An exploratory randomized, double-blind trial of accelerated deep TMS for patients with suicidal thoughts and behaviors

Background Suicidality is a leading cause of death in major depressive disorder (MDD), yet actively suicidal patients are rarely included in neuromodulation trials. Evidence for deep transcranial magnetic stimulation (dTMS) in this group is limited. Objective Assess the safety and efficacy of accelerated H1/H7 dTMS in MDD inpatients with active suicidality. Methods In a double-blind, randomized, sham-controlled pilot trial, 39 inpatients received ten days of accelerated dTMS (three daily intermittent theta-burst sessions) using H1, H7, or sham coils. Columbia Suicide Severity Rating Scale (C-SSRS), Quick Inventory of Depressive Symptomatology (QIDS), and Montgomery-Åsberg Depression Rating Scale (MADRS) were completed at baseline, day 5, and day 10. Results Of the 39 enrolled patients, 31 completed at least nine treatment days and were included in the efficacy analysis. Adverse events were mild and transient; two patients discontinued treatment. Active arms (H1/H7) produced greater reductions in QIDS than sham. C-SSRS suicidal ideation/behavior category declined over time in all groups, but only the active cohort showed a lower suicidal ideation intensity by day 10. Conclusions Accelerated dTMS with either coil appears to be safe, tolerable, and logistically feasible for acutely suicidal MDD inpatients. Active stimulation yielded a clinically meaningful antidepressant response and a promising signal for faster resolution of suicidality. Those preliminary findings encourage inclusion of suicidal individuals in neuromodulation studies and support dTMS as a potential rapid intervention during psychiatric crises; confirmation in larger multicenter samples is warranted.