Confirmatory Efficacy and Safety Trial of Magnetic Seizure Therapy for Depression (CREST-MST): study protocol for a randomized non-inferiority trial of magnetic seizure therapy versus electroconvulsive therapy

Zafiris J Daskalakis, Carol Tamminga, Alanah Throop, Lucy Palmer, Julia Dimitrova, Faranak Farzan, Kevin E Thorpe, Shawn M McClintock, Daniel M Blumberger, Zafiris J Daskalakis, Carol Tamminga, Alanah Throop, Lucy Palmer, Julia Dimitrova, Faranak Farzan, Kevin E Thorpe, Shawn M McClintock, Daniel M Blumberger

Abstract

Background: Electroconvulsive therapy (ECT) is well-established and effective for treatment-resistant depression (TRD), but in Canada and the USA, less than 1% of patients with TRD receive ECT mainly due to its cognitive adverse effects (i.e. amnesia). Thus, new treatment alternatives for TRD are urgently needed. One such treatment is magnetic seizure therapy (MST). ECT involves applying a train of high-frequency electrical stimuli to induce a seizure, whereas MST involves applying a train of high-frequency magnetic stimuli to induce a seizure.

Methods: In this manuscript, we introduce our international, two-site, double-blinded, randomized, non-inferiority clinical trial to develop MST as an effective and safe treatment for TRD. This trial will compare the efficacy of MST to right unilateral ultra-brief pulse width electroconvulsive therapy (RUL-UB-ECT) with a combined primary endpoint of remission of depression and superior cognitive adverse effects in 260 patients with TRD. Amelioration of suicidal ideation will be assessed as a secondary endpoint. Inpatients or outpatients, over 18 years of age with a MINI International Neuropsychiatric Interview (MINI) diagnosis of non-psychotic major depressive disorder (MDD) can be enrolled in the study provided that they meet illness severity and full eligibility criteria. Participants are randomized to receive MST or RUL-UB ECT, 2-3 days per week over seven weeks, or a maximum of 21 treatments. The study will involve before-, during-, and after-treatment assessments of depression severity, suicidal ideation, subjective side-effects, and cognitive performance consistent with an intent-to-treat study design approach.

Discussion: Positive results from this trial could have an immediate and tremendous impact for patients with TRD. If MST demonstrates comparable antidepressant treatment efficacy to ECT, but with greater cognitive safety, it could rapidly be adopted into clinical practice. Indeed, given that the administration of MST is nearly identical to ECT, the majority of ECT facilities in North America could readily adopt MST. Furthermore, the potential for cognitive safety could lead to improved treatment acceptability. Healthcare providers, patients and care partners, and policymakers would therefore demand this form of convulsive therapy.

Trial status: Enrollment for this study began on June 26, 2018, and is estimated to complete recruitment by July 2024. At the time of submission, we have enrolled and randomized 117 participants.

Trial registration: ClinicalTrials.gov NCT03191058 , Registered on June 19, 2017. Primary sponsor: Daniel Blumberger (DMB), Principal Investigator Daniel.Blumberger@camh.ca , 416-535-8501 x 33662 Contact for public queries: DMB, Daniel.Blumberger@camh.ca Contact for scientific queries: ZJD, Zdaskalakis@health.ucsd.edu.

Keywords: Brain stimulation, Randomized controlled trial; Depression; Electroconvulsive therapy; Magnetic seizure therapy; Major depressive disorder; Treatment-resistant depression.

Conflict of interest statement

The study received in-kind equipment support from MagVenture A/S (Farum, Denmark) for this investigator-initiated research. In the last 5 years, ZJD has received research and equipment in-kind support for an investigator-initiated study through Brainsway Inc and Magventure Inc. His work is supported by the Canadian Institutes of Health Research (CIHR), the National Institutes of Mental Health (NIMH), Brain Canada and the Temerty Family and Grant Family and through the Centre for Addiction and Mental Health (CAMH) Foundation and the Campbell Institute. FF has no competing interests related to this trial. FF received funding from NARSAD (Grand ID: 22317). She has also received funding from Michael Smith Foundation for Health Research (Scholar Award), NSERC, and CIHR. SMH has received research support from NIH. He is a consultant to Pearson Assessment. He received a teaching honoraria from Duke University School of Medicine. DMB has received research support from CIHR, NIH, Brain Canada and the Temerty Family through the CAMH Foundation and the Campbell Family Research Institute. He received research support and in-kind equipment support for an investigator-initiated study from Brainsway Ltd and MagVenture Inc. He is the site principal investigator for three sponsor-initiated studies for Brainsway Ltd. He received medication supplies for an investigator-initiated trial from Indivior.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Study design
Fig. 2
Fig. 2
MagPro XP with Cool Twin Coil (MagVenture A/S, Farum, Denmark)

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