One-Day cTBS Over the Precuneus (OcTOPUS)
One-Day cTBS Over the Precuneus (OcTOPUS)
The goal of this clinical trial is to learn whether two forms of one-day accelerated transcranial magnetic stimulation (TMS) can reduce depressive symptoms in adults with treatment-resistant depression. Treatment-resistant depression is depression that has not improved enough after at least two adequate antidepressant medication treatments. TMS is a non-invasive treatment that uses magnetic pulses to stimulate specific areas of the brain.
The main questions this study aims to answer are:
- Does continuous theta-burst stimulation (cTBS) targeting the precuneus reduce depressive symptoms 4 weeks after treatment compared with sham stimulation?
- Does intermittent theta-burst stimulation (iTBS) targeting the left dorsolateral prefrontal cortex reduce depressive symptoms 4 weeks after treatment compared with sham stimulation?
Researchers will compare precuneus cTBS, left dorsolateral prefrontal cortex iTBS, and sham stimulation to determine whether either active treatment reduces depressive symptoms more than sham stimulation. Participants will be randomly assigned to one of the three groups and will not be told which treatment they initially receive.
Participants will:
- Complete screening procedures and baseline assessments of depression, rumination, and cognitive function
- Receive 20 sessions of active or sham TMS during one in-person study day
- Complete follow-up assessments 1, 2, 3, and 4 weeks after the intervention
- Report any side effects or medical problems experienced during the study
Participants initially assigned to sham stimulation may choose to receive active TMS after completing the 4-week follow-up period. Those who choose this option will receive either precuneus cTBS or left dorsolateral prefrontal cortex iTBS and will complete additional follow-up assessments.
Study Overview
Status
Conditions
Detailed Description
Treatment-resistant depression may involve dysfunction across distributed brain networks rather than a disturbance confined to a single brain region. The precuneus is a posterior hub of the default mode network and is involved in internally directed and self-referential processing. Altered interactions among the default mode, affective, and cognitive control networks have been implicated in depressive symptoms and rumination. In this study, precuneus continuous theta-burst stimulation (cTBS) is conceptualized as a hypothesis-driven network intervention that may modulate precuneus-centered network interactions implicated in depression.
A double-cone coil will be used to increase electric-field penetration toward the medial posteromedial cortex beneath the Pz scalp location of the international 10-20 electroencephalography system. Intermittent theta-burst stimulation (iTBS) of the left dorsolateral prefrontal cortex is included as an additional active treatment arm because this region is an established stimulation target for depression treatment. The three-arm design allows the novel precuneus target and the established left dorsolateral prefrontal cortex target to be evaluated within the same accelerated treatment framework and compared with sham stimulation.
Participants will be assigned to the three initial study groups using the minimal sufficient balance (MSB) randomization method, with sex and baseline depression severity, as measured by the Montgomery-Åsberg Depression Rating Scale, used as balancing factors. The target allocation ratio for the randomized, sham-controlled phase will be 1:1:1. Group allocation will be concealed from participants. Each active or sham intervention will consist of 20 stimulation sessions administered during a single day, with session onsets separated by approximately 30 minutes.
The primary efficacy analyses will use a longitudinal mixed-model framework to estimate treatment effects and evaluate the two prespecified active-versus-sham comparisons. The familywise type I error rate will be controlled across these two comparisons. The direct comparison between precuneus cTBS and left dorsolateral prefrontal cortex iTBS will be considered exploratory.
After completing the 4-week follow-up period, participants initially assigned to sham stimulation may elect to enter an open-label active TMS extension. Extension participants will be assigned to precuneus cTBS or left dorsolateral prefrontal cortex iTBS using the MSB method, with a target allocation ratio of 1:1. Sex and depression severity at the end of the sham-controlled phase, as measured by the Week 4 Montgomery-Åsberg Depression Rating Scale score, will be used as balancing factors. Because only a subset of participants assigned to sham stimulation is expected to enter the extension, extension analyses will be considered exploratory and hypothesis-generating.
Study Type
Enrollment (Estimated)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Hakjoo Kim Kim, Ph.D.
- Phone Number: 979-777-0679
- Email: khj213@gmail.com
Study Locations
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Massachusetts
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Belmont, Massachusetts, United States, 02478
- Recruiting
- Mclean Hospital
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Contact:
- Hakjoo Kim, PhD
- Phone Number: 617-855-4203
- Email: hkim128@mclean.harvard.edu
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Principal Investigator:
- Hakjoo Kim, PhD
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Adult
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Age 18 years or older.
- Able to speak, read, and understand English sufficiently to complete the study assessments and provide informed consent independently.
- Diagnosis of major depressive disorder according to DSM-5-TR criteria, confirmed by a qualified physician.
- Treatment-resistant depression, defined as an inadequate response to at least two adequate trials of antidepressant pharmacotherapy.
- Patient Health Questionnaire-9 (PHQ-9) total score of 10 or higher.
Exclusion Criteria:
- Any condition identified through TMS safety screening that, in the judgment of a study physician, presents an unacceptable safety risk for TMS. Such conditions may include:
- A history of a serious adverse reaction during TMS treatment.
- A history of seizure.
- A history of stroke.
- A history of serious head injury or neurosurgery.
- Metal in the head outside the mouth, such as shrapnel, surgical clips, or metal fragments.
- An implanted device, such as a cardiac pacemaker, cochlear implant, medical pump, or intracardiac line.
- Frequent or severe headaches.
- Another brain-related condition or an illness that caused brain injury.
- A family history of epilepsy.
- Permanent tattoos on the head or neck.
- Current recreational drug use.
- Current pregnancy or possible pregnancy.
- Use of a medication or combination of medications, a recent medication change, or medication withdrawal that, in the judgment of a study physician, presents an unacceptable safety risk, including a clinically significant increase in seizure risk.
- Current or lifetime diagnosis of bipolar I disorder, bipolar II disorder, a schizophrenia spectrum disorder, or another primary psychotic disorder.
- Active suicidal ideation with intent or plan requiring immediate clinical intervention, or another acute safety concern that cannot be safely managed within the study.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
|
Experimental: Precuneus cTBS
Participants receive 20 sessions of active continuous theta-burst stimulation (cTBS) targeting the Pz location of the international 10-20 EEG system during a single day.
Stimulation is delivered using a double-cone coil at 80% of the participant's resting motor threshold.
Each session consists of 600 pulses delivered over approximately 40 seconds, for a total of 12,000 pulses.
Session onsets are separated by approximately 30 minutes.
If stimulation at 80% of resting motor threshold is not tolerated, the intensity may be reduced to the highest tolerable level.
|
Active continuous theta-burst stimulation is delivered to the Pz location of the international 10-20 EEG system to target the precuneus.
Stimulation is administered with a double-cone coil at 80% of the participant's resting motor threshold.
Each session consists of 600 pulses delivered over approximately 40 seconds.
Participants receive 20 sessions during a single day, for a total of 12,000 pulses, with session onsets separated by approximately 30 minutes.
If 80% of resting motor threshold is not tolerated, the intensity may be reduced to the highest tolerable level.
Other Names:
|
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Experimental: Left dlPFC iTBS
Participants receive 20 sessions of active intermittent theta-burst stimulation (iTBS) targeting the left dorsolateral prefrontal cortex during a single day.
The target is identified using the Beam F3 method, and stimulation is delivered using a figure-of-eight coil at 80% of the participant's resting motor threshold.
Each session consists of 600 pulses delivered over approximately 3 minutes, for a total of 12,000 pulses.
Session onsets are separated by approximately 30 minutes.
If stimulation at 80% of resting motor threshold is not tolerated, the intensity may be reduced to the highest tolerable level.
|
Active intermittent theta-burst stimulation is delivered to the left dorsolateral prefrontal cortex.
The stimulation target is identified using the Beam F3 method.
Stimulation is administered with a figure-of-eight coil at 80% of the participant's resting motor threshold.
Each session consists of 600 pulses delivered over approximately 3 minutes.
Participants receive 20 sessions during a single day, for a total of 12,000 pulses, with session onsets separated by approximately 30 minutes.
If 80% of resting motor threshold is not tolerated, the intensity may be reduced to the highest tolerable level.
Other Names:
|
|
Sham Comparator: Sham TMS
Participants receive 20 sessions of sham TMS at the left dorsolateral prefrontal cortex location identified using the Beam F3 method during a single day.
A figure-of-eight coil is inverted so that the active surface faces away from the scalp.
The device is operated at 80% of the participant's resting motor threshold, and sham stimulation follows the same stimulation pattern and approximate 3-minute duration as active iTBS.
Session onsets are separated by approximately 30 minutes.
After completing the Week 4 assessment, participants may enter an optional open-label extension and are randomized to receive active precuneus cTBS or left dlPFC iTBS.
|
Sham transcranial magnetic stimulation is administered at the left dorsolateral prefrontal cortex location identified using the Beam F3 method.
A figure-of-eight coil is inverted so that the active surface faces away from the scalp.
The stimulator is operated at 80% of the participant's resting motor threshold using the same intermittent theta-burst timing and approximate session duration as the active left dorsolateral prefrontal cortex intervention.
Participants receive 20 sham sessions during a single day, with session onsets separated by approximately 30 minutes.
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Montgomery-Åsberg Depression Rating Scale (MADRS) Total Score at Week 4
Time Frame: Baseline and 1, 2, 3, and 4 weeks after the intervention
|
The MADRS is a clinician-administered 10-item scale used to assess the severity of depressive symptoms.
Each item is scored from 0 to 6, yielding a total score ranging from 0 to 60. Higher scores indicate greater depressive symptom severity.
MADRS total scores will be assessed at baseline and at Weeks 1, 2, 3, and 4 after the intervention.
Post-intervention scores will be compared between treatment groups with adjustment for baseline MADRS total score.
The primary treatment comparison will be conducted at Week 4.
|
Baseline and 1, 2, 3, and 4 weeks after the intervention
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
17-Item Hamilton Depression Rating Scale (HAM-D-17) Total Score Through Week 4
Time Frame: Baseline and 1, 2, 3, and 4 weeks after the intervention
|
The HAM-D-17 is a clinician-administered 17-item scale used to assess the severity of depressive symptoms.
The total score ranges from 0 to 52, with higher scores indicating greater depressive symptom severity.
HAM-D-17 total scores will be assessed at baseline and at Weeks 1, 2, 3, and 4 after the intervention.
Post-intervention scores will be compared between treatment groups with adjustment for baseline HAM-D-17 total score.
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Baseline and 1, 2, 3, and 4 weeks after the intervention
|
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Patient Health Questionnaire-9 (PHQ-9) Total Score Through Week 4
Time Frame: Baseline and 1, 2, 3, and 4 weeks after the intervention
|
The PHQ-9 is a 9-item self-report measure used to assess depressive symptom severity.
Each item is scored from 0 to 3, yielding a total score ranging from 0 to 27.
Higher scores indicate greater depressive symptom severity.
PHQ-9 total scores will be assessed at baseline and at Weeks 1, 2, 3, and 4 after the intervention.
Post-intervention scores will be compared between treatment groups with adjustment for baseline PHQ-9 total score.
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Baseline and 1, 2, 3, and 4 weeks after the intervention
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Ruminative Responses Scale (RRS) Total Score Through Week 4
Time Frame: Baseline and 1, 2, 3, and 4 weeks after the intervention
|
The RRS is a 22-item self-report measure used to assess the tendency to engage in ruminative responses.
Each item is scored from 1 to 4, yielding a total score ranging from 22 to 88.
Higher scores indicate greater levels of rumination.
RRS total scores will be assessed at baseline and at Weeks 1, 2, 3, and 4 after the intervention.
Post-intervention scores will be compared between treatment groups with adjustment for baseline RRS total score.
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Baseline and 1, 2, 3, and 4 weeks after the intervention
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Montreal Cognitive Assessment (MoCA) Total Score at Week 4
Time Frame: Baseline and 4 weeks after the intervention
|
The MoCA is a clinician-administered cognitive screening measure that assesses multiple cognitive domains.
The total score ranges from 0 to 30, with higher scores indicating better cognitive performance.
MoCA total scores will be assessed at baseline and at Week 4 after the intervention.
The Week 4 score will be compared between treatment groups with adjustment for baseline MoCA total score.
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Baseline and 4 weeks after the intervention
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MGH/McLean Objective Neurocognitive Assessment (MONA) Total Score at Week 4
Time Frame: Baseline and 4 weeks after the intervention
|
The MONA is an objective neurocognitive assessment that evaluates multiple cognitive domains.
The total score ranges from 0 to 30, with higher scores indicating better cognitive performance.
MONA total scores will be assessed at baseline and at Week 4 after the intervention.
The Week 4 score will be compared between treatment groups with adjustment for baseline MONA total score.
|
Baseline and 4 weeks after the intervention
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Collaborators and Investigators
Sponsor
Publications and helpful links
General Publications
- Cole EJ, Phillips AL, Bentzley BS, Stimpson KH, Nejad R, Barmak F, Veerapal C, Khan N, Cherian K, Felber E, Brown R, Choi E, King S, Pankow H, Bishop JH, Azeez A, Coetzee J, Rapier R, Odenwald N, Carreon D, Hawkins J, Chang M, Keller J, Raj K, DeBattista C, Jo B, Espil FM, Schatzberg AF, Sudheimer KD, Williams NR. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial. Am J Psychiatry. 2022 Feb;179(2):132-141. doi: 10.1176/appi.ajp.2021.20101429. Epub 2021 Oct 29.
- Sendi M, Halko M, Traynor J, Brown J, Copersino M, Nickerson L, Harnett N, van Rooij S, Pizzagalli D, House S, Beaudoin F, An X, Neylan T, Clifford G, Jovanovic T, Linnstaedt S, Germine L, Bollen K, Rauch S, Haran J, Storrow A, Lewandowski C, Musey P Jr, Hendry P, Sheikh S, Jones C, Punches B, Swor R, Gentile N, Hudak L, Pascual J, Seamon M, Harris E, Pearson C, Peak D, Domeier R, Rathlev N, O'Neil B, Sergot P, Sanchez L, Bruce S, Sheridan J, Harte S, Kessler R, Koenen K, Phelps E, Salat D, Mayberg H, McLean S, Stevens J, Calhoun V, Ressler K, Dillon D. Comprehensive mapping of cognitive and emotion networks in stress, anxiety, and depression implicates the precuneus as a critical hub. Res Sq [Preprint]. 2025 Aug 26:rs.3.rs-7200801. doi: 10.21203/rs.3.rs-7200801/v1.
- Kim H, Halko M, Copersino ML, Traynor J, Dillon D, Sendi M, Razafsha M, Uflacker A, Bharathan AV, Coyle M, Ganesh P, Nolan J, Parlikar RU, Pettibone T, Gunadeva N, Hur KH, Downar J, McGirr A, Ressler K, Brown J. 6 - Depression and Anxiety Symptom Change Following One-Day Ultra-Accelerated TMS Targeting dlPFC or Network-Guided Precuneus: Preliminary Findings. Transcranial Magnetic Stimulation. 2026;7(Suppl 1):100228. doi:10.1016/j.transm.2026.100228
- Vaughn DA, Marino B, Engelbertson A, Dojnov A, Johnson L, Stine M, Vila-Rodriguez F, Weiss N, Nanos G, Downar J. Real-world effectiveness of a single-day regimen for transcranial magnetic stimulation using Optimized, Neuroplasticity-Enhanced techniques in Depression (ONE-D): An open-label case series. Transcranial Magnetic Stimulation. 2025;5:100200. doi:10.1016/j.transm.2025.100200
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
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More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- 2026P001989
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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