Accelerated intermittent theta burst stimulation (iTBS) may be a potential alternative treatment for depression in older adults who are unable to continue electroconvulsive therapy (ECT), according to a case study published in The American Journal of Geriatric Psychiatry.

ECT is an effective therapy in older patients with severe major depressive disorder that has been resistant to treatment. The COVID-19 pandemic may exacerbate depression, particularly in older adults who may be experiencing greater stress due to various factors such as isolation. Social distancing measures may also contribute to interruption in ECT treatments. The need for general anesthesia and bag-mask ventilation during ECT places patients and clinicians at risk for infection by aerosolized virus. Accelerated iTBS may therefore provide a suitable alternative during this pandemic. This treatment is noninvasive, does not require anesthesia or manual ventilation, and may be performed over shorter time periods, thus reducing potential exposure to aerosolized pathogens.

In the reported case study, a 66-year-old woman with treatment-resistant depression was treated with accelerated iTBS during a relapse (Patient Health Care Questionnaire-9: PHQ-9, 16; Beck Depression Inventory- II: BDI-II, 37) that occurred during the COVID-19 pandemic. The case authors used a protocol of 600 pulses per 5-minute session with 8 sessions per day over 5 consecutive days. The patient was ultimately able to achieve remission of depression (PHQ-9, 4; BDI-II, 9). The tapering phase consisted of 3 consecutive treatment days for 1 week, 4 weekly treatment days, and 1 biweekly treatment for a total of 8 treatment days.

“[Accelerated iTBS] represents an important advancement in neurostimulation, and older adults should be thoughtfully included in future clinical trials that examine the efficacy of this intervention. Our case not only illustrates the potential for this approach to be effective in older adults with moderate to severe depression but also highlights that a methodological modification to current aiTBS protocols that deliver 1800 pulses per session (i.e., reducing the number of pulses to 600) may not sacrifice effectiveness,” the authors concluded.

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Konstantinou GN, Downar J, Daskalakis ZJ, Blumberger DM. Accelerated intermittent theta burst stimulation in late-life depression: a possible option for older depressed adults in need of ECT during the COVID-19 pandemic [published online July 15, 2020]. Am J Geriatr Psychiatry. doi:10.1016/j.jagp.2020.07.007