الفهرس 
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Abstract
The World Health Organization (WHO) recently reported that depression is a major cause of disability worldwide, with more than 320 million people affected globally.
About a third of patients with major depressive disorder do not respond to pharmacotherapy or psychotherapy In several studies, treatment-refractory depressive (TRD) patients had poor medical outcomes, resulting in a high socioeconomic burden.
For patients with treatment-resistant depression, non-invasive brain stimulation via techniques such as repetitive transcranial magnetic stimulation (rTMS) is an emerging option.
The form of rTMS with the most supporting evidence is a high-frequency (10 Hz) protocol, in which rTMS is delivered to the left dorsolateral prefrontal cortex over 37.5 min.
The FDA approval specifically cited the use of high frequency rTMS in patients who had failed to achieve satisfactory improvement from one prior adequate antidepressant medication in the current episode.
One form of TBS, intermittent TBS (iTBS), delivers 600 pulses in just 3 min, yet shows similar or more potent excitatory effects than conventional 10 Hz stimulation Several pilot trials nd two meta-analyses indicate that iTBS is superior to sham treatment for treatment resistant depression.
Previous studies addressed non-inferiority of iTBS treatment compared with the current standard 10 Hz rTMS for treatment-resistant depression, but several limitations exist in the previous studies as the absence of placebo or absence of standard practice comparative conditions (Blumberger et al., 2018).
To our knowledge, this is the first randomized double-blinded controlled trial comparing the effectiveness of conventional 10 Hz repetitive transcranial magnetic stimulation (rTMS) and intermittent Theta burst stimulation (iTBS) with sham in the same setting in patients with major depressive disorder who had failed to achieve satisfactory response from one prior adequate antidepressant treatment trial in the current episode.
In conclusion, we have found that both conventional 10 HZ rTMS and iTBS are effective, efficacious and tolerable for management of treatment resistant major depressive disorder.
In this RCT of active 10Hz rTMS, iTBS versus sham TMS, active TMS resulted in a significant decrease in HDRS-17 scores compared to sham TMS.
Improvement were shown in continuous and categorical outcomes in both active groups (10Hz rTMS and iTBS) in comparison to sham (ie, change in depression, anxiety and quality of life scores and response and remission incidence).
The improvement in anxiety and quality of life was measured by HAM-A and QOLs.
Response rates of depression were significantly different for 10Hz rTMS (73.3%) and iTBS (66.7%) versus the sham coil (13.3%). Remission rates for the 10Hz rTMS were 20%, iTBS were 40 % and for the sham coil were 6.7 % and this was a significant difference between iTBS and sham but the 10Hz rTMS comparison with sham has failed to show a statistically significant difference.
This may be attributed to the small sample size in which continuous measures were significant but categorical ones were not in some comparison between the active and sham methods.
The treatment by either active techniques was relatively well tolerated, with no difference in adverse effect profile between the sham and the active TMS treatment arms.
Of course, these findings indicate that the 3 min iTBS protocol might serve comparably to the standard 37•5 min 10 Hz rTMS protocol as an intervention for treatment resistant depression.
We found that iTBS has effectiveness and a similar adverse event profile and acceptability compared with the standard, FDA-approved 10 Hz rTMS protocol for treatment-resistant depression.
A typical iTBS treatment session (including setup) takes about 5–10 min, compared with about 45 min for standard 10 Hz rTMS. Therefore, the number of patients treated per machine, per day can be tripled or quadrupled by use of iTBS. The effectiveness of 3 min sessions reported here could also facilitate efforts to accelerate rTMS courses from weeks to days via several daily sessions.
More broadly, the potential for increased capacity, improved access, reduced waiting times, and potentially reduced costs per remission should have a positive effect, aiding health insurers and governments in implementing wider coverage of rTMS as an increasingly practical intervention for patients with medication-resistant depression (Baeken et al., 2013; Duprat et al., 2016).
In conclusion, the current study showed that repetitive transcranial magnetic stimulation (rTMS) by either 10 HZ method or iTBS improved depression, anxiety and quality of life in patients with MDD.
For the existing study, we suggest that an extension phase of the study continued to follow up the participants for long-term effect of rTMS in order to assess the long-lasting effects and the need for maintenance treatment sessions to prevent relapse.
Importantly, future studies should seek to examine the underlying neurobiological mechanisms of high-frequency rTMS and iTBS as potential predictors of response.
The addition of a functional neuroimaging component to clinical treatment trials may help to clarify the differential therapeutic effects of these two forms of stimulation.