A randomized, double blind, sham-controlled trial of repetitive transcranial magnetic stimulation (rTMS) in the treatment of Negative Symptoms in Schizophrenia

Journal Pre-proof A randomized, double blind, sham-controlled trial of repetitive transcranial magnetic stimulation (rTMS) in the treatment of Negative Symptoms in Schizophrenia Nand Kumar, Sreevishnu Bhatta, Ashima Nehra Wadhawan, Sujata Minhas, Prashant Gupta PII:

S1935-861X(20)30038-3

DOI:

https://doi.org/10.1016/j.brs.2020.02.016

Reference:

BRS 1672

To appear in:

Brain Stimulation

Received Date: 17 July 2019 Revised Date:

13 February 2020

Accepted Date: 17 February 2020

Please cite this article as: Kumar N, Bhatta S, Wadhawan AN, Minhas S, Gupta P, A randomized, double blind, sham-controlled trial of repetitive transcranial magnetic stimulation (rTMS) in the treatment of Negative Symptoms in Schizophrenia, Brain Stimulation, https://doi.org/10.1016/j.brs.2020.02.016. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 The Author(s). Published by Elsevier Inc.

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Manuscript Number: BRS-D-19-00618

Title: A randomized, double blind, sham-controlled trial of repetitive transcranial magnetic stimulation (rTMS) in the treatment of Negative Symptoms in Schizophrenia. Article Type: Original Article Keywords: schizophrenia; Negative symptoms; rTMS; repetitive transcranial magnetic stimulation Corresponding Author: Professor Nand Kumar, M.D Corresponding Author's Institution: All India Institute of Medical Sciences First Author: Nand Kumar, M.D Order of Authors: Nand Kumar, M.D; Sreevishnu Bhatta, Ph.D; Ashima Nehra Wadhawan, Ph.D; Sujata Minhas, Ph.D; Prashant Gupta, M.D

Abstract: Background: Research has implicated hypofrontality in the pathogenesis of Negative symptoms of schizophrenia.These symptoms are often resistant to treatment. Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to reverse this hypofrontality. Higher frequency rTMS has shown better promise, but so far there has been very little research in this area. Objective: We aimed to evaluate the efficacy of high-frequency (20 Hz) unilateral rTMS over the left Dorso-Lateral Pre-frontal Cortex (DLPFC) in the improvement of Negative symptoms in Schizophrenia. Methods:100 patients of schizophrenia with predominantly negative symptoms,were enrolled for this randomized,shamcontrolled, double-blind trial.Each participant received 20 sessions of rTMS at 20 Hz frequency and 100% motor threshold, via either the active or the sham coil, over 4 weeks. A total of 2000 pulses were imparted in 10 trains per session. Negative symptoms were assessed with the SANS and PANSS. CDSS was used to rule out depressive symptoms. Assessments were carried out at baseline, post-intervention, and 1-month, 2-months, 3-months and 4-months followups. Results: The improvement in the negative symptoms ( Anhedonia, Alogia, Avolition, Attention impairment) in active group wasstatistically significant at 0.01 and 0.05 (p-value) as compared to sham group. Conclusions: These results suggest that high-frequency rTMS may lead to improvement in negative symptoms of schizophrenia. It may be worth considering its use as an adjunct to pharmacological treatment of negative symptoms.

Cover letter Mark S. George, MD Editor-in-Chief:

Subject: Regarding resubmission of original research article A randomized, double blind, shamcontrolled trial of repetitive Transcranial Magnetic Stimulation (rTMS) in the treatment of Negative Symptoms in Schizophrenia”. Sir, Schizophrenia with predominant negative symptoms is difficult to treat clinical conditions with poor response to pharmacotherapy and new treatment modality is need of the hour. Kindly find attached the revised manuscript related to effectiveness of high frequency rTMS in person suffering from Schizophrenia with predominant Negative symptoms for your perusal and consideration for publication in prestigious Brain stimulation journal. With Warm Regards Prof Nand Kumar, M.D AIIMS New Delhi India

Title: A randomized, double blind, sham-controlled trial of repetitive Transcranial Magnetic Stimulation(rTMS)in the treatment of Negative symptoms in Schizophrenia.

Introduction Negative symptoms in schizophrenia are a core feature of the disease and contribute to a substantial burden associated with the illness1. They include affective flattening or apathy, alogia, avolition or amotivation, anhedonia, impaired attention and social withdrawal2. Despite the substantial research on schizophrenia over the years, the treatment for negative symptoms remains elusive. Unlike the positive symptoms, they are often resistant to antipsychotic drugs and psychological treatments1. Research has indicated that pre-frontal brain dysfunction, especially in the dorso-lateral pre-frontal cortex (DLPFC) may be involved in the aetiology of negative symptoms of schizophrenia3,4. Neuro-imaging studies have shown hypometabolism and hypoperfusion of pre-frontal regions in patients suffering from negative symptoms5. Studies have suggested that this hypofrontality is more pronounced on the left side 6–8. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique which has been shown to be useful in the treatment of several psychiatric and neuro-psychiatric disorders, including depression, PTSD, migraine, etc. 9–11. More recently, some authors have used it for the treatment of negative symptoms as well, with varying outcomes12-15. It has been hypothesized that rTMS may lead to reversal of hypofrontality which is seen in the brains of patients having negative symptoms5,16. Most of the studies till date have evaluated the effects of 10 Hz pulses, in shorter treatment protocols which deliver up to 20,000 pulses to the brain15,17–20. But, higher frequency treatments over longer times and higher number of total magnetic pulses administered have tended to show better improvements in research18,21,22. Literature on effects of rTMS on negative symptoms of schizophrenia is composed mainly of the studies with very small sample sizes and have inadequate power to detect inter-group

differences15,18,20. Moreover, methodological rigour has been a problem in a number of these studies. E.g., the number of randomized, double-blind, sham-controlled trials has been rather limited, the sham rTMS controls in a number of these studies may themselves induce some voltage in the brain, and the different approach to their administration, as compared to the active treatment may affect the blinding. Further, the time durations for which the patients in these studies have been followed up is rather less, mostly up to one month. Hence, little is known about the sustainability of the effects of rTMS in negative symptoms. Hence, given the need for an effective treatment of negative symptoms of schizophrenia and the need to explore potential role for rTMS in this using robust study designs, we aim to evaluate the efficacy of 20 sessions of high-frequency (20 Hz) unilateral rTMS intervention over the left DLPFC in the improvement of negative symptoms in schizophrenia and compare it to sham controls, in a randomized, double-blind trial. Methods Study Design:The study was conceptualized as a randomized sham-controlled double-blind trial. The study was conducted at the All Indian Institute of Medical Sciences (AIIMS), New Delhi which has dedicated rTMS unit with a fully functioning rTMS lab since 2009. Along with this, we have weekly running TMS clinic. Sample size calculation: Barr and colleagues (2012) evaluated the efficacy of 20 Hz RTMS on negative symptoms of schizophrenia against sham controls in a double-blind RCT12. This study yielded a mean SANS total score of 31.67 ± 13.94 in the sham group post-intervention. Anticipating 8 units of difference in SANS total score post-intervention between the groups with a combined SD of 13.97, alpha error of 5% and power of 80%, the estimated sample size was 34 per group. Our study included a sample of 50 per group accounting for about 30% losses in follow up. Randomization Procedure:For Randomization of enrolled patients, 100 sequentially numbered opaque envelopes (with either ‘sham’ or ‘active’ written on it) were prepared as per a computer-generated random sequence by the Biostatistics Department of AIIMS, New Delhi. Only two rTMS technicians had access to them. As per the random sequence they would allot a number to the randomized patient and provide the intervention as mentioned on the card inside.

The subjects were blinded regarding the treatment being given, also the rater was blinded for the allocation, only the rTMS trained Technician who administered rTMS were aware of the allocation from the time of randomization to the time of data analysis. A trained doctor, unrelated to the research project, was present at all times during the intervention to tackle any emergent conditions. Patients who were right-handed, clinically diagnosed as having schizophrenia as per ICD-10 criteria for at least one year and receiving psychiatric treatment at the psychiatry outpatient department of AIIMS, New Delhi, been on stable doses of medicines (if receiving) for the last 4 weeks, but continued to have significant negative symptoms, i.e., score ≥15 on N scale of Positive and Negative Syndrome Scale (PANSS) , with willingness to give informed consent were only included in the study. We did not include patients who had received rTMS treatment in the past for a similar condition. Patients with Co morbid ICD-10 Axis I diagnosis, or Axis II Personality Disorder or who qualify any other exclusion criteria common to every TMS protocol were excluded. rTMS protocol: We used the Magstim Rapid2 and Magstim Rapid2 plus machine for this study. For intervention group, rTMSMagstim’s 70mm figure-of-8Double Rapid2 Air Cooled Coil (P/N 3910-00 S/NO 728) was used, while for sham group, Magstim’s sham coil (P/N 3950-00 S/ NO105) was used. The coils were identical in external appearance which ensured that the patients remained blind to the intervention. After clinical assessment and before starting the rTMS intervention, motor threshold of all the patients was determined followed by the localization of stimulation site. Left dorso-lateral prefrontal cortex (DLPFC) was taken as the site for stimulation. We defined the site of stimulation as a point, 5.5 cm anterior and then 0.5 cm lateral from the point where optimum stimulation of the right abductor pollicisbrevis muscle was observed on stimulation of cortical representation of left cerebral cortex. Same procedure was followed for both groups of patients. After marking site of stimulation and eliciting motor threshold, following stimulation parameters to left DLPFC were used. The study subjects were administered 20 sessions of high frequency rTMS per day (5 consecutive sessions per week for 4 weeks) at 20 Hz frequency, 100% motor threshold (MT), for 10 secs with inter-train time interval ranging from 90 seconds to 120 seconds (as calculated automatically by the TMS machine for in built safety measures) depending on the protocol intensity, total of 2000 pulses imparted in 10 trains. Both sham and active group patients received the same stimulation parameters. Each session lasted for approximately 30 minutes.

Assessment: The assessments were carried out by a trained psychologist appointed for the project. The following instruments were used in assessment: Mini International Neuropsychiatric Interview (MINI) version 5.0.023 Positive and Negative Syndrome Scale (PANSS) 24, 25. Scale for Assessing Negative Symptoms in schizophrenia (SANS) 2, 26. Clinical Global Impressions scale- severity index (CGI-S) 27 Calgary Depression Scale for Schizophrenia (CDSS) 28, 29.

Procedure: Patients who were receiving treatment for schizophrenia and stable on their medications for at least 4 weeks, but who continued to have substantial negative symptoms, were referred by their respective clinicians to our research team for participation in the study. Those who fulfilled the inclusion criteria and agreed to provide a written informed consent were randomized to either of the study arms. In case a patient lacked the capacity to consent, their legal guardians were invited to provide consent. After baseline assessment on the abovementioned instruments, rTMS intervention was provided as per mentioned protocol. Same assessments were also carried out at the completion of the intervention (completion of 20 sessions of rTMS) and monthly follow-ups for four months subsequently. Analysis: Data was analysed using Stata version 14.2 (StataCorp. 2015). Descriptive analysis was done for socio-demographic data (Table 1). Two-sample t test with equal variances and Chi-square test were used to compare the two groups at baseline. Significance value was set at .05. We performed an Intention to Treat (ITT) analysis, i.e., all individuals, who were randomized to experimental arms at the baseline, were included in the analysis irrespective of whether they continued with the study protocol or dropped out. Missing values were imputed as per last observation carried forward. Generalized Estimating Equations (GEE) 30 were used to compare the outcome measures between the two groups over time from pre-intervention to 4-months follow-up assessment. Ethics: An ethical approval of the study was taken from the Institute Ethics Committee of AIIMS, New Delhi. The trial protocol was registered with the Clinical Trials Registry- India (CTRI) athttp://ctri.nic.in/Clinicaltrials/login.php with the number CTRI/2019/05/019099.

Results A total of 497 patients were screened for inclusion, and 100 of them were randomized to active treatment arm (n=50) or sham treatment arm (n=50)(figure 1). An attrition rate of 8% (n=4) in the active rTMS arm and 6% (n=3) in the sham treatment arm was seen during the intervention. This further increased to 32% in active and 38% in sham groups. The number of dropouts in the two groups were statistically similar (χ2=0.396, p=.53). Demographic and clinical characteristics Table 1 shows the baseline demographic and clinical characteristics of the participants. No significant differences were found between the active and the sham treatment groups in demographic characteristics at the baseline. Also, clinical variables (illness duration, family history, medication use and scores on PANSS& its subscales, SANS& its subscales, CGI-S and CDSS) were statistically similar between the two groups at baseline. rTMS safety and tolerability One patient in the active treatment group developed a partial seizure during treatment in the 5th session after which the intervention was discontinued. Another patient in the active arm had aggravation of positive psychotic symptoms, and her intervention had to be stopped after 6 sessions. Other than these two events, both active intervention and sham were well tolerated. Outcome measures: Negative symptoms of schizophrenia: The total SANS score reduced significantly after the intervention in both the active (60.6 ± 11.75 to 43.9 ± 12.67, p< .01) as well as sham (61.5 ± 13.69 to 50.5 ± 14.11, p< .01) rTMS arms on paired sample t-test. Though the baseline total SANS scores were statistically similar in both the groups, the post-intervention scores were significantly lesser among the subjects who received active rTMS as compared to those who received sham (table 2). Among the SANS sub-domains, the difference in post-intervention scores between active and sham groups was statistically significant in affective flattening and avolition domains, but not others. Statistically significant differences were seen in the change in SANS domain scores (pre-intervention vs post

intervention) between active and sham groups in anhedonia, alogia and attention impairment domains. During the four months follow up of the study participants, the initial reduction in SANS total and domain scores seemed to be maintained (figure 2). The change in scores from post intervention to 4-month follow up was not statistically different between the two groups, except in anhedonia domain. Statistically significant difference in the scores on anhedonia, alogia, avolition, attention impairment was seen at the end of study (Pre-interventionto 4 monthsfollow-up).

The results from PANSS negative scale painted a similar picture. The scores were statistically similar at the baseline, but a significant difference was seen between the groups after the intervention, with active rTMS group having lower mean score (table 3). The drop in scores was significantly more in the active rTMS group after the intervention. This difference was maintained throughout the follow-up duration, whereby the change in scores from post-intervention to the end of 4-months follow-up was not significantly different between the groups. The PANSS positive scale did not show any statistically significant difference between active and sham groups either at the baseline, after the intervention or through the follow-up period (table 3& figure 3).Though the total PANSS scores and the general psychopathology scale scores or the change in thesescores did not show difference between the two groups immediately after the intervention, there was a significant difference between the groups during the follow-ups. Depressive symptoms: Since depression was already ruled out among the participants during screening, the CDSS scores were negligible at baseline. The two groups of participants did not differ in terms of depressive symptoms at any time points of measurement (table 4). Clinical Global Impression (CGI): The mean CGI severity index (CGI-S) score was similar between the active and sham participants at the baseline, but a significantly higher reduction in this score was seen among the active group participants after the intervention (table 4). It appeared to follow the patterns of SANS total and PANSS negative scale, whereby the change in scores seemed to be maintained over time, i.e., significant (or tending to be significant) difference between the groups

after the intervention and at each follow-up (figure 4). This difference seemed to primarily stem from the reduction in illness severity (CGI-S score) immediately on completion of intervention, as exemplified by the significant difference between the change in scores from pre- to post intervention between the two groups, and no such difference from post-intervention to 4 months follow-up. Discussion We examined the effects of 20 sessions of 20 Hz rTMS over left DLPFC in the treatment of negative symptoms in schizophrenia among patients who were continuing treatment as usual and found favourable effects of rTMS intervention. We used a novel protocol in which eachparticipant received a total of 2000 pulses (in 10 trains) in one session, at 100% motor threshold and inter-train interval between 90 to 120 seconds. Significant differences were seen in our study, in negative symptoms, as measured by PANSS negative symptom scale and SANS, between the active and sham treatment groups after the rTMS intervention. Ours is one of the largest published sample size studies, evaluating any rTMS interventions for negative symptoms of schizophrenia, available till date, and hence is adequately powered to detect small differences. Previous studies have used rather small samples; maximum of 23 participants in the 20 Hz active intervention group 22. Further, we could find only four RCTs (published in English language) which assessed the effect of 20 Hz pulses on negative symptoms 12,21,22,31. There are suggestions from the literature that rTMS interventions with frequencies greater than 10 Hz might lead to better improvement in negative symptoms 18. Our results provide further validation to these findings. Novak and colleagues (2006) administered 20 Hz, total20,000 pulses unilaterally,31 while Barr and colleagues (2012) administered 20 Hz, 15,000 pulses to each hemisphere 12. Both failed to find any significant improvement in negative symptoms.On the other hand, Zhao et al (2014) and Rabany et al (2014) administered a total of 30,000 and 33,600 at 20 Hz pulses, respectively, and both reported at least some statistically significant improvements in the negative symptoms. We administered a total of 40,000 pulses unilaterally (highest reported till date) to each patient over 20 sessions, and

found significant reductions in negative symptoms. This possibly indicates towards a potential critical number of pulses beyond which the rTMS treatment becomes effective and warrants further investigation. Similar increase in efficacy with number of pulses has been observed in studies on depression32,33. It should be noted that the participants who received sham rTMS also had statistically significant improvements after the intervention. We used a specially designed sham coil which ensures that no magnetic pulses are delivered to the patients who receive this intervention.One may speculate a possible placebo-effect in sucha situation, whereby the mere setting of rTMS application showed some improvement among the subjects.Nevertheless, a clear statistically significant advantage in the improvement in negative symptoms was seen among participants randomized to active group as compared to the control group. Though our results yielded significant beneficial effects of rTMS in negative symptoms along with corresponding changes in CGI severity index, the overall change in negative symptoms was only modest.The difference in SANS total score (sham = 50.5 ± 14.11 vs active = 43.9 ±12.67) and PANSS negative symptom scale score (sham = 20.82 ± 4.89 vs rTMS = 18.48 ± 5.40) was approximately 7 points and 2 points, respectively, post-intervention. Hence, the translation of the statistical improvement to clinical improvement needs to be done with caution, and potentially invites further research on this issue. The importance of the results of our study is re-iterated by the fact that we followed our patients for a substantially long duration. But, given the long duration of follow up, the attrition rate in our study was substantial. One-third (33/100) of the sample had dropped out towards the end. The primary reason for most of the drop outs was logistic difficulty in commuting to the centre. Transport or monetary assistance may have helped in reducing the drop outs. The number of drop-outs did not differ significantly between the two arms. In our review, we came across a single study which had a follow-up period comparable to ours. Dlabac-Delange and colleagues (2015) found sustained improvement in SANS scores over a period of 3 months with 10 Hz, total of 30000 pulses to each

hemisphere13. Similarly, the favourable effects of rTMS in our study also seemed to be sustained over 4 months of follow-up after the intervention. It remains to be seen in future research that how long such beneficial effects may be sustained and whether there is any role for booster sessions. An important advantage in our study was the use of sham coil. Majority of the studies use the intervention coil as sham by tilting it to 90degree

12,13,31

. This method has been found to induce at least

some voltage in the brain 34,whereas, a sham coil is devoid of this effect. Only Prikryl and colleagues have used a sham coil in evaluation of efficacy for negative symptoms previously 35. Moreover, the sham coil in our study was identical to the active coil in appearanceand the same stimulation parameters were used in the sham as the active coil. This helped in ensuring more stringent patient blinding. The blinding was further strengthened by the use of Sequentially Numbered Opaque Sealed Envelopes (SNOSE), which were carefully handled. Depression is a common confounder for negative symptoms of schizophrenia due to their overlapping conditions. Moreover, depression is known to respond to rTMS interventions over left DLPFC. Hence, we made an efforts to control for this confounder by screening to exclude the subjects having depression. Moreover, the CDSS, which is a scale for measuring depressive symptoms specifically in people having schizophrenia, was used to measure the severity of depressive symptoms at baseline and to evaluate changes if any through follow-ups. Both the groups had statistically similar CDSS scores at baseline, and no significant changes were seen at any time points during the study. A major limitation of our study was that we located the DLPFC by manual measurements over the scalp. Even though the “5 cm rule” has been a standard practice, studies have shown that neuro navigational techniques are more accurate in localizing the stimulation site36. Also, our study participants continued their respective usual pharmacological interventions during the study period as prescribed by their clinicians. One may argue that this might lead to some confounding of the outcomes. But, we did not find any difference in the medications administered to the participants of active or sham group at the baseline. Moreover, we included only those patients who were receiving stable doses of medicines for at least one month, without any recent dose or medication changes. Hence, the chances of medicines being a confounder are low. Continuation of treatment as usual is in keeping with the ethical guidelines as rTMS is not yet a proven exclusive treatment modality for schizophrenia.

We did not take an upper limit cut-off for PANSS positive scale scores. This was done to make the study inclusions more representative of the real-world conditions. Nevertheless, since our sample included only the patients who were already on stable treatment, the incidence of positive symptoms in our study was quite low. The maximum PANSS positive scale score in our study sample was 16. Conclusion Our study showed benefits of high frequency (20 Hz) rTMS at 100% motor threshold with 2000 pulses per session administered through 10 trains over left DLPFC for 20 sessions over 4 weeks for patients suffering from schizophrenia with predominant Negative symptoms. This study adds to the existing literature with its robust design and large sample size despite few limitations and paves the path for future research regarding administration of high frequency rTMS for regular clinical treatment of Negative symptoms in schizophrenia with adequate safety measures. Acknowledgement: The study is fully funded by Department of science and Technology under CSRI Initiative (vide grant No DST No:SR/CSRI/48/2013(G). I sincerely acknowledge the contribution of technical staff of the Neuromodulation lab for mental health for their assistance in completing this project.

Conflict of Interest: The authors declare that they have no conflict of Interest.

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Depression. Am J Psychiatry. 2003;160(5):835-845. doi:10.1176/appi.ajp.160.5.835. 33.

George MS, Post RM. Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation for Acute Treatment of Medication-Resistant Depression. Am J Psychiatry. 2011;168(4):356-364. doi:10.1176/appi.ajp.2010.10060864.

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Table 1: Baseline socio-demographic and clinical characteristics of the sample population Active rTMS arm (n = 50)

Sham rTMS arm (n = 50)

p

32.4 ± 9.20

30.8 ± 9.34

0.38

29 (58.0) 21 (42.0)

28 (56.0) 22 (44.0)

Marital status, n(%) Never married Currently married Others

23 (46.0) 19 (38.0) 8 (16.0)

28 (56.0) 18 (36.0) 4 (8.0)

Education, n(%) Intermediate Graduate Matric Middle Others

12 (24.0) 9 (18.0) 9 (18.0) 9 (18.0) 11 (22.0)

14 (28.0) 10 (20.0) 9 (18.0) 9 (18.0) 8 (8.0)

Employment status, n(%) Employed Unemployed

6 (12.0) 44 (88.0)

8 (16.0) 42 (84.0)

Occupation, n(%) Not known Home maker Student Skilled/unskilled Others

27 (54.0) 6 (12.0) 6 (12.0) 9 (18.0) 2 (4.0)

26 (52.0) 9 (18.0) 5 (10.0) 8 (16.0) 2 (4.0)

Religion, n(%) Hindu Others

46 (92.0) 4 (8.0)

47 (94.0) 3 (6.0)

Residential Area, n(%) Delhi Outside Delhi

18 (36.0) 32 (64.0)

24 (48.0) 26 (52.0)

125.7±76.43

101.5±84.67

Age in years,(mean ± SD) Sex, n(%)

0.84 Male Female

Duration of illness, in months (mean ± SD) Family History of psychotic illness in 1st degree relative,n(%) Yes No

0.67

0.98

0.56

0.97

0.53

0.22

0.13

0.71

17 (34.0) 33 (66.0)

15 (30.6) 34 (69.4)

PANSS (mean ± SD) Total Positive Negative General

65.66 ± 8.43 9.68 ± 2.44 24.34 ± 4.32 31.64 ± 5.01

67.02 ± 10.07 9.94 ± 2.70 24.9 ± 5.01 32.18 ± 5.66

0.49 0.62 0.55 0.61

SANS (mean ± SD) Total

60.66 ± 11.75

61.46± 13.69

0.74

Affective flattening Alogia Anhedonia Attention impairment Avolition CGI-S (mean ± SD) Antipsychotic drugs, n(%) Risperidone Olanzapine Others (Amisulpiride, Clozapine, Quetiapine, Aripiprazole, No antipsychotic) Combinations of two or more antipsychotic drugs Anticholinergic drugs (Trihexyphenidyl),n(%) Yes No Sedative/Hypnotic drugs (Clonazepam, Lorazepam), n(%) Yes No Antidepressant drugs (Fluoxetine, Escitalopram, Sertraline), n(%) Yes No

15.76± 6.57 11.3 ± 3.26 16.62 ± 2.42 6.7 ± 3.23 10.22 ± 2.82

17.76 ± 6.01 11.06 ± 3.61 16.42 ± 2.80 5.76 ± 3.44 10.66 ± 2.92

0.12 0.73 0.70 0.16 0.45

4.62 ± 0.70

4.52 ± 0.74

0.49

15 (30.0) 8 (16.0) 14 (28.0)

18 (36.0) 12 (24.0) 7 (14.0)

13 (26.0)

13 (26.0)

0.33

0.42 23 (46.0) 27 (54.0)

27 (54.0) 23 (46.0) 0.37

5 (10.0) 45 (90.0)

8 (16.0) 42 (84.0) 0.13

13 (26.0) 37 (74.0)

7 (14.0) 43 (86.0)

Table 2: Comparison of SANS scores between the two study groups across the assessment time points Pre-

Post-

1 month follow

2 months

3 months

4 months

Reduction

Intervention

intervention

up

follow up

follow up

follow up

(95% CI)

Pre-intervention

Post-intervention

Pre-intervention

to post-

to 4 months follow-

to 4 months

intervention

up

follow-up

N Sham Active

50 50

50 50

50 50

50 50

50 50

50 50

SANS total Sham

61.5 ± 13.69

50.5 ±14.11

48.3±16.33

45.7 ± 18.13

44.6 ± 17.81

43.7 ± 18.46

11.0 (8.25, 13.67)

6.8 (3.26, 10.26)

17.7 (13.40, 22.04)

60.6 ± 11.75

43.9 ±12.67

38.9 ± 13.73

36.6 ± 14.72

35.2 ± 14.14

33.8 ± 15.79

16.6 (13.86, 19.42)

10.2 (7.75, 12.65)

26.8 (22.79, 30.89)

0.73

0.02

< 0.01

< 0.01

< 0.01

< 0.01

< 0.01

0.12

< 0.01

SANS affective flattening Sham Active p

17.8± 6.01 15.8± 6.57 0.12

12.7± 6.82 10.3± 5.91 0.05

11.9± 6.54 8.8± 5.93 0.01

11.3± 6.86 7.9± 5.84 < 0.01

10.8± 6.68 7.4± 5.36 < 0.01

10.6± 6.83 7.2± 5.97 < 0.01

5.1 (3.10, 6.12) 5.5 (4.31, 6.61) 0.62

2.1 (0.64, 3.64) 3.1 (2.25, 3.99) 0.27

7.2 (5.52, 8.88) 8.6 (7.06, 10.10) 0.24

SANS anhedonia Sham Active p

16.4± 2.80 16.6± 2.42 0.70

15.2± 3.62 14.3± 3.27 0.18

14.6± 3.42 12.9± 3.60 0.02

14.1± 3.94 12.4± 3.93 0.04

14.0± 3.91 12.1± 4.16 0.02

13.8± 4.24 11.6± 4.63 0.01

1.2 (0.53, 1.87) 2.3 (1.71, 2.97) 0.02

1.4 (0.74, 2.06) 2.7 (1.75, 3.61) 0.03

2.6 (1.64, 3.56) 5.0 (3.88, 6.16) < 0.01

SANS alogia Sham Active p

11.1± 3.61 11.3± 3.26 0.73

8.8± 4.16 7.2± 4.33 0.07

8.3± 4.51 6.3± 4.38 0.03

7.7± 4.89 6.0± 4.50 0.08

7.5± 5.13 5.6± 4.33 0.06

7.4± 4.87 5.3± 4.60 0.03

2.3 (1.51, 3.02) 4.1 (3.05, 5.11) < 0.01

1.4 (0.27, 2.53) 1.9 (1.13, 2.71) 0.46

3.7 (2.37, 4.95) 6.0 (4.85, 7.15) < 0.01

SANS avolition Sham Active p

10.7± 2.92 10.2± 2.82 0.44

8.9± 2.83 7.9± 2.28 0.05

8.6± 3.20 6.9± 2.45 < 0.01

8.1± 3.58 6.5± 2.90 0.02

8.0± 3.29 6.4± 2.84 < 0.01

7.9± 3.18 6.2± 3.15 < 0.01

1.7 (1.15, 2.33) 2.3 (1.65, 2.99) 0.21

1.0 (0.35, 1.73) 1.7 (0.94, 2.50) 0.20

2.8 (1.98, 3.58) 4.0 (3.09, 4.99) 0.05

SANS attention impairment Sham Active p

5.8± 3.44 6.7± 3.23 0.16

4.9± 3.19 4.3± 3.46 0.37

4.9± 3.18 4.1± 3.10 0.18

4.5±3.27 3.8± 3.88 0.25

4.3± 3.47 3.7± 2.96 0.34

4.1± 3.46 3.6± 3.00 0.44

0.9 (0.24, 1.56) 2.4 (1.74, 3.14) < 0.01

0.8 (0.18, 1.38) 0.7 (0.03, 1.33) 0.82

1.7(0.97, 2.39) 3.1(2.29, 3.95) 0.01

Active p

Table 3: Comparison of PANSS scores between the two study groups across the assessment time points Pre-

Post-

1 month

2 months

3 months

4 months

Reduction in scores

Intervention

intervention

follow up

follow up

follow up

follow up

(95% CI) Pre-intervention

Post-intervention

Pre-intervention

to post-

to 4 months follow-

to 4 months

intervention

up

follow-up

N Sham Active

50 50

50 50

50 50

50 50

50 50

50 50

PANSS total Sham Active P

67.0 ± 10.97 65.7 ± 8.43 0.48

57.5 ± 9.94 54.1 ±10.50 0.10

56.7 ± 9.97 50.9 ±10.10 <0.01

55.5 ± 11.69 50.4± 10.38 0.02

55.0 ± 12.13 49.1 ± 10.39 0.01

55.2 ± 11.44 48.4 ± 10.76 <0.01

9.5 (7.26, 11.82) 11.6 (9.47, 13.65) 0.20

2.3 (0.05, 4.47) 5.7 (4.03, 7.45) 0.02

11.8 (8.95, 14.65) 17.3 (14.65, 19.95) < 0.01

PANSS positive scale Sham Active P

9.9 ± 2.70 9.7 ± 2.44 0.62

8.7 ± 2.12 8.5 ± 1.85 0.62

8.6 ± 2.01 8.3 ± 1.79 0.38

8.7 ± 2.26 8.5 ± 2.31 0.76

8.7 ± 2.28 8.3 ± 1.96 0.40

8.9 ± 2.41 8.3 ± 2.09 0.22

1.2 (0.65, 1.83) 1.2 (0.74, 1.61) 0.87

-0.2 (-0.72, 0.36) 0.2 (-0.2, 0.56) 0.29

1.1 (0.47, 1.65) 1.4 (0.76, 1.97) 0.48

PANSS negative scale Sham Active P

24.9 ± 5.01 24.3 ± 4.32 0.55

20.8 ± 4.89 18.5 ± 5.40 0.03

20.1 ± 5.44 17.0 ± 5.23 <0.01

19.4 ± 5.66 16.8 ± 5.18 0.02

19.3 ± 6.09 16.2 ± 4.89 <0.01

19.3 ± 5.92 15.7 ± 4.93 <0.01

4.1 (3.09, 5.07) 5.9 (4.92, 6.80) 0.01

1.5 (0.31, 2.77) 2.7 (1.86, 3.62) 0.12

5.6 (4.07, 7.18) 8.6 (7.40, 9.80) <0.01

PANSS general scale Sham

32.2 ± 5.65

27.9 ±5.23

27.9 ± 4.79

27.4 ± 5.67

27.1 ± 5.66

27.1 ± 5.20

4.2 (3.10, 5.34)

0.9 (-0.06, 1.85)

5.1 (3.75, 6.49)

31.6 ± 5.01

27.1 ±5.46

25.6 ± 5.15

25.2 ± 5.31

24.6 ± 5.49

24.3 ± 5.57

4.5 (3.38, 5.66)

2.8 (1.91, 3.73)

7.3 (5.93, 8.75)

0.62

0.43

0.02

0.05

0.03

0.01

0.71

<0.01

0.03

Active p

Table 4: Comparison of CGI-S and CDSS scores between the two study groups across the assessment time points Pre-

Post-

1 month

2 months

3 months

4 months

Reduction$

Intervention

intervention

follow up

follow up

follow up

follow up

(95% CI)

Pre-intervention

Post-

Pre-intervention

to post-

intervention to 4

to 4 months

intervention

months follow-

follow-up

up N Sham Active

50 50

50 50

50 50

50 50

50 50

50 50

Sham

4.5 ± 0.73

4.2 ±0.68

3.9 ± 0.65

3.9 ± 0.76

3.9 ± 0.77

3.8 ± 0.79

0.3 (0.17, 0.43)

0.4 (0.20, 0.57)

0.7 (0.44, 0.91)

Active

4.6 ± 0.69

3.9 ±0.70

3.7 ± 0.84

3.6 ± 0.92

3.4 ± 0.86

3.4 ± 0.90

0.7 (0.52, 0.92)

0.5 (0.36, 0.68)

1.2 (0.97, 1.51)

p-value

0.49

0.02

0.07

0.08

<0.01

<0.01

<0.01

0.27

<0.01

CDSS Sham Active p-value

0.3 ± 1.05 0.3 ± 0.74 1

0.12 ± 0.72 0.12 ± 0.44 1

0.22 ± 0.91 0.1 ± 0.36 0.39

0.12 ± 0.44 0.02 ± 0.14 0.13

0.24 ± 0.98 0.12 ± 0.59 0.46

0.26 ± 0.97 0.02 ± 0.14 0.09

0.2 (-0.01, 0.37) 0.2 (0.00, 0.36) 1

-0.1 (-0.42, 0.14) 0.1 (-0.01, 0.22) 0.13

0.04 (-0.3, 0.4) 0.3 (0.1, 0.5) 0.24

CGI-S

Figure 1: CONSORT flow diagram depicting the flow of participants through the study Assessed for eligibility (n= 497) Not meeting inclusion criteria (n= 322)

Enrollment Eligible (n= 175)

Declined to participate (n= 75)

Consented & Randomized (n= 100)

Allocated to active intervention: n= 50

Allocation

Allocated to sham intervention: n= 50

Completed allocated intervention: n= 46

Intervention

Completed allocated intervention: n= 47

Did not complete allocated intervention: n= 4 Reasons: • Problems in coming daily for intervention: n=2 • Partial seizure: n=1 th Intervention stopped after 5 session • Emergence of positive symptoms: n=1 Intervention stopped after 6 sessions

Did not complete allocated intervention: n= 3 • All 3 discontinued intervention because of logistic issues of travelling to the centre daily. All had received more than 5 session before discontinuation

Assessed: n= 46 Lost to follow-up: n= 0

1 month postintervention

Assessed: n= 43 Lost to follow-up: n= 4

Assessed: n= 38 Lost to follow-up: n= 8

2 months postintervention

Assessed: n= 36 Lost to follow-up: n= 7

Assessed: n= 36 Lost to follow-up: n= 2

3 months postintervention

Assessed: n= 34 Lost to follow-up: n= 2

Assessed: n= 36 Lost to follow-up: n= 0

4 months postintervention

Assessed: n= 31 Lost to follow-up: n= 3

Analysed: n= 50

ITT analysis

Analysed: n= 50

Figure 2: Comparison of SANS scores at baseline, post-intervention and follow-ups between the two study groups 70

SANS: total score

60

20 18

SANS: affective flattening

16 50

14 12

40

10 30

8 6

20

*Average difference = 7.6±2.73 (p <.01) 10

2

0

0

Active

12

4

Sham

SANS: alogia

Active

18 16

Sham

SANS: anhedonia

10 14 8

12 10

6 8 4

6 4

2 2 0

0

Active

12

Sham

SANS: avolition

Active

8

Sham

SANS: attention impairment

7

10

6 8

5

6

4 3

4

2 2

1

0

0

Active

Sham

Active

Sham

*Average difference in scores between the active and the sham rTMS groups, over all time points (pre-intervention, post intervention i.e after 20 sessions of rTMS, subsequent assessments for 4 consecutive months post intervention)

Figure 3: Comparison of PANSS scores at baseline, post-intervention and follow-ups between the two study groups

*Average difference = 4.7 ± 1.91 (p = .01)

*Average difference in scores between the active and the sham rTMS groups, over all time points (pre-intervention, post intervention i.e after 20 sessions of rTMS, subsequent assessments for 4 consecutive months post intervention)

Figure 4: Comparison of CGI-S scores at baseline, post-intervention and follow-ups between the two study groups 5 4.5

CGI-S

4 3.5 3 2.5 2 1.5 1

*Average difference = .3±0.13 (p <.04)

0.5 0

Aactive

Sham

*Average difference in scores between the active and the sham rTMS groups, over all time points (pre-intervention, post intervention i.e after 20 sessions of rTMS, subsequent assessments for 4 consecutive months post intervention)