rTMS, VNS and DBS — consultant viva · Psych Vivas

Prompt

Examiner places cards: 10 Hz / 120% MT / 3000 pulses, THREE-D, SAINT/SNT, Rush VNS acute, Aaronson 5-year, Mayberg open-label, Holtzheimer SCC, Dougherty VC/VS, malignant catatonia, ferromagnetic implant.

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect named trials, parameter scaffolds, and negative-result literacy without inventing local item numbers as universal law.[1][3]

Core questions and model points

What is rTMS? Non-invasive magnetic induction of cortical current; antidepressant protocols commonly target left DLPFC; no seizure required (contrast ECT).[1][2]
Classic acute parameters? ~10 Hz, ~120% resting MT, ~3000 pulses/session, daily ~4–6 weeks (O'Reardon/George lineage).[1][2]
What is THREE-D? iTBS non-inferior to 10 Hz rTMS for depression with much shorter sessions.[3]
Accelerated iTBS? SAINT open-label and SNT sham RCT support intensive multi-session/day connectivity-guided approaches — specialist, not default community mild-depression care.[4]
VNS evidence? Acute sham primary HRSD response non-significant; longer-term observational comparative data (Aaronson) more encouraging; delayed benefit; voice/surgical AEs.[5][6]
DBS evidence? Mayberg open-label SCC hope; Holtzheimer SCC and Dougherty VC/VS sham RCTs failed primary endpoints — specialist/research only with honest consent.[7][8]
Safety? Metal/seizure screen, MT determination, hearing protection; manage peri-rTMS seizure by aborting session and ABC support (Rossi framework).[9]
Catatonia card? Do not substitute elective rTMS for urgent ECT pathways in malignant catatonia — severity and urgency still point to ECT-class care when life-threatening syndromes are present.[1][3]

Pass criteria

Correct rTMS/iTBS parameter and THREE-D one-liners.[1][3]
Honest VNS acute vs long-term reading.[5][6]
Honest DBS negative pivotal RCTs.[7][8]
Safety screen + MT + seizure response.[9]
Does not dethrone ECT for high-acuity syndromes.[1][3]

References

[1]O'Reardon JP, Solvason HB, Janicak PG, et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial Biol Psychiatry, 2007.PMID 17573044
[2]George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial Arch Gen Psychiatry, 2010.PMID 20439832
[3]Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial Lancet, 2018.PMID 29726344
[4]Cole EJ, Phillips AL, Bentzley BS, et al. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial Am J Psychiatry, 2022.PMID 34711062
[5]Rush AJ, Marangell LB, Sackeim HA, et al. Vagus nerve stimulation for treatment-resistant depression: a randomized, controlled acute phase trial Biol Psychiatry, 2005.PMID 16139580
[6]Aaronson ST, Sears P, Ruvuna F, et al. A 5-Year Observational Study of Patients With Treatment-Resistant Depression Treated With Vagus Nerve Stimulation or Treatment as Usual: Comparison of Response, Remission, and Suicidality Am J Psychiatry, 2017.PMID 28359201
[7]Holtzheimer PE, Husain MM, Lisanby SH, et al. Subcallosal cingulate deep brain stimulation for treatment-resistant depression: a multisite, randomised, sham-controlled trial Lancet Psychiatry, 2017.PMID 28988904
[8]Dougherty DD, Rezai AR, Carpenter LL, et al. A Randomized Sham-Controlled Trial of Deep Brain Stimulation of the Ventral Capsule/Ventral Striatum for Chronic Treatment-Resistant Depression Biol Psychiatry, 2015.PMID 25726497
[9]Rossi S, Hallett M, Rossini PM, Pascual-Leone A; Safety of TMS Consensus Group Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research Clin Neurophysiol, 2009.PMID 19833552

Core questions and model points

What is rTMS? Non-invasive magnetic induction of cortical current; antidepressant protocols commonly target left DLPFC; no seizure required (contrast ECT).[1][2]

Classic acute parameters? ~10 Hz, ~120% resting MT, ~3000 pulses/session, daily ~4–6 weeks (O'Reardon/George lineage).[1][2]

What is THREE-D? iTBS non-inferior to 10 Hz rTMS for depression with much shorter sessions.[3]

Accelerated iTBS? SAINT open-label and SNT sham RCT support intensive multi-session/day connectivity-guided approaches — specialist, not default community mild-depression care.[4]

VNS evidence? Acute sham primary HRSD response non-significant; longer-term observational comparative data (Aaronson) more encouraging; delayed benefit; voice/surgical AEs.[5][6]

DBS evidence? Mayberg open-label SCC hope; Holtzheimer SCC and Dougherty VC/VS sham RCTs failed primary endpoints — specialist/research only with honest consent.[7][8]

Safety? Metal/seizure screen, MT determination, hearing protection; manage peri-rTMS seizure by aborting session and ABC support (Rossi framework).[9]

Catatonia card? Do not substitute elective rTMS for urgent ECT pathways in malignant catatonia — severity and urgency still point to ECT-class care when life-threatening syndromes are present.[1][3]

Pass criteria

Correct rTMS/iTBS parameter and THREE-D one-liners.[1][3]

Honest VNS acute vs long-term reading.[5][6]

Honest DBS negative pivotal RCTs.[7][8]

Safety screen + MT + seizure response.[9]

Does not dethrone ECT for high-acuity syndromes.[1][3]

References

[1]O'Reardon JP, Solvason HB, Janicak PG, et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial Biol Psychiatry, 2007.PMID 17573044
[2]George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial Arch Gen Psychiatry, 2010.PMID 20439832
[3]Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial Lancet, 2018.PMID 29726344
[4]Cole EJ, Phillips AL, Bentzley BS, et al. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial Am J Psychiatry, 2022.PMID 34711062
[5]Rush AJ, Marangell LB, Sackeim HA, et al. Vagus nerve stimulation for treatment-resistant depression: a randomized, controlled acute phase trial Biol Psychiatry, 2005.PMID 16139580
[6]Aaronson ST, Sears P, Ruvuna F, et al. A 5-Year Observational Study of Patients With Treatment-Resistant Depression Treated With Vagus Nerve Stimulation or Treatment as Usual: Comparison of Response, Remission, and Suicidality Am J Psychiatry, 2017.PMID 28359201
[7]Holtzheimer PE, Husain MM, Lisanby SH, et al. Subcallosal cingulate deep brain stimulation for treatment-resistant depression: a multisite, randomised, sham-controlled trial Lancet Psychiatry, 2017.PMID 28988904
[8]Dougherty DD, Rezai AR, Carpenter LL, et al. A Randomized Sham-Controlled Trial of Deep Brain Stimulation of the Ventral Capsule/Ventral Striatum for Chronic Treatment-Resistant Depression Biol Psychiatry, 2015.PMID 25726497
[9]Rossi S, Hallett M, Rossini PM, Pascual-Leone A; Safety of TMS Consensus Group Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research Clin Neurophysiol, 2009.PMID 19833552