Accelerated vs. Conventional Theta Burst Stimulation for Late-life Depression

Inclusion Criteria: 1. are voluntary and competent to consent to treatment 2. are an outpatient 3. are ≥ 60 years old 4. have a Mini International Neuropsychiatric Interview (MINI 7.0) confirmed diagnosis of MDD, with a current MDE 5. have failed to achieve a clinical response to an adequate dose of an antidepressant based on an Antidepressant Treatment History Form (ATHF) score of ≥ 3 in the current episode or have failed to tolerate two separate trials of an antidepressant 6. have a score ≥ 10 on the Patient Health Questionnaire (PHQ-9) 7. have had no increase or initiation of any antidepressant or antipsychotic medication in the 4 weeks prior to screening 8. are able to adhere to the treatment schedule 9. pass the TMS adult safety screening (TASS) questionnaire Exclusion Criteria: 1. have a Mini International Neuropsychiatric Interview (MINI 7.0) confirmed diagnosis of substance dependence or abuse within the last 3 months 2. have a concomitant major unstable medical illness as determined by one of the study physicians 3. have active suicidal intent 4. have presumed or probable dementia or clinical evidence of dementia as assessed by Short Blessed Test score ≥ 10 5. have a lifetime MINI diagnosis of bipolar I or II disorder, or primary psychotic disorder 6. have current psychotic symptoms 7. have a diagnosis of obsessive compulsive disorder, post-traumatic stress disorder (current or within the last year), anxiety disorder (generalized anxiety disorder, social anxiety disorder, panic disorder), or dysthymia, assessed by a study investigator to be primary and causing greater impairment than MDD 8. have a diagnosis of any personality disorder as assessed by a study investigator to be primary and causing greater impairment than MDD 9. did not respond to a course of ECT in the current depressive episode 10. have received rTMS in the current episode; patients who have had rTMS in a previous episode would be eligible 11. have a history of a primary seizure disorder or a seizure associated with an intracranial lesion 12. have an intracranial implant (e.g., aneurysm clips, shunts, stimulators, cochlear implants, or electrodes) or any other metal object within or near the head, excluding the mouth, that cannot be safely removed 13. have an implanted electronic device that is currently in function such as a defibrillator 14. have a non-correctable clinically significant sensory impairment (i.e., cannot hear well enough to cooperate with interview) 15. have clinically significant laboratory abnormality, in the opinion of a study investigator 16. currently take more than lorazepam 2 mg daily (or equivalent) or any dose of an anticonvulsant 17. if participating in psychotherapy, must have been in stable treatment for at least 3 months prior to entry into the study, with no anticipation of change in the frequency of therapeutic sessions, or the therapeutic focus over the duration of the study