurosurgery to treat a neurological or psychiatric disorder - Evidence or history of significant neurological disorder, including moderate-severe head trauma, stroke, Parkinson's disease or other movement disorder (except benign essential tremor), epilepsy, history of seizures, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary or secondary tumors within the central nervous system - Implanted electronic devices and/or conductive objects in or near the head, including metal plates, aneurysm coils, cochlear implants, ocular implants, deep brain stimulation devices and stents - Any implanted device that is activated or controlled in any way by physiological signals, including, but not limited to: deep brain stimulators, cochlear implants, and vagus nerve stimulators - Patients with major depressive disorder who have failed to receive clinical benefit from Vagus Nerve Stimulation (VNS) or are currently receiving these therapies. - History of seizures (except juvenile febrile seizures) or any condition/concurrent medication that could notably lower seizure threshold - Individuals who are pregnant, nursing, contemplating pregnancy within the length of the study or, in the opinion of the investigator, not adherent to a medically acceptable method of birth control - History or presence of any disease, medical condition or physical condition that, in the opinion of the investigator, may compromise, interfere, limit, effect, or reduce the participant's ability to complete a treatment study lasting up to 21 weeks - Abnormal bloodwork for electrolytes, thyroid and liver function - Individuals who are taking > 300 mg daily dose of bupropion in any formulation (immediate, extended, or slow-release) - Individuals who are taking tricyclic antidepressants.

Study is Available At:

Original ID:

21-08023811; prev 1810019



Secondary ID:


Study Acronym:


Brief Title:

Biomarker-guided rTMS for Treatment Resistant Depression

Official Title:

Efficacy of Biomarker-guided rTMS for Treatment Resistant Depression

Overall Status:


Study Phase:

Phase 3



Minimum Age:

22 Years

Maximum Age:

65 Years

Quick Facts

Healthy Volunteers
Oversight Has DMC
Study Is FDA Regulated
Study Is Section 801
Has Expanded Access

Study Source:

Weill Medical College of Cornell University

Oversight Authority:

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Reasons Why Stopped:

Study Type:


Study Design:

Number of Arms:


Number of Groups:


Total Enrollment:


Enrollment Type:


Overall Contact Information

Official Name:Conor Liston, MD, PhD
Principal Investigator
Weill Medical College of Cornell University
Primary Contact:Megan Johnson
Backup Contact:Faith Gunning, PhD

Study Dates

Start Date:September 1, 2021
Completion Date:August 2026
Completion Type:Anticipated
Primary Completion Date:April 2026
Primary Completion Type:Anticipated
Verification Date:June 2022
Last Changed Date:June 24, 2022
First Received Date:July 31, 2019

Study Outcomes

Outcome Type:Primary Outcome
Measure:Change in depression, as measured by the Hamilton Depression Rating Scale (HAMD17)
Time Frame:Baseline and 1 Week Post Treatment (8-10 weeks)
Safety Issues:False
Description:The Hamilton Depression Rating Scale (HAMD17) is a 17 item clinician-rated measure of depression severity. Scores of 0-7 = Normal, 8-13 = Mild Depression, 14-18 = Moderate Depression, 19-22 = Severe Depression, ≥ 23 = Very Severe Depression
Outcome Type:Secondary Outcome
Measure:Change in depression, as measured by the Quick Inventory of Depressive Symptomology (QIDS)
Time Frame:Baseline and Post Treatment (7-9 weeks)
Safety Issues:False
Description:The Quick Inventory of Depressive Symptomology (QIDS) is a 16 item self-report measure of depression severity. Scores range from 0 to 27, with higher scores indicating greater severity of depression.
Outcome Type:Secondary Outcome
Measure:Change in Resting State fMRI Connectivity
Time Frame:Baseline and after completion of treatment (7-9 weeks)
Safety Issues:False
Description:Calculated from Functional Magnetic Resonance Imaging (fMRI) scan conducted while participant is awake but not completing any tasks in the scanner. Used to determine biotype of depression for treatment assignment and to determine if any changes in resting

Study Interventions

Intervention Type:Device
Name:Repetitive Transcranial Magnetic Stimulation
Description:iTBS rTMS targeting the left DLPFC
Arm Name:Standard of Care
Intervention Type:Device
Name:Repetitive Transcranial Magnetic Stimulation
Description:iTBS rTMS targeting the DMPFC or left DLPFC
Arm Name:Opposite Side Arm

Study Arms

Study Arm Type:Active Comparator
Arm Name:Opposite Side Arm
Description:iTBS rTMS targeting the opposite site (DLPFC or DMPFC) than the one we hypothesize will be most effective for that subject's biotype (disconfirmation arm).
Study Arm Type:Experimental
Arm Name:Targeted Side Arm
Description:iTBS rTMS targeting the area of the brain (DLPFC or dorsomedial prefrontal cortex DMPFC)) that we hypothesize will be most effective for that subject's biotype (confirmation arm).
Study Arm Type:Active Comparator
Arm Name:Standard of Care
Description:FDA-cleared, standard-of-care iTBS repetitive Transcranial Magnetic Stimulation targeting the left dorsolateral prefrontal cortex (DLPFC), regardless of the depression subtype (biotype) determined by a magnetic resonance imaging (MRI) scan.

Study Agencies

Agency Class:Other
Agency Type:Lead Sponsor
Agency Name:Weill Medical College of Cornell University
Agency Class:NIH
Agency Type:Collaborator
Agency Name:National Institute of Mental Health (NIMH)

Sample and Retention Information

There are no available Sample and Retention Information

Study References

There are no available Study References

Data Source:

Date Processed: August 16, 2022

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