Accelerated Transcranial Magnetic Stimulation (TMS) for Depression (ATMS)

Inclusion Criteria: Age 18-80 years. Patients who meet DSM-IV criteria for Major Depressive Episode, severe, treatment resistant, with or without psychotic features. Consent to treatment with rTMS. Exclusion Criteria: Patients with Delirium or Substance Dependence within the last 6 months. Patients will be screened initially with the Michigan Alcohol Screening Test (MAST) and Mini-Mental Status Examination and further evaluated if clinically indicated. Patients with other significant central neurological disorders including increased intracranial pressure, brain mass, epileptic seizures, stroke, transient ischemic attack within two years, cerebral aneurysm, dementia, multiple sclerosis or other major CNS dysfunction. Pregnant women. Patients with cardiac pacemakers, other intracardiac lines, cochlear implants, aneurism clips, or other intracranial implants with the exception of dental fillings. Patients with significant heart disease or with acute, unstable medical conditions that require stabilization (e.g., uncontrolled hypertension, bleeding) prior to treatment. Patients who require continued treatment with antipsychotics including clozapine and risperidone, benzodiazepines, lithium or anticonvulsants. Patients will be allowed to continue on a stable dose of antidepressants and use zolpidem, since the latter is not felt to affect seizure threshold. Patients who are unable to ambulate independently and complete the assessment protocol.