Exercise + TBS for Depression

Overseen By Stacey Shim, MSc

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: The Royal Ottawa Mental Health Centre

Must not be taking: Illegal drugs, Cannabis, Lorazepam

Disqualifiers: Bipolar, Substance abuse, Unstable illness, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 14

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial explores whether adding regular exercise to intermittent theta burst stimulation (iTBS) can better assist individuals with treatment-resistant depression. Participants will either combine exercise with iTBS or receive only the iTBS treatment. The researchers aim to determine if exercise enhances the effects of iTBS in alleviating depression symptoms. This trial may suit those whose depression hasn't improved with medication and who are not currently active in exercise. As an unphased trial, it provides a unique opportunity to investigate innovative treatment combinations for depression.

Do I have to stop taking my current medications for the trial?

You need to keep your current psychotropic medication and/or psychotherapy regimen unchanged for at least four weeks before and during the study.

What prior data suggests that combining structured exercise with iTBS is safe for treating depression?

Research shows that both regular exercise and a brain treatment called theta burst stimulation (iTBS) safely help with depression. Exercise, such as walking or jogging, can improve mood and typically doesn't cause serious side effects.

Theta burst stimulation is also safe. Studies have found that it reduces depression symptoms and has side effects similar to other common treatments. One study showed that iTBS remained safe even with frequent use over a short period.

These findings suggest that both exercise and iTBS are safe and well-tolerated for people with depression. It's always important to consult a healthcare provider to understand what these treatments might mean personally. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Theta Burst Stimulation (TBS) for depression is unique because it combines brain stimulation with physical exercise, offering a novel approach to treatment. Researchers are excited about this method because TBS delivers rapid pulses of magnetic energy to the brain, potentially providing faster results than traditional antidepressants, which can take weeks to work. Additionally, incorporating exercise, known for its mood-enhancing effects, alongside TBS could enhance overall treatment effectiveness, offering a dual benefit that standard medications alone may not provide.

What evidence suggests that this trial's treatments could be effective for depression?

Research has shown that intermittent theta burst stimulation (iTBS) can reduce depression symptoms. One study found that 38.1% of patients with major depression improved, and 9.5% experienced complete relief from symptoms. In this trial, participants in the Intervention Group will receive a combination of exercise and iTBS, which might enhance the treatment's effectiveness. Meanwhile, the Standard Group will receive iTBS alone after a period of stable treatment. Exercise, such as walking, jogging, and strength training, also helps with depression. ^{1 2 4 5 6}

Who Is on the Research Team?

Sara Tremblay, PhD

Principal Investigator

Royal Ottawa Mental Health Centre

Are You a Good Fit for This Trial?

This trial is for individuals with difficult-to-treat depression who are physically inactive. It aims to see if adding structured exercise to a treatment called intermittent Theta Burst Stimulation (iTBS) can help more than iTBS alone.

Inclusion Criteria

Able to provide voluntary informed consent

I have been diagnosed with major depression or persistent depressive disorder, without psychosis.

Able to engage in structured exercise as per the Get Active Questionnaire (GAQ)

Exclusion Criteria

Current or past (<3 months) substance (excluding caffeine or nicotine) or alcohol abuse/dependence, as defined in DSM-5 criteria

Current use of cannabis

Acute suicidality or threat to life from self-neglect

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Priming Phase

Participants in the intervention group undergo 4 weeks of exercise to enhance brain plasticity mechanisms.

4 weeks

3 visits per week (in-person)

Synergetic Phase

Participants in the intervention group continue exercise while receiving iTBS treatment for 6 weeks.

6 weeks

5 visits per week (in-person)

Control Phase

Participants in the control group receive stable treatment for 4 weeks followed by 6 weeks of iTBS alone.

10 weeks

5 visits per week (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment.

6 weeks

1 visit (in-person)

What Are the Treatments Tested in This Trial?

Interventions

• Structured Exercise
• Theta Burst Stimulation

Trial Overview The study tests whether combining regular, moderate-to-vigorous exercise with iTBS is more effective in treating major depressive disorder than just iTBS on its own. Participants will be compared to see the difference in therapeutic benefits.

How Is the Trial Designed?

Group I: Standard Group Experimental Treatment 1 Intervention

Standard care of 4 weeks of stable treatment (i.e. no changes to antidepressant regimen or physical activity) followed by 6 weeks of iTBS alone.

Group II: Intervention Group Experimental Treatment 1 Intervention

4-weeks of exercise (moderate-to-vigorous intensity) followed by 6 weeks of iTBS combined with exercise.

Who Is Running the Clinical Trial?

The Royal Ottawa Mental Health Centre

Lead Sponsor

Trials

24

Recruited

2,300+

University of Ottawa

Collaborator

Trials

231

Recruited

267,000+

Published Research Related to This Trial

Theta burst stimulation (TBS) shows significant efficacy in reducing depression symptoms, with a large effect size (Hedges' g = 1.0) based on a meta-analysis of 5 randomized controlled trials involving 221 subjects.

Active TBS resulted in higher response rates compared to sham TBS (35.6% vs. 17.5%), although there was no significant difference in remission rates, indicating that while TBS is promising, further research is needed to optimize treatment parameters.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy of theta burst stimulation (TBS) for major depression: An exploratory meta-analysis of randomized and sham-controlled trials. Berlim, MT., McGirr, A., Rodrigues Dos Santos, N., et al.[2018]

In a study of 60 treatment-refractory patients with major depressive disorder, both intermittent and combined theta-burst stimulation showed significantly better antidepressant responses compared to continuous theta-burst stimulation and sham treatment after 2 weeks.

Theta-burst stimulation is well-tolerated and effective, especially in patients with lower levels of treatment refractoriness, indicating that the severity of refractoriness can influence treatment outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy of prefrontal theta-burst stimulation in refractory depression: a randomized sham-controlled study. Li, CT., Chen, MH., Juan, CH., et al.[2022]

Bilateral theta-burst stimulation (TBS) significantly improved depressive symptoms and remission rates in patients with major depressive disorder (MDD), showing a response rate of 55.1% compared to 20.3% for sham stimulation across six randomized controlled trials involving 285 participants.

The treatment was well-tolerated, with similar rates of discontinuation and adverse events (like headache and dizziness) between the TBS and sham groups, indicating its safety as an intervention for mood disorders.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Bilateral theta burst stimulation for patients with acute unipolar or bipolar depressive episodes: A systematic review of randomized controlled studies. Qin, ZJ., Huang, SQ., Lan, XJ., et al.[2023]

In a randomized-controlled trial involving 32 patients with major depression, bilateral theta burst stimulation (TBS) to the dorsolateral prefrontal cortex showed a significant increase in treatment response compared to sham stimulation, with 9 responders in the TBS group versus 4 in the sham group.

The study also indicated a trend towards higher remission rates in the TBS group as measured by the Beck Depression Inventory, suggesting that TBS may enhance the effectiveness of ongoing medication and psychotherapy in treating major depression.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Treatment of major depression with bilateral theta burst stimulation: a randomized controlled pilot trial. Plewnia, C., Pasqualetti, P., Große, S., et al.[2018]

In a randomized, double-blind trial involving 56 patients, intermittent theta burst stimulation (iTBS) over the dorsomedial prefrontal cortex showed a significant reduction in negative symptoms for patients with depression, but not for those with schizophrenia.

The treatment was generally safe and well-tolerated, with serious adverse events occurring only in the sham group, indicating that iTBS may be a promising intervention for depressive symptoms in certain patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Dorsomedial prefrontal theta burst stimulation to treat anhedonia, avolition, and blunted affect in schizophrenia or depression - a randomized controlled trial. Bodén, R., Bengtsson, J., Thörnblom, E., et al.[2021]

Continuous theta burst stimulation (cTBS) was found to be safe and well-tolerated in patients with major depressive disorder (MDD) or bipolar depression (BD), with no significant differences in adverse events compared to sham treatment.

However, the meta-analysis of three randomized controlled trials involving 78 participants showed no significant improvement in depression scores or response rates with cTBS compared to sham, indicating that cTBS may not provide a therapeutic advantage for treating major depressive episodes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adjunctive continuous theta burst stimulation for major depressive disorder or bipolar depression: A meta-analysis of randomized controlled studies. Cai, DB., Qin, XD., Qin, ZJ., et al.[2023]

Theta burst stimulation (TBS) is as effective and safe as standard repetitive transcranial magnetic stimulation (rTMS) for treating depression, based on a meta-analysis of nine randomized controlled trials involving 1124 patients.

The study found no significant differences in response rates or adverse events between TBS and rTMS, suggesting that TBS could be a viable alternative due to its shorter treatment sessions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy and Safety of Theta Burst vs Repetitive Transcranial Magnetic Stimulation for the Treatment of Depression: A Meta-Analysis of Randomized Controlled Trials. Liu, C., Li, L., Li, B., et al.[2023]

Citations

1. bmj.com bmj.com/content/384/bmj-2023-075847

Effect of exercise for depression: systematic review and ... Conclusions Exercise is an effective treatment for depression, with walking or jogging, yoga, and strength training more effective than other ...

2. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC474733/

The Benefits of Exercise for the Clinically Depressed Results have been inconclusive, with exercise being more effective than some activities and similar to others in its ability to aid in the reduction of ...

3. sciencedirect.com sciencedirect.com/science/article/pii/S1728869X25000127

Use of multicomponent structured exercise to improve ... The findings of meta-analysis suggest that MSE showed a significant improvement in older adults' depression, but with evidence of low certainty. The MSE as a ...

4. tandfonline.com tandfonline.com/doi/full/10.1080/1750984X.2023.2266823

The effectiveness of structured sport and exercise ... All included studies showed clinical improvements in adolescents' anxiety or depression (anxiety, n = 5 and depression, n = 7). There is evidence that ...

5. frontiersin.org frontiersin.org/journals/public-health/articles/10.3389/fpubh.2025.1616925/full

The impact of high-intensity exercise on patients with ... Among high-intensity exercise interventions, both aerobic and resistance training effectively alleviated depressive symptoms, whereas ...

6. clinicaltrials.gov clinicaltrials.gov/study/NCT00964054

Depression Outcomes Study of Exercise (DOSE) Our recently completed randomized trial of exercise treatment in adults found response and remission rates of 46% and 42%, in those randomized ...