{"doi":"10.1016/j.brs.2020.08.001","title":"Do deviations from the 5 sessions per week schedule impact outcomes of transcranial magnetic stimulation for major depressive disorder?","abstract":"In regulatory trials of transcranial magnetic stimulation (TMS) for medication-resistant major depressive disorder (MDD) using both figure- 8 coils [[1]O’Reardon J.P. Solvason H.B. Janicak P.G. Sampson S. Isenberg K.E. Nahas Z. et al.Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial.Biol Psychiatr. 2007; 62: 1208-1216Abstract Full Text Full Text PDF PubMed Scopus (1014) Google Scholar,[2]George M.S. Lisanby S.H. Avery D. McDonald W.M. Durkalski V. Pavlicova M. et al.Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial.Arch Gen Psychiatr. 2010; 67: 507-516Crossref PubMed Scopus (606) Google Scholar] and H-coil devices [[3]Levkovitz Y. Harel E.V. Roth Y. Braw Y. Most D. Katz L.N. et al.Deep transcranial magnetic stimulation over the prefrontal cortex: evaluation of antidepressant and cognitive effects in depressive patients.Brain Stimul. 2009; 2: 188-200Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar], acute phase treatment was administered on a once-daily schedule of five sessions/week for the first four-six weeks. This schedule has been adopted in TMS clinical practices for the past decade. Circumstances preventing strict adherence to this standard schedule (i.e. holidays, travel plans, illnesses/injuries) occasionally arise. A randomized clinical trial demonstrated that a TMS schedule of three sessions/week was not inferior to the standard five/week regimen on final treatment outcomes, though the group assigned to daily sessions achieved symptom reduction in a shorter period of time [[4]Galletly C. Gill S. Clarke P. Burton C. Fitzgerald P.B. A randomized trial comparing repetitive transcranial magnetic stimulation given 3 days/week and 5 days/week for the treatment of major depression: is efficacy related to the duration of treatment or the number of treatments?.Psychol Med. 2012; 42: 981-988Crossref PubMed Scopus (35) Google Scholar]. In that study, however, participants who dropped out due to lack of efficacy were not included in the outcome analyses, and presumably all who were analyzed adhered to their assigned treatment schedule (3 or 5 per week). A very practical question remains for depressed patients and their TMS clinicians: is missing scheduled sessions during the acute phase associated with inferior outcomes? If so, does it matter if lapses in consecutive treatments occur earlier or later in the course? To address this question, we retrospectively reviewed deidentified data from 316 naturalistically-treated MDD patients undergoing an initial acute course of TMS therapy between 2010 and 2019 at Butler Hospital’s TMS clinic, initiated with the standard “on-label” 10 Hz protocol (3000 daily pulses at a 120% intensity relative to individual motor threshold) delivered to the left dorsolateral prefrontal cortex. Treatment dates for all sessions (excluding final taper-phase, which includes intentional gap days), were ascertained using the NeuroStar software system. Maximum treatment gap (MaxGap) was calculated for each patient as the greatest number of successive days elapsed between any two consecutive sessions in their acute phase. Cases (n = 13) with MaxGap>14, a period comprising more than one-third of the standard acute phase, were excluded from the analyses. For each participant, we examined treatment schedule density (TSD) ratio, calculated as (total number of TMS sessions)/(total number of days required to deliver those sessions), with a higher value corresponding to more consecutive treatment days. TSD was calculated for blocks representing the first 5 (TSD5), 10 (TSD10), 15 (TSD15), 20 (TSD20), and 30 (TSD30) sessions. A patient starting their course on a Monday and completing the first 5 sessions without a break would have TSD5 = 5 sessions/5 days = 1.0. Since the clinic is closed on weekends, a patient starting the first sess","journal":"Brain stimulation","year":2020,"id":108674,"datarank":0.24141568686511508,"base_score":1.6094379124341003,"endowment":1.6094379124341003,"self_citation_contribution":0.24141568686511508,"citation_network_contribution":0.0,"self_endowment_contribution":0.24141568686511508,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":4,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9596,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2020-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":521262,"name":"Eric Tirrell","orcid":null,"position":1,"is_corresponding":false},{"id":520427,"name":"Andrew M. Fukuda","orcid":"0000-0002-7927-6602","position":2,"is_corresponding":false},{"id":521263,"name":"Asi Polly Gobin","orcid":null,"position":3,"is_corresponding":false},{"id":350653,"name":"Brian C. Kavanaugh","orcid":"0000-0002-4785-4439","position":4,"is_corresponding":false},{"id":520428,"name":"Lawrence H. Price","orcid":"0000-0002-2074-4520","position":5,"is_corresponding":false},{"id":106038,"name":"Linda L. Carpenter","orcid":"0000-0002-9651-3307","position":6,"is_corresponding":false},{"id":520426,"name":"Fatih Kokdere","orcid":"0000-0003-3232-3253","position":0,"is_corresponding":true}],"reference_count":4,"raw_metadata":{"citation_network_status":"fetched"},"created_at":"2026-07-18T23:12:46.854423Z","pmid":"32768691","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}