rTMS and Theta Burst Stimulation in Late-Life Depression: Suicidal Ideation Findings from the FOUR-D Trial
For healthcare professionals only. Educational use. TMS is not approved for treating suicidal ideation.
Late-life depression remains a significant clinical challenge and is closely associated with suicidal ideation, particularly in patients with treatment-resistant depression. While transcranial magnetic stimulation (TMS) has been studied in major depressive disorder, data focused specifically on older adults have been more limited. A secondary analysis of the FOUR-D trial adds to this evidence base by examining adults aged 60 years and older who received bilateral dorsolateral prefrontal cortex stimulation with either 10 Hz repetitive transcranial magnetic stimulation (rTMS) or theta burst stimulation (TBS).
In this study population, both rTMS and TBS were associated with reductions in suicidal ideation over the course of treatment. This is a clinically relevant finding in late-life depression, where suicidal symptoms remain an important concern and where older adults have historically been underrepresented in neuromodulation research.
The analysis also found that theta burst stimulation showed outcomes comparable to standard 10 Hz rTMS, despite requiring substantially shorter treatment sessions. This finding is relevant when considering how different stimulation protocols may perform in routine clinical settings, particularly in populations where treatment burden and visit duration may influence care pathways.
Additional observations from the study provide further context for future research. Women showed higher remission rates than men in the TBS group, and improvements in cognitive flexibility were associated with faster remission of suicidal ideation. These findings do not establish treatment guidance, but they may help inform future investigation into patient-level factors associated with response.
The study also reported that remission rates in this older cohort were higher than those previously described in mixed-age populations. This observation challenges assumptions that older adults may respond less robustly to neuromodulation and supports continued inclusion of this population in clinical research involving TMS and related stimulation protocols.
Taken together, these results expand the evidence base for transcranial magnetic stimulation (TMS) in late-life depression and suggest that both rTMS and TBS may be associated with improvement in suicidal ideation in older adults with treatment-resistant depression. Because this was a secondary analysis, the findings should be interpreted within the context of the study design and should not be understood as establishing causality or comparative efficacy.
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