Synchronization of accelerated intermittent Theta-Burst-Stimulation (aiTBS) with VNS in difficult-to-treat depression (DTD)

Introduction Patients with difficult-to-treat depression (DTD) need multimodal treatment with combination of psychotherapy, pharmacotherapy and neuromodulation. In severe cases, combination of neuromodulatory techniques may be considered to achieve symptom relief. Objectives To describe a novel treatment approach, which combines VNS in synchronization with accelerated intermittent Theta-Burst-Stimulation (aiTBS) over three weeks in two cases with difficult-to-treat depression. Methods In this presentation we describe two cases of DTD, which have been implanted with VNS and did not respond to aiTBS previously. Patients then were offered a synchronized treatment regimen, where each stimulus train of aiTBS was synchronized with ON-time of VNS. To start each train simultaneously with VNS ON-time, we set treatment cycle of each aiTBS and VNS to 19 sec. Patients received 2400-3000 TBS pulses daily for 3 weeks over left dorsolateral prefrontal cortex (DLPFC) at 100% of resting motor threshold. Results In the first patient the MADRS score decreased from 37 to 26 (-30%) and in the other patient there was a decrease of MADRS score from 20 to 9 (-55%), which corresponded to remission after 3 weeks of treatment. The synchronized treatment procedure was well-tolerated in both cases. As both patients experienced significant improvement, we planned maintenance treatment in both cases. Conclusions Synchronization of aiTBS with VNS is a novel treatment approach in patients with DTD, which can lead to improvement even if patients previously did not respond to aiTBS without synchronization with VNS. Disclosure of Interest None Declared