Youth and Parent Perspectives on Standard and Truncated Neuronavigated aiTBS for Treatment Naive Adolescent Depression: A Qualitative Study
DOI: Pending DOI
Synopsis
Adolescent depression is rising, and first-line treatments have limited efficacy and notable side effects. Accelerated intermittent theta burst stimulation (aiTBS) shows rapid benefit in adults but is understudied in youth. Little is known about how adolescents and parents view this treatment. In this open-label pilot study, adolescents and parents completed in semi-structured interviews at baseline and immediately following treatment. Most reported symptom improvement, felt the treatment was safe, and preferred aiTBS over medication. Efficacy drove treatment decision making, and participants advocated for increased awareness of this treatment. Findings support aiTBS as an acceptable first-line option for treating adolescent depression.
Background
Rates of adolescent depression are rising while first line treatment options offer limited efficacy and considerable side effects.1–3 Repetitive transcranial magnetic stimulation (rTMS) was recently cleared by the FDA for adolescent depression in ages 15–21, creating a novel treatment option. Accelerated fMRI-guided intermittent theta burst stimulation (aiTBS) has demonstrated rapid improvement in adults but is understudied in youth. 4,5 It has been argued that TMS merits consideration as a first-line option for depression rather than a treatment reserved for medication failure, yet participant preference for TMS relative to standard first-line treatments has not been studied.6 Qualitative work on how families weigh pediatric neuromodulation is also limited, despite the importance of patient and caregiver perspectives in shaping treatment uptake and adherence. This qualitative analysis uses interviews performed during a pilot trial evaluating standard (full dose) and truncated (half-dose) aiTBS protocols administered as a first-line treatment in medication-naive adolescents with major depression. The study examined (1) how adolescents and parents described their treatment preferences, experience and decision-making, and (2) the concerns, barriers, and informational needs they raised.
Methods
Treatment-naïve adolescents took part in an open-label pilot study investigating standard (10 x 10min sessions, 50min intervals for 5 days) and truncated (5 x 10min sessions, 50min intervals for 5 days) neuronavigated aiTBS. Adolescents (n=12) and parents (n=6) completed semi-structured interviews at baseline and post treatment. Interviews were analyzed using a grounded theory approach.7 Two researchers independently conducted initial coding, generating preliminary codes from the transcripts. These codes were collaboratively refined and grouped into broader thematic categories through an iterative, comparative process, with consensus meetings to resolve discrepancies. Analysis continued until thematic coherence was reached.
Results
Most adolescents reported symptom improvement following aiTBS, parents also noted these improvements, in mood, energy, cognition, social engagement, relationships, and day-to-day functioning. Several participants described feeling “lighter.” Reported side effects were mild and transient, most commonly fatigue, scalp pain confined to the stimulation period, and mild headache. Participants framed these as an acceptable trade-off compared with perceived medication side effects, and at immediate follow-up all participants and parents viewed TMS to be highly safe.
Treatment preferences favored aiTBS at baseline and immediate follow up. Almost all participants viewed aiTBS as a more favorable option than antidepressants and said they would repeat TMS for the same or different symptoms. Medication was viewed negatively due to side effect profile, concerns about dependency, and negative accounts from friends and family. Psychotherapy was seen as neutral or favorable. Participant and parent decision-making was multifactorial, weighing efficacy, convenience, and side effects, although efficacy was noted to be the most important. Family experiences with prior treatment and caregiver input shaped adolescent choices. Participants did independent research after learning about the trial, using online forums or AI platforms to inform their decision.
Barriers were generally mild and seen as worthwhile. Scheduling around school and work was the most common challenge. Cost was identified as a significant anticipated barrier outside of the trial. Workarounds included medical notes, online classes, and weekend sessions. Participants found the time between treatment sessions to be suitable to work on school or other projects.
Awareness around TMS as a treatment was low. Most participants had not heard of TMS before the trial, and most were unaware of alternative treatments at all outside of medication and therapy. Common misconceptions around TMS included TMS being experimental, painful, or “shocks to the brain.”
Initial attitudes ranged from skeptical or fearful, often shaped by misconceptions. At the same time, participants remained curious and hopeful. After treatment, all participants and parents reported satisfaction and more positive views, even those who experienced lower symptom resolution or no change. Many participants advocated for TMS as a first-line option, with hopes for improved insurance coverage, reduced cost, and greater public education. The truncated protocol was generally preferred, but only if its efficacy was comparable to the standard protocol.
Discussion
These findings suggest that adolescents and parents are hopeful for a new treatment alternative and see TMS as a safe, tolerable, and effective option for first-line treatment of depression in treatment-naive adolescents. Families emphasized effectiveness as the deciding factor, perceived TMS as having a favorable safety profile, and found the benefits to outweigh the logistical demands and side effects. A consistent finding was the gap in awareness – most families had never heard of TMS and held misconceptions before enrolling, yet many became strong advocates after treatment. This highlights that parents and adolescents are hopeful for a treatment alternative and need for earlier discussion of neuromodulation in adolescent depression care and for increased public information about the treatment. There is limited literature examining how treatment-naïve adolescents and parents perceive aiTBS and its use as a first-line therapy; to our knowledge, this is among the first studies to incorporate patient and parent perspectives on neuromodulation in this context. Future work should address the cost and access barriers that currently limit aiTBS outside a trial setting, expand public and clinician awareness so families encounter the option earlier in care, develop accessible educational materials that correct common misconceptions, and conduct further studies evaluating the truncated protocol given its potential to ease the scheduling and time burden on families.
Disclosures
Nothing to disclose by any author(s).
References
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