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Intensive Accelerated Theta Burst Stimulation in Treatment of Patients With Bipolar Depression and Suicidality

Primary Purpose

Bipolar Depression

Status
Recruiting
Phase
Not Applicable
Locations
Egypt
Study Type
Interventional
Intervention
Transcranial Magnetic Stimulation MagPro R30 with the MCF-B70 figure-of-eight coil (MagVenture, Denmark)
Sponsored by
Zagazig University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Bipolar Depression

Eligibility Criteria

19 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Diagnosis of Major depressive episode as a part of bipolar (I or II) disorder and confirmed by Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) Meet the threshold on the total MADRS score of >/=35 at baseline visit (severe) Meet the threshold on the total BDI-II score of >/=30 at baseline visit (severe) Ongoing suicidal ideation and/or behavior (confirmed with Columbia Scale for the Rating of Suicide Severity (C-SSRS) , score >/=3 (moderate to high risk) Age 19 years or older (Adults, Older Adults) Right handedness Both genders Able to provide informed consent to participate in the study Participants were required to have been taking a stable pharmacological regimen for 2 weeks before screening that had to include a mood stabilizer (lithium >0.6 mEq/L or valproate >350 mM/L), an atypical antipsychotic, or a combination of a mood stabilizer and an atypical antipsychotic. For participants with BD type II, lamotrigine monotherapy was acceptable if the dose was greater than 100 mg daily Pass the TMS adult safety screening (TASS) questionnaire Exclusion Criteria: No current substance abuse disorder for the past 3 months (previous substance abuse not exclusionary) Any psychotic disorder or current active psychotic symptoms No dementia or other major neurological disorders No major medical illness, for example metastatic cancer, end stage renal disease Not able to verify contact information. Participants must be able to follow through with the study & must have verified contact information and at least one verified contact Pregnancy. While there are no known risks to a fetus this is a new use of TMS, which has not been tested, thus pregnancy is exclusionary Any history of any clinically significant neurological disorder, including organic brain disease, epilepsy, stroke, brain lesions, previous neurosurgery, or personal history of head trauma that resulted in loss of consciousness for > 5 minutes and retrograde amnesia for > 30 minutes Conductive, ferromagnetic or other magnetic sensitive metals that are implanted or are non-removable within 30 cm treatment coil (around the head) Score on Young Mania Rating Scale (YMRS) greater than 12 (patients with mixed features have been shown not to respond well to TMS treatment) Rapid cycling Bipolar illness (patients with > 4 mood episodes within the past year will be excluded, as they have a higher risk of switch to mania) Non response to ECT in current episode. Current severe insomnia (must sleep a minimum of 5 hours the night before stimulation) Are currently (or in the last 4 weeks) taking lorazepam greater than 2 mg daily (or equivalent) due to the potential to limit rTMS efficacy

Sites / Locations

  • Zagazig UniversityRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Active Comparator

Active Comparator

Arm Label

Left unilateral aTBS

Sequential bilateral aTBS

Arm Description

Participants who are randomly assigned to this group will receive iTBS (intermittent theta burst stimulation) to the left dorsolateral prefrontal cortex (LDLPFC) determined using Beam method for 1800 pulses with an intertreatment interval of fifty minutes. Stimulation was at 90% of resting motor threshold. Patients received ten sessions every day for five consecutive days for a total of fifty sessions (90,000 pulses).

Participants who are randomly assigned to this group will receive ten sessions daily for five consecutive days for a total of fifty sessions. During each session continuous theta burst stimulation (cTBS) in which (1800 pulses) are delivered continuously over 120 seconds to the right dorsolateral prefrontal cortex (RDLPFC) is administered first, followed by iTBS in which 1800 pulses are delivered in 2 second bursts, repeated every 10 seconds for 570 seconds (1800 pulses) to the left dorsolateral prefrontal cortex (LDLPFC) with using beam method for target localization. Stimulation was at 90% of resting motor threshold.

Outcomes

Primary Outcome Measures

Change in suicidal ideation and behaviors as measured by Columbia Suicide Severity Rating Scale (C-SSRS)
The SI severity scale is composed of five yes=no questions of increasingly severe suicidal thoughts: a wish to be dead (1), non-specific suicidal thoughts (2), suicidal thoughts with a method (3), suicidal intent without specific plan (4), and suicidal intent with specific plan (5). This scale was scored from 0 to 5 according to the most severe suicidal ideation endorsed. Higher scores mean worse outcome. Suicidal behaviors were assessed dichotomously (yes=no) and include actual suicide attempts, interrupted suicide attempts, aborted suicide attempts, other preparatory acts (e.g., collecting pills, writing suicide note), and non-suicidal self-injury (NSSI).

Secondary Outcome Measures

Change from baseline Montgomery-Åsberg Depression Rating Scale (MADRS) Score
The Montgomery-Åsberg Depression Rating Scale (MADRS), is a ten item diagnostic questionnaire used to measure the severity of depressive episodes in patients with mood disorders. Higher MADRS score indicates more severe depression, and each item yields a score of 0 to 6. The overall score ranges from 0 to 60. Remission is defined as MADRS ≤10. Response is defined as a reduction of >/=50% of MADRS baseline score.

Full Information

First Posted
June 24, 2023
Last Updated
July 8, 2023
Sponsor
Zagazig University
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1. Study Identification

Unique Protocol Identification Number
NCT05939115
Brief Title
Intensive Accelerated Theta Burst Stimulation in Treatment of Patients With Bipolar Depression and Suicidality
Official Title
Efficacy of Unilateral Versus Bilateral Accelerated Theta Burst Stimulation in Treatment of Patients With Bipolar Depression and Suicidality
Study Type
Interventional

2. Study Status

Record Verification Date
June 2023
Overall Recruitment Status
Recruiting
Study Start Date
June 1, 2023 (Actual)
Primary Completion Date
May 2025 (Anticipated)
Study Completion Date
June 2025 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Zagazig University

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Product Manufactured in and Exported from the U.S.
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
The objective of this study is to compare the efficacy of left unilateral versus bilateral accelerated Theta Burst Stimulation (TBS) in suicidal reduction and in reduction of severity of depressive symptoms in patients with bipolar depression.
Detailed Description
Introduction: Repetitive transcranial magnetic stimulation (rTMS) therapy is a noninvasive neurostimulation treatment that has been adopted as a first-line treatment for pharmacotherapy-resistant major depressive disorder (MDD) (Milev et al., 2016). rTMS induces electrical activity in the cortex using magnetic fields generated outside of the head. However, the evidence for antidepressant efficacy of rTMS in the treatment of bipolar depression is limited and derived primarily from small trials (Tavares et al., 2017, Dolberg et al., 2002, Nahas et al., 2003, Beyne et al., 2014, Tamas et al., 2007) and subsets of trials in major depression that included individuals with bipolar disorder (McGirr et al., 2016, Nguyen et al., 2021 ). The proposed study will examine sequential bilateral versus Unilateral accelerated theta burst stimulation (aTBS) in treatment of patients with bipolar depression and suicidality. Hypothesis: We assume that bilateral accelerated TBS is superior than left unilateral accelerated TBS in treatment of suicidality while bilateral accelerated TBS is as effective as left unilateral accelerated TBS in treatment of depressive symptoms in bipolar patients. Aim: This study aims to reduce morbidity and mortality of bipolar depressive patients and to improve overall functioning. Objectives: To compare efficacy of left unilateral versus bilateral accelerated TBS in suicidal reduction in patients with bipolar depression. To compare efficacy of left unilateral versus bilateral accelerated TBS in reduction of severity of depressive symptoms in bipolar disorder as well as response and remission rates. To investigate association between the reduction of suicidality and the reduction of depressive symptoms Subjects and methods Technical design: Site of the study: psychiatric department TMS Unit at Zagazig University Hospital Sample size: Assuming that Percent of improvment of depression scale in bipolar patients ( response rate) in unilateral TMS was 47% and bilateral TMS was 80% (Kazemi et al.,2016) so at power of study 80% and confidence interval 95%, the sample size was calculated to be 58 cases ( 29 in each group) ( Open Epi ) The samples will be allocated randomly into two groups (1:1) : First group: will be treated by left unilateral accelerated TBS Second group: will be treated by bilateral accelerated TBS Operational design Study design: Open label randomized clinical trial with two parallel treatment arms Methods: Patients will be allocated randomly into two groups (1:1). The randomization scheme was generated by using the Web site Randomization.com ⟨http://www.randomization.com⟩. Group 1 will receive (left unilateral aTBS); group 2 will receive ( bilateral aTBS) Device: MagPro R30 with the MCF-B70 figure-of-eight coil (MagVenture, Denmark) Details of treatment sessions: Group 1 (left unilateral aTBS): "Active comparator" They will receive accelerated iTBS. Stimulation with F-8 coil was administered to the left dorsolateral prefrontal cortex (DL-PFC) determined using Beam method. Stimulation was at 90% MT intermittent theta burst (iTBS) for 1800 pulses with an intertreatment interval of fifty minutes. Patients received ten sessions every day for five consecutive days for a total of fifty sessions (90,000 pulses). Group 2 ( bilateral aTBS) : "Active comparator" Bilateral accelerated theta burst stimulation (aTBS). Ten sessions are administered daily for five consecutive days for a total of fifty sessions .During each session continuous theta burst stimulation (cTBS) in which (1800 pulses) are delivered continuously over 120 seconds to the right dorsolateral prefrontal cortex (RDLPFC) is administered first, followed by iTBS in which 1800 pulses are delivered in 2 second bursts, repeated every 10 seconds for 570 seconds (1800 pulses) to the left dorsolateral prefrontal cortex (LDLPFC) with using beam method for target localization . The theta burst stimulation (TBS) parameters were adopted from prior work, with 3-pulse 50 Hz bursts given every 200 ms (at 5 Hz) with an intensity of 90% of resting motor threthold (RMT) Motor threshold: Using single pulse TMS, the scalp position of lowest motor threshold over primary motor cortex to produce visual contraction of the first dorsal (thumb) interosseous or abductor pollicis brevis muscle . Resting motor threshold (MT) was defined using the Adaptive Pest online algorithm. Participants : All the participants who will be enrolled in the study will be subjected to the following: A semi-structured interview will be employed to obtain socio-demographic and clinical data. Psychometric tools: The scales will be done at baseline and at the end of each day of five treatment days . Montgomery-Asberg depression rating scale (MADRS) The Beck Depression Inventory Columbia Suicide Severity Rating Scale (C-SSRS) Young Mania Rating Scale (YMRS) Administrative design Approval was obtained from the Institutional Review Board (IRB) and the Department of Psychiatry, Zagazig University, Egypt. A written consent will be signed by the study participants.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Bipolar Depression

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
58 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Left unilateral aTBS
Arm Type
Active Comparator
Arm Description
Participants who are randomly assigned to this group will receive iTBS (intermittent theta burst stimulation) to the left dorsolateral prefrontal cortex (LDLPFC) determined using Beam method for 1800 pulses with an intertreatment interval of fifty minutes. Stimulation was at 90% of resting motor threshold. Patients received ten sessions every day for five consecutive days for a total of fifty sessions (90,000 pulses).
Arm Title
Sequential bilateral aTBS
Arm Type
Active Comparator
Arm Description
Participants who are randomly assigned to this group will receive ten sessions daily for five consecutive days for a total of fifty sessions. During each session continuous theta burst stimulation (cTBS) in which (1800 pulses) are delivered continuously over 120 seconds to the right dorsolateral prefrontal cortex (RDLPFC) is administered first, followed by iTBS in which 1800 pulses are delivered in 2 second bursts, repeated every 10 seconds for 570 seconds (1800 pulses) to the left dorsolateral prefrontal cortex (LDLPFC) with using beam method for target localization. Stimulation was at 90% of resting motor threshold.
Intervention Type
Device
Intervention Name(s)
Transcranial Magnetic Stimulation MagPro R30 with the MCF-B70 figure-of-eight coil (MagVenture, Denmark)
Intervention Description
TMS Therapy System with Theta Burst Stimulation
Primary Outcome Measure Information:
Title
Change in suicidal ideation and behaviors as measured by Columbia Suicide Severity Rating Scale (C-SSRS)
Description
The SI severity scale is composed of five yes=no questions of increasingly severe suicidal thoughts: a wish to be dead (1), non-specific suicidal thoughts (2), suicidal thoughts with a method (3), suicidal intent without specific plan (4), and suicidal intent with specific plan (5). This scale was scored from 0 to 5 according to the most severe suicidal ideation endorsed. Higher scores mean worse outcome. Suicidal behaviors were assessed dichotomously (yes=no) and include actual suicide attempts, interrupted suicide attempts, aborted suicide attempts, other preparatory acts (e.g., collecting pills, writing suicide note), and non-suicidal self-injury (NSSI).
Time Frame
Assessed at baseline (day 0) , post-inpatient treatment completion (day 5) , 1 month ,3 month and 6 month.
Secondary Outcome Measure Information:
Title
Change from baseline Montgomery-Åsberg Depression Rating Scale (MADRS) Score
Description
The Montgomery-Åsberg Depression Rating Scale (MADRS), is a ten item diagnostic questionnaire used to measure the severity of depressive episodes in patients with mood disorders. Higher MADRS score indicates more severe depression, and each item yields a score of 0 to 6. The overall score ranges from 0 to 60. Remission is defined as MADRS ≤10. Response is defined as a reduction of >/=50% of MADRS baseline score.
Time Frame
Assessed at baseline (day 0) , post-inpatient treatment completion (day 5) , 1 month ,3 month and 6 month.

10. Eligibility

Sex
All
Minimum Age & Unit of Time
19 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Diagnosis of Major depressive episode as a part of bipolar (I or II) disorder and confirmed by Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) Meet the threshold on the total MADRS score of >/=35 at baseline visit (severe) Meet the threshold on the total BDI-II score of >/=30 at baseline visit (severe) Ongoing suicidal ideation and/or behavior (confirmed with Columbia Scale for the Rating of Suicide Severity (C-SSRS) , score >/=3 (moderate to high risk) Age 19 years or older (Adults, Older Adults) Right handedness Both genders Able to provide informed consent to participate in the study Participants were required to have been taking a stable pharmacological regimen for 2 weeks before screening that had to include a mood stabilizer (lithium >0.6 mEq/L or valproate >350 mM/L), an atypical antipsychotic, or a combination of a mood stabilizer and an atypical antipsychotic. For participants with BD type II, lamotrigine monotherapy was acceptable if the dose was greater than 100 mg daily Pass the TMS adult safety screening (TASS) questionnaire Exclusion Criteria: No current substance abuse disorder for the past 3 months (previous substance abuse not exclusionary) Any psychotic disorder or current active psychotic symptoms No dementia or other major neurological disorders No major medical illness, for example metastatic cancer, end stage renal disease Not able to verify contact information. Participants must be able to follow through with the study & must have verified contact information and at least one verified contact Pregnancy. While there are no known risks to a fetus this is a new use of TMS, which has not been tested, thus pregnancy is exclusionary Any history of any clinically significant neurological disorder, including organic brain disease, epilepsy, stroke, brain lesions, previous neurosurgery, or personal history of head trauma that resulted in loss of consciousness for > 5 minutes and retrograde amnesia for > 30 minutes Conductive, ferromagnetic or other magnetic sensitive metals that are implanted or are non-removable within 30 cm treatment coil (around the head) Score on Young Mania Rating Scale (YMRS) greater than 12 (patients with mixed features have been shown not to respond well to TMS treatment) Rapid cycling Bipolar illness (patients with > 4 mood episodes within the past year will be excluded, as they have a higher risk of switch to mania) Non response to ECT in current episode. Current severe insomnia (must sleep a minimum of 5 hours the night before stimulation) Are currently (or in the last 4 weeks) taking lorazepam greater than 2 mg daily (or equivalent) due to the potential to limit rTMS efficacy
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Medhat M Bassiony, Professor
Phone
+2001005334253
Email
mbassiony@hotmail.com
First Name & Middle Initial & Last Name or Official Title & Degree
Alaa E Zayed, Ass.Lecturer
Phone
+2001116277409
Email
alaaelsayedzayed@gmail.com
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Medhat M Bassiony, Professor
Organizational Affiliation
Zagazig University
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
Usama M Youssef, Professor
Organizational Affiliation
Zagazig University
Official's Role
Study Director
First Name & Middle Initial & Last Name & Degree
Ghada M Salah El-Deen, Professor
Organizational Affiliation
Zagazig University
Official's Role
Study Director
First Name & Middle Initial & Last Name & Degree
Hayam M El-Gohary, Professor
Organizational Affiliation
Zagazig University
Official's Role
Study Director
First Name & Middle Initial & Last Name & Degree
Alaa E Zayed, Ass.Lecturer
Organizational Affiliation
Zagazig University
Official's Role
Study Director
Facility Information:
Facility Name
Zagazig University
City
Zagazig
ZIP/Postal Code
7120730
Country
Egypt
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Medhat M Bassiony, Professor
Phone
+2001005334253
Email
mbassiony@hotmail.com
First Name & Middle Initial & Last Name & Degree
Alaa E Zayed, Ass.Lecturer
Phone
+2001116277409
Email
alaaelsayedzayed@gmail.com

12. IPD Sharing Statement

Plan to Share IPD
No

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Intensive Accelerated Theta Burst Stimulation in Treatment of Patients With Bipolar Depression and Suicidality

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