Selecting and consenting rTMS, VNS or DBS for TRD (MEQ)

(i) Ladder and first device. He meets pragmatic TRD (multiple adequate failed trials including lithium augmentation), is non-psychotic and ambulatory — suitable for outpatient rTMS/iTBS as the first device-class consideration. VNS is a chronic multi-failure implant with delayed benefit, not first magnet-equivalent. DBS is specialist/research intracranial care after exhaustive prior options, not routine after three lines. No guarantee of cure for any modality.[7][8]

(ii) Protocol and safety. Classic left DLPFC 10 Hz scaffold: about 120% resting motor threshold, about 3000 pulses/session, daily (weekdays) for about 4–6 weeks (O'Reardon lineage). Alternative: iTBS ~600 pulses ~3 minutes — non-inferior to 10 Hz (THREE-D). Pre-treatment: confirm diagnosis/failed trials, seizure history, ferromagnetic metal/cochlear implant screen, pregnancy if relevant, meds affecting seizure threshold, determine MT, hearing protection, outcome scale (MADRS/PHQ-9), concurrent AD plan, crisis plan.[1][2][8]

(iii) VNS evidence honesty. Acute sham-controlled RCT primary HRSD response not significant (~15% active vs ~10% sham). Longer naturalistic and five-year observational comparative data (Aaronson vs TAU) more favourable on response/remission/suicidality measures — counsel months-scale benefit, surgical/voice risks, ongoing psychiatric care.[3][4]

(iv) DBS evidence honesty. Mayberg open-label SCC work generated hope, but Holtzheimer SCC sham RCT and Dougherty VC/VS sham RCT failed primary efficacy endpoints. Consent must include surgical risks and this RCT reality; offer only via specialist centres.[5][6]

(v) When ECT still first. Psychotic depression, catatonia, food–fluid refusal, high-intent acute suicidality needing rapid reliable response, prior excellent ECT response with patient preference after informed discussion, or rTMS contraindicated/unavailable when severity is high — ECT remains the high-acuity somatic standard; devices do not abolish its role.[7]