rTMS for Depression in Autism

(rTMS-MDD Trial)

Overseen By Anjuli G Ner, HBSc

Age: < 65

Sex: Any

Trial Phase: Academic

Sponsor: Centre for Addiction and Mental Health

Must not be taking: Benzodiazepines, Anticonvulsants

Disqualifiers: Substance use disorder, Seizures, Pregnancy, others

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

Approved in 3 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 33

Duration: 6 weeks

80 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests whether repetitive Transcranial Magnetic Stimulation (rTMS) can reduce depression in young people with autism. Depression poses a significant challenge for those with autism, and few proven treatments exist. rTMS has shown promise in helping individuals with depression who do not have autism, so researchers aim to determine its effectiveness for those with autism. The trial seeks English-speaking participants with autism who have stable health conditions and experience depression symptoms. As an unphased trial, participants can contribute to groundbreaking research that may lead to new treatment options for depression in autism.

Will I have to stop taking my current medications?

The trial does not specify if you need to stop taking your current medications, but you must not have changed your psychotropic medications or increased their dosage in the last 30 days.

What prior data suggests that rTMS is safe for treating depression in youth with autism?

Research has shown that theta burst stimulation, a type of transcranial magnetic stimulation (TMS), is safe for individuals with autism spectrum disorder (ASD). Past studies found that this treatment was well-tolerated by those with ASD, even when they also had major depressive disorder (MDD). The therapy proved effective and did not cause serious side effects.

An earlier study tested high-dose theta burst stimulation on children with ASD. The results demonstrated its safety and practicality. Participants did not experience severe side effects, and the treatment was generally well-received.

These findings suggest that this non-invasive brain stimulation method is a promising and safe option for managing depression symptoms in individuals with ASD. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about Active Bilateral Theta Burst Stimulation (BL-TBS) for depression in autism because it uses a cutting-edge technique called repetitive transcranial magnetic stimulation (rTMS). Unlike traditional antidepressants, which rely on chemical changes in the brain, rTMS offers a non-invasive approach that directly stimulates specific brain regions, potentially providing faster and more targeted relief. Specifically, BL-TBS targets the dorsolateral prefrontal cortex (DLPFC), which is associated with mood regulation, using precise MRI-guided neuronavigation. This method may offer hope for individuals who have not responded well to standard antidepressant medications.

What evidence suggests that rTMS might be an effective treatment for depression in autism?

Research has shown that repetitive transcranial magnetic stimulation (rTMS) may help treat depression. Studies have found that rTMS can effectively improve depression symptoms in people without autism. Regarding autism, early research suggests that rTMS might enhance brain function and reduce symptoms, including depression. Previous trials demonstrated that rTMS is safe and well-tolerated in young people with autism. In this trial, participants will receive either Active Bilateral Theta Burst Stimulation or Sham Bilateral Theta Burst Stimulation to evaluate the effectiveness of this non-invasive method for managing depression in those with autism spectrum disorder (ASD). ^{2 3 6 7 8}

Who Is on the Research Team?

Stephanie H Ameis, MD, MSC

Principal Investigator

Centre for Addiction and Mental Health

Are You a Good Fit for This Trial?

This trial is for young adults with autism who are also dealing with depression. They should be fluent in English, able to consent, clinically stable without medication changes for a month, and have an IQ of 70 or above. Those who are actively suicidal, pregnant, have seizures history or recent substance abuse can't participate.

Inclusion Criteria

Global Assessment of Function (GAF) scores (≤60) that is sustained over a lead-in period of two weeks AND/OR VABS-III below adequate functioning at baseline assessment.

My mental health treatment hasn't changed in the last 30 days.

Fluent in English

Exclusion Criteria

Significantly debilitating medical or neurologic illness, or acute or unstable medical illnesses as determined by study physician

Metal implants or a pace-maker, claustrophobia that would preclude the MRI scan

Actively suicidal (i.e., suicidal ideation with plan and intent) or high risk for suicide as assessed by a study psychiatrist

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive bilateral theta burst stimulation (BL-TBS) to dorsolateral prefrontal cortex (DLPFC) 5 days per week for 6 weeks

6 weeks

30 visits (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment

12 weeks

3 visits (in-person)

What Are the Treatments Tested in This Trial?

Interventions

• Active Bilateral Theta Burst Stimulation
• Sham Bilateral Theta Burst Stimulation

Trial Overview

The study tests rTMS (a type of brain stimulation) to see if it helps improve depression symptoms in autistic youth. Participants will receive either the real rTMS treatment or a sham (fake) version to compare outcomes in a controlled setting.

How Is the Trial Designed?

Group I: Active bilateral theta burst stimulation Active Control 1 Intervention

An X100 stimulator with a B65 A/P type coil (Magventure Inc.) will be used. The coil is positioned under MRI guidance using real-time neuronavigation using Brainsight \[x,y,z= -38, 44, 26(left), +38, 44, 26 (right). BL-TBS will be delivered at 90% RMT, corrected for scalp to cortex distance, to targeted left and right DLPFC sites, differing only in stimulation pattern and total number of pulses (triplet 50 Hz bursts, repeated at 200 msec (i.e., 5 Hz); right DLPFC (continuous TBS, cTBS): 120 seconds uninterrupted bursts (total of 600 pulses); left DLPFC (intermittent TBS, iTBS: 2 seconds on and 8 seconds off; 600 pulses per session; total duration of 3 min 9 seconds/hemisphere).

Group II: Sham bilateral theta burst stimulation Placebo Group 1 Intervention

An X100 stimulator with a B65 A/P type coil (Magventure Inc.) will be used with the active coil facing away from the scalp, for sham stimulation. The coil is positioned under MRI guidance using real-time neuronavigation using Brainsight \[x,y,z= -38, 44, 26(left), +38, 44, 26 (right). To reproduce the nociceptive qualities of the stimulation, the B65-type stimulation coil - sham side - includes a built in electrical stimulator in the coil connector which "fires" a synchronous electrical pulse along with the TMS stimulus through electrodes mounted on the forehead or near the area of stimulation, to generate auditory and somatosensory (vibration) stimuli.

Active Bilateral Theta Burst Stimulation is already approved in United States, European Union, Canada for the following indications:

Approved in United States as rTMS for:

• Major Depressive Disorder
• Obsessive-Compulsive Disorder

Approved in European Union as rTMS for:

• Major Depressive Disorder

Approved in Canada as rTMS for:

• Major Depressive Disorder
• Obsessive-Compulsive Disorder

Who Is Running the Clinical Trial?

Centre for Addiction and Mental Health

Lead Sponsor

Trials

388

Recruited

84,200+

Published Research Related to This Trial

In a randomized controlled trial involving 56 patients with moderate to severe depression, bilateral theta-burst stimulation (TBS) and repetitive transcranial magnetic stimulation (rTMS) did not show significant improvements in depression scores compared to sham treatment.

However, there was a noted tendency for both active treatments to increase the responder rate, particularly for the TBS group, suggesting that further research may be needed to explore its potential benefits.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Bilateral prefrontal rTMS and theta burst TMS as an add-on treatment for depression: a randomized placebo controlled trial. Prasser, J., Schecklmann, M., Poeppl, TB., et al.[2015]

In a well-designed 8-week randomized, double-blind sham-controlled trial involving 60 participants with autism spectrum disorder (ASD), inhibitory continuous theta burst stimulation (cTBS) did not show superior efficacy compared to sham stimulation in improving clinical or neuropsychological outcomes.

Both the active and sham groups exhibited similar improvements over time, suggesting that previous positive results from open-label trials may be influenced by placebo effects, indicating a need for more rigorous studies on rTMS/TBS in ASD.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A lack of efficacy of continuous theta burst stimulation over the left dorsolateral prefrontal cortex in autism: A double blind randomized sham-controlled trial. Ni, HC., Chen, YL., Chao, YP., 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]

Intermittent theta-burst stimulation (iTBS) targeting the left visual cortex (VC) was found to be non-inferior to targeting the left dorsolateral prefrontal cortex (DLPFC) in improving depressive symptoms in patients with major depressive disorder (MDD), based on a study of 75 participants over 14 days.

The VC group experienced lower rates of suicidal ideation and fewer adverse events, such as eye discomfort and pain, suggesting that VC-targeted iTBS may be a safer option for treating MDD.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Non-inferiority of intermittent theta burst stimulation over the left V1 vs. classical target for depression: A randomized, double-blind trial. Kong, Y., Zhou, J., Zhao, M., et al.[2023]

In a pilot study involving 13 adults with autism spectrum disorder (ASD), intermittent theta burst stimulation (iTBS) applied over the bilateral posterior superior temporal sulcus (pSTS) showed significant immediate improvements in parent-rated autistic symptoms after 5 days of treatment.

The effectiveness of iTBS on cognitive flexibility and clinical symptoms was influenced by individual factors such as baseline social-communicative impairment, cognitive performance, and concurrent psychotropic medication use, highlighting the need for personalized approaches in future trials.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

5-day multi-session intermittent theta burst stimulation over bilateral posterior superior temporal sulci in adults with autism-a pilot study. Ni, HC., Lin, HY., Chen, YL., et al.[2022]

In a study of 54 patients with major depression, the combination of intermittent theta burst stimulation (iTBS) and low-frequency rTMS (LF-rTMS) significantly improved depression and anxiety symptoms more than high-frequency rTMS (HF-rTMS).

The results suggest that iTBS combined with LF-rTMS may be a promising alternative therapy for major depression, offering both efficacy and time-saving benefits compared to traditional methods.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Left intermittent theta burst stimulation combined with right low-frequency rTMS as an additional treatment for major depression: A retrospective study. Mi, Y., Ji, Y., Lou, Z., et al.[2022]

In a study of 27 participants, a prolonged intermittent theta burst stimulation (piTBS) protocol using 1,800 pulses showed limited effectiveness for major depressive disorder, with only 18.2% of participants achieving a response and 9.1% reaching remission.

Safety and tolerability were concerns, as 18.5% of participants experienced issues, suggesting that while piTBS is a promising approach, further research is needed to optimize its parameters and improve outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Prolonged intermittent theta burst stimulation in the treatment of major depressive disorder: a case series. Richard, M., Noiseux, C., Desbeaumes Jodoin, V., et al.[2022]

Accelerated intermittent theta burst stimulation (TBS) was found to be safe and well tolerated in 12 suicidal therapy-resistant depressed patients, showing a significant decrease in suicidal ideation over time.

However, the reduction in suicidal thoughts was not definitively linked to the active TBS treatment compared to sham stimulation, indicating that further research is needed to confirm its efficacy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The acute effects of accelerated repetitive Transcranial Magnetic Stimulation on suicide risk in unipolar depression: preliminary results. Desmyter, S., Duprat, R., Baeken, C., et al.[2022]

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]

Citations

1.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC9486126/

5-day multi-session intermittent theta burst stimulation over ...

A double-blind, randomized trial of deep repetitive transcranial magnetic stimulation (rTMS) for autism spectrum disorder. Brain stimul. 2014;7:206–211. doi ...

2.

clinicaltrials.gov

clinicaltrials.gov/study/NCT05271357?tab=table

Transcranial Magnetic Stimulation for Depression in Autism ...

The overarching goal of this study is to examine treatment effects and elucidate the physiological biomarkers of a newer form of non-invasive brain stimulation ...

3.

link.springer.com

link.springer.com/article/10.1007/s10803-024-06244-2

Accelerated Theta Burst Transcranial Magnetic Stimulation ...

Inclusion criteria for participants included: (1) age 12–26 years, (2) diagnosed with ASD (and confirmed by Autism Diagnostic Observation ...

4.

sciencedirect.com

sciencedirect.com/science/article/pii/S2405844024082823

A systematic review of transcranial magnetic stimulation ...

Transcranial magnetic stimulation (TMS) is a promising and emerging tool for the intervention of ASD by reducing both core and associate symptoms.

5.

neuromodulationjournal.org

neuromodulationjournal.org/article/S1094-7159(23)00742-0/abstract

Efficacy and Safety of Theta Burst Versus Repetitive ...

Theta burst stimulation (TBS) is more energy- and time-efficient than is standard repetitive transcranial magnetic stimulation (rTMS).

6.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC11995711/

Feasibility, safety, and efficacy of high-dose intermittent ...

We aim to preliminarily investigate the feasibility, safety, and efficacy of high-dose iTBS in children with autism spectrum disorder (ASD).

7.

pubmed.ncbi.nlm.nih.gov

pubmed.ncbi.nlm.nih.gov/38744742/

Accelerated Theta Burst Transcranial Magnetic Stimulation ...

Overall, ATBS treatment was highly effective and well-tolerated in individuals with ASD and co-occurring MDD. The findings support the need ...

8.

sciencedirect.com

sciencedirect.com/science/article/abs/pii/S1094715923007420

Review Articles Efficacy and Safety of Theta Burst Versus ...

Theta burst stimulation (TBS) is more energy- and time-efficient than is standard repetitive transcranial magnetic stimulation (rTMS).