Intermittent theta-burst stimulation (iTBS) Modulates Abnormal Brain Activity During Emotional Arousal in Adolescent Depression

Intermittent theta-burst stimulation (iTBS) Modulates Abnormal Brain Activity During Emotional Arousal in Adolescent Depression | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Intermittent theta-burst stimulation (iTBS) Modulates Abnormal Brain Activity During Emotional Arousal in Adolescent Depression Zeyang Zhao, Yuan Liu, Jiang Wang, Peiying Li, Zhi Yang, Ling Sun, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8011953/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background The rising incidence of adolescent depression in China causes significant impairments, necessitating rapid treatments such as accelerated Intermittent theta-burst stimulation(iTBS). However, responses to treatment vary. We used naturalistic functional magnetic resonance imaging(N-fMRI) to investigate the impact of depression on the neural processing of emotional arousal. The objectives of this study were: 1) to identify brain regions associated with treatment response, and 2) to correlate these neural signatures with clinical outcomes following accelerated iTBS. Methods Fifty-eight adolescents with depression and twenty-nine healthy controls underwent fMRI while viewing emotion-evoking videos. Forty-three patients completed accelerated iTBS treatment, with pre- and post-treatment fMRI scans. Statistical analysis of the MRI data was performed in SPM12, employing cluster-based family-wise error correction at a significance threshold of p < 0.05. Results Whole-brain analysis revealed that adolescents with depression exhibited significantly reduced emotion-arousal activation in the left superior frontal gyrus (L-SFG) and left middle frontal gyrus (L-MFG) compared to healthy controls during high-to-medium emotional arousal. Hamilton Depression Scale scores significantly decreased after iTBS treatment. L-MFG showed a marginally significant increase in emotion-arousal activation after iTBS. Correlation analysis between the Euclidean distance of treatment targets to the L-SFG and psychological scale scores revealed a significant negative association between the Euclidean distance and Generalized Anxiety Disorder-7 reduction rate. Conclusion This exploratory study suggests that abnormal activity in the L-SFG and L-MFG underlies the variable efficacy of accelerated iTBS in adolescent depression. Our findings indicate that proximity to the L-SFG is correlated with treatment response, and L-MFG beta values showed slightly increased post-treatment. These regions represent potential neuroanatomical targets for future investigation as biomarkers for iTBS mechanisms. Adolescent depression Naturalistic fMRI iTBS emotional arousal Figures Figure 1 Figure 2 Figure 3 1 Introduction Depressive disorder is a prevalent psychiatric condition characterized by high prevalence, recurrence rates, and disability 1 , imposing a considerable economic burden worldwide 2 . Notably, adolescents face elevated risks of depression due to incomplete psychological development and limited capacity to cope with stress 3 . In China, the prevalence of adolescent depressive disorder has shown a persistent upward trend, with 14.8% of adolescents exhibiting varying degrees of depression risk 4 . These studies highlight the need for attention to adolescent patients with depression. Given the academic pressures adolescents often face, both they and their parents may prefer faster treatment plans. As a treatment modality with longer-lasting effects and shorter treatment durations 5 , accelerated intermittent theta-burst stimulation (iTBS) effectively meets the needs of adolescent depression patients and their families. Stanford Neuromodulation Therapy (SNT) has demonstrated 6 that accelerated and high-dose iTBS protocols exhibit favorable tolerability, safety, and efficacy in treating treatment-resistant depression patients. Accelerated iTBS has also proven to be safe and effective for adolescents with depression 7 , 8 . However, there are variations in therapeutic outcomes among different individuals after treatment. This variability in treatment efficacy may stem from abnormalities in patients' brain activity, especially brain circuits underlying emotion processing. Adolescents with depressive disorders frequently exhibit significant deficits in emotional regulation. Emotion, as conceptualized by Russell's circumplex model 9 , is not a monolithic entity but is constructed from two fundamental dimensions: valence (the pleasantness or unpleasantness of an emotion) and arousal (the intensity or activation level of the emotional state). The regulation of arousal is a critical component of healthy emotional functioning. Given that pronounced dysregulation of the arousal system is a transdiagnostic feature across various psychiatric conditions, including depression and post-traumatic stress disorder (PTSD), it has become a key objective of antidepressant treatment research to investigate its neural correlates 10 . To accurately capture the brain dynamics underlying these real-world emotional challenges in adolescents, it is therefore essential to employ paradigms that can evoke and measure brain activity during states of heightened emotional arousal. The naturalistic functional magnetic resonance imaging(N-fMRI) is a parallel approach to resting-state functional magnetic resonance imaging(rs-fMRI), in which subjects are often told to watch movies that could evoke various emotional states and thoughts, allowing monitoring of brain response to close-to-real-life conditions 11 – 14 . N-fMRI presents a particularly well-suited methodological approach for adolescence. N-fMRI can effectively convey social and emotional contexts, eliciting corresponding brain responses 11 , 13 , 15 – 18 . This ecological validity is crucial for studying the nuanced social and emotional deficits characteristic of adolescent depression 14 , 19 , 20 . Furthermore, N-fMRI has demonstrated robust test-retest reliability 21 , 22 and is more effective at mitigating head motion control in children and adolescents 23 . Compared to traditional task-based paradigms that focus on specific condition contrasts, naturalistic paradigms offer opportunities to integrate data across different spatiotemporal scales 24 . By allowing for the integrated analysis of brain activity across multiple spatiotemporal scales, N-fMRI offers distinct advantages for identifying the subtle, distributed neural abnormalities 11 , 16 that may underlie the variable treatment outcomes observed in adolescent depression. The naturalistic video stimuli used in this study were adopted from Zhang et al.'s prior work, which demonstrated high validity of naturalistic fMRI metrics in identifying social anxiety disorder (SAD) in children and adolescents using a similar paradigm 25 . These video clips, depicting scenarios of social stress and emotional interactions, are particularly effective in evoking anxiety-related symptoms in the context of emotional arousal. Given that anxiety is a highly prevalent comorbidity in depression and that the chosen stimuli are potent in eliciting anxiety-related arousal, we specifically utilized the Generalized Anxiety Disorder-7 (GAD-7) scale to quantify this relevant symptom dimension. This approach allowed us to investigate whether neural responses to socially challenging content were linked to clinical measures of anxiety in our depressed adolescent cohort. The present study was designed to investigate the neural substrates underlying the inter-individual variability in accelerated iTBS treatment response among adolescents with depression. Leveraging a N-fMRI paradigm previously validated to elicit emotional arousal 25 – 27 , we sought to identify pre-treatment neural markers that are predictive of clinical outcomes. By examining whole-brain activation patterns using a general linear model (GLM), we formulated two primary hypotheses: We hypothesized that, at baseline, adolescents with depression would exhibit aberrant neural activation within key emotion-regulation circuits during the emotional arousal task compared to healthy controls. Furthermore, we predicted that this dysfunctional activation would be significantly modulated—trending towards normalization—following a full course of iTBS treatment. Crucially, we hypothesized that the magnitude of this baseline neural dysfunction, and/or its modulation post-treatment, would significantly correlate with the degree of clinical improvement, thereby serving as a potential biomarker for treatment efficacy. By linking aberrant brain function during emotional arousal to treatment response, this research aims to provide a neurobiological basis for personalizing neuromodulation therapies in this vulnerable population. 2 Methods 2.1 Participants This study recruited 58 adolescent patients with depression and 29 healthy adolescent participants from Tianjin Anding Hospital. Healthy subjects were recruited via posters, with physical and mental illnesses excluded. These patients were diagnosed with depressive disorder by psychiatrists using DSM-5 as the diagnostic criterion, and this diagnosis was confirmed through MINI-KID interviews conducted by evaluators on the recruited participants. The participants with organic brain disorders (such as brain tumors, traumatic brain injuries and neurodegenerative diseases), physical disabilities, severe visual or hearing impairments, a history of severe head trauma, substance and/or alcohol addiction or severe suicidal tendency were excluded. After meeting the inclusion and exclusion criteria, the participants signed informed consent forms to be included in this study. Among them, 43 adolescent patients with depression completed TMS treatment and underwent natural stimulus fMRI scans. Of these 43 patients who completed TMS treatment, 19 received personalized target treatment. Detailed inclusion and exclusion criteria can be found in the supplementary materials. This study was approved by the Ethics Committee of Tianjin Anding Hospital. 2.2 Experimental procedure First, after participants signed the informed consent form, the collection of scale data and MRI scans commenced. Among them, the psychological scales included the Montgomery-Asberg Depression Rating Scale ​​(MADRS​), Hamilton Depression Rating Scale (​​HAMD), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). Some subjects were not captured on the GAD-7 and PHQ-9 scales. Following TMS treatment, participants completed repeat scale evaluations and MRI scanning. This resulted in two MRI scans for the patient group. Healthy control participants underwent MRI scanning only once. 2.3 TMS Treatment The AIM-III Magnetic Stimulation Robot (Mag TD; Yiruide Medical Equipment New Technology Co., Ltd., Wuhan, China) was used to administer iTBS. The device was fitted with an active, 70-mm figure-of-eight, air-cooled coil. After the initial cranial MRI scan, researchers specialized in data analysis calculated the target coordinates and then transmitted them to the TMS treatment team. The subjects in this study comprised participants receiving two treatment regimens: one involving two days of treatment 7 , 8 and another involving four days of treatment. Among the four-day treatment group, 19 subjects received personalised targeted therapy, while the remaining subjects received treatment targeting the standard location. The personalized targets were standard space coordinates derived from the most negative functional connectivity between Left Dorsolateral Prefrontal Cortex(L-DLPFC) and pregenual anterior cingulate cortex(pgACC) 28 . The remaining patients were treated using standard space coordinates (-41, 16, 54) 29 , which were subsequently transformed to individual space. Following the completion of the second day's treatment within the four-day accelerated therapy programme, a rest period of five to seven days is required before proceeding with the remaining two days of transcranial magnetic stimulation therapy. Each treatment session lasted 10 minutes with 50-minute intervals between sessions, repeated 5 times daily, totaling 20 sessions of iTBS. The stimulation parameters were set at 100% resting motor threshold (RMT), However, because adolescents are less tolerant, the RMT was reduced to 70%-100%, with an intra-burst frequency of 50Hz and inter-burst frequency of 5Hz, consisting of 2-second stimulation periods followed by 8-second rest periods, delivering 1800 pulses per treatment session. A total of 36,000 pulses were administered throughout the entire treatment period. 2.4 Naturalistic Stimulus Video This study utilized video materials from our previous research 25 to elicit emotional responses in participants and observe corresponding brain activity. The video consisted of four public service announcements and cartoon clips edited into a 7’50’’s compilation. The selection criteria for these materials were: ability to evoke positive or negative emotions, comprehensibility without audio or subtitles, and representation of engaging contexts. To account for the potential influence of language on participants' comprehension, the audio track and subtitles of the experimental stimuli were removed 12 , and the videos were presented without sound. The video content depicted scenarios of school-related social stress and emotional interactions between children and parents. After fMRI scanning during video viewing, participants completed a post-scan assessment to evaluate their engagement and comprehension through questionnaire responses. The entire video is divided into 59 segments, each lasting 8s, with the last segment lasting 6s. After excluding those with emotional disorders, 33 raters were obtained. Before the experiment, the assessors were led to practice to ensure that they were familiar with the scoring rules and accurately understood the difference arousal. Based on the responses of 33 raters to natural stimulus videos, we established normative values for emotional arousal based on their ratings of video segments. These were then categorized into three levels each (arousal: low, medium, high). After excluding segments that contained overlapping video clips, each level was composed of the top, middle, and bottom 15% of the average scores, resulting in 9 segments for each level. 2.5 MRI Data Acquisition MRI data were acquired using a Siemens 3.0 Tesla scanner (Siemens Healthineers, Erlangen, Germany) at Tianjin Anding Hospital. Participants were instructed to attentively watch the video while maintaining head stillness. The video was presented without sound. The N-fMRI scans were acquired using a GE-EPI sequence with the following parameters: TR = 800 ms, TE = 30 ms, FOV = 208 × 208 mm², matrix size = 104 × 104, flip angle = 56°, slice thickness = 2 mm, number of slices = 72, voxel size = 2 × 2 × 2 mm³, number of time points = 614. T1-weighted structural images were acquired using an MP-RAGE sequence with the following parameters: TR = 2000 ms, TE = 2.32 ms, FOV = 230 × 230 mm², matrix size = 256 × 256, flip angle = 8°, slice thickness = 0.90 mm, number of slices = 208, voxel size = 0.9 × 0.9 × 0.9 mm³. 2.6 MRI Data Analysis 2.6.1 Data Preprocessing Preprocessing was performed using DPARSF software ( http://rfmri.org/DPARSF ) following the standard preprocessing pipeline recommended by the software, Which is implemented in Matlab R2020a (Mathworks, Inc., Sherborn, MA). For each participant's fMRI scan data, the last 27 volumes were discarded, retaining only 587 volumes. Preprocessing included realignment to correct for head motion during functional acquisition and coregistration of the high-resolution T1 structural image to the mean realigned functional volume. Segmentation of the T1 image and normalization of all images to Montreal Neurological Institute (MNI) space were then performed using the DARTEL method, resampling to 2×2×2 mm³ voxels. Nuisance covariates – comprising white matter (WM) and cerebrospinal fluid (CSF) signals, the global signal, head motion parameters (Friston 24), and polynomial trends – were regressed out. Finally, the normalized functional images underwent spatial smoothing with a Gaussian kernel (6 mm full width at half maximum (FWHM)).​ 2.6.2 Whole-Brain Analysis 2.6.2.1 Individual-level Analysis​​ Subject-specific General Linear Models (GLMs) were implemented in SPM12 to model the Blood Oxygenation Level-Dependent (BOLD) response to naturalistic video stimuli. The design matrix incorporated separate regressors for each video, convolved with SPM12’s canonical hemodynamic response function (HRF), to model condition-specific responses. Both emotional arousal ratings provided by participants were explicitly modeled within the GLM framework. To mitigate low-frequency signal drift, a high-pass filter with a cutoff period of 128 seconds was applied. The GLMs were estimated subject to standard linear assumptions (linearity, independence, and homogeneity of variance). During the analysis, covariates such as gender, age, and head movement were excluded to eliminate confounding effects. A total of six first-level directional contrasts were computed representing pairwise differences between rating levels: High > Low, Low > High, High > Medium, Medium > High, Medium > Low, Low > Medium. ​​ 2.6.2.2 Group-level Analysis To identify significant neural emotion-arousal activation differences between adolescents with depression (MDD) and healthy controls (HC), a series of two-sample t-tests were performed on each of the twelve contrast images (i.e., one group-level model per contrast). ​​Crucially, to control for the family-wise error (FWE) rate arising from massive univariate testing across the whole brain, statistical inference was performed using cluster-based correction​​ (implemented within SPM12). Cluster-forming was initiated at a voxel-wise threshold of ​​ p < 0.001. The significance of spatially contiguous clusters resulting from this initial threshold was then assessed based on their extent under Gaussian Random Field Theory. Only clusters surviving a ​​cluster-level Family-Wise Error (FWE) corrected threshold of p < 0.05​​ were considered statistically significant. ​​ 2.6.2.3 Follow-up ROI Analysis For adolescents with depressive disorders patients who underwent fMRI scanning both before and after treatment (n = 43), secondary small volume analyses 30 were conducted on regions demonstrating significant between-group differences in the whole-brain analyses. For the extraction of effect size we used Marsbar-0.45 ( http://www.sourceforge.net/projects/marsbar ). Spherical regions of interest (ROIs) with a 6mm radius were defined bilaterally centered on the peak coordinates (-20, 34, 34; -32, 34, 28) identified in the whole-brain MDD vs HC contrasts relevant to therapeutic change. Mean beta parameter estimates from these ROIs for the key contrasts (High > Medium) were extracted for each patient’s pre-treatment and post-treatment scans. Potential treatment-related changes in emotion-arousal activation levels within these MDD patients were assessed using paired-sample t-tests. 2.7 Euclidean Distance Calculation For patients undergoing personalized targeted therapy, we calculated the Euclidean distance between the coordinates of their treatment targets in standard space and the peak activation coordinates identified in the whole-brain analysis. After excluding one individual due to missing questionnaire data, IBM SPSS Statistics Version 27.0 (IBM Corp., Armonk, NY, USA) was used to analyze the correlation between these Euclidean distances and the psychological scale scores. 3 Results 3.1 Participant Characteristics The demographic information of the adolescent patients with depression and the healthy participants is presented in Table 1 . Chi-square tests or independent samples t-tests revealed no significant differences between the patient group and the control group in terms of gender ( χ ² = 0.66, p = 0.417) or age ( t = -1.08, p = 0.288). Patients exhibited significant clinical improvement: HAMD scores decreased substantially after iTBS treatment (pre > post, t = 7.009, p < 0.001). Table 1 Demographic characteristics of the participants (M ± SD). Items MDD HC before after Sample size 58 43 29 Sex(M/F) 17/41 15/28 14/22 Age(year) 14.98 ± 1.47 14.93 ± 1.49 15.52 ± 2.46 HAMD 22.53 ± 7.26 16.95 ± 8.00 GAD-7 a … … … HAMD, Hamilton Depression scale; M, male; F, female; GAD-7 a means some subjects were not captured on the GAD-7 scales. 3.2 Whole-Brain Analysis Results In the group-level analysis of naturalistic stimulus data, significant clusters demonstrating between-group differences were identified ​​after applying cluster-level Family-Wise Error (FWE) correction​​ (voxel-level threshold: p < 0.001; significance threshold: p < 0.05 FWE-corrected). Specifically, for the ​​High vs Medium Arousal contrast​​, two clusters survived correction: one in the left superior frontal gyrus (L-SFG; peak MNI coordinates: -20, 34, 34) and another in the left middle frontal gyrus (L-MFG; peak MNI coordinates: -32, 34, 28), as visualized in Fig. 2 . Adolescent depression patients (MDD) exhibited significantly reduced emotion-arousal activation in these regions relative to healthy controls (HC) (HC > MDD, L-SFG: t = 4.27, FWE-corrected p < 0.05; L-MFG: t = 4.16, FWE-corrected p < 0.05). 3.3 ROI Small Voxel Analysis Results Building upon whole-brain analysis findings, spherical ROIs (6mm radius) were centered on the L-MFG (peak MNI: -32, 34, 28) and L-SFG (peak MNI: -20, 34, 34) coordinates identified in the ​​High vs Medium Arousal contrast​​. Beta values extracted from these regions in adolescent depression patients pre- and post-iTBS treatment revealed differential responses. ​​For the L-MFG, paired-sample t-tests indicated a trend-level increase in emotion-arousal activation after treatment (​​post > pre​​, t = -1.69, p = 0.098). Although not meeting conventional significance thresholds, this directional effect suggests ​​elevated​​ neural responsiveness in the L-MFG following TMS intervention (Fig. 3 ). Critically, concomitant with this neural change, patients exhibited significant clinical improvement​​ on the HAMD: HAMD scores decreased substantially after iTBS treatment (​​pre > post​​, t = 7.009, p < 0.001). No significant treatment-related changes​​ were observed in the L-SFG. 3.4 Euclidean Distance Calculation Results The target coordinates in standard space, derived from the most negative functional connectivity between L-DLPFC and pgACC, are shown in Fig. 4(A). We calculated the Euclidean distance between each subject's target coordinates and the peak emotion-arousal activation coordinates in the L-SFG (-20, 34, 34) and L-MFG (-32, 34, 28). Correlational analysis between these Euclidean distances and psychological scale scores revealed a significant negative correlation between GAD-7 reduction rates and the distance to the L-SFG ( r = -0.468, p < 0.05), as illustrated in Fig. 4(B). This indicates that closer proximity of the treatment target to the L-SFG was associated with greater anxiety symptom relief and better treatment efficacy in adolescent depression patients. No significant correlations were found with other psychological scales. 4 Discussion This study investigated the neural correlates of emotional processing deficits in adolescent depression and their therapeutic modulation by iTBS. Whole-brain analyses comparing patients and healthy controls revealed significantly ​​reduced emotion-arousal activation​​ within the left frontocortical circuitry—specifically in the L-SFG and L-MFG—during high versus medium arousal processing. Subsequent accelerated treatment with iTBS triggered significant clinical symptom improvement accompanied by a marginal enhancement of L-MFG emotion-arousal activation. This pattern of convergent neurobehavioral changes suggests that iTBS may engage prefrontal compensatory mechanisms, partially reversing task-specific hypoactivation implicated in emotional arousal dysregulation. In this study, N-fMRI and iTBS were combined and used in adolescent depressed patients for the first time, and N-fMRI was used to explore the abnormal brain activity of adolescent depressed patients in the presence of emotional arousal. The question of the difference in efficacy of patients after accelerated iTBS treatment was explored in depth. The significantly reduced emotion-arousal activation in the L-SFG and L-MFG in adolescent depression patients compared to healthy controls, suggests these regions may serve as critical neurophysiological substrates for depression. Over the past two decades, a widely accepted theoretical framework posits that depression results from dysregulation in these prefrontal-limbic circuits 31 , 32 . The present study investigated abnormal brain activity in depressed patients using the relatively novel N-fMRI technique, and the results are consistent with previous findings, both of which indicate the importance of the frontal lobes in depressed patients. In addition, studies have indicated that fluctuations in the global fMRI signal are synchronized with physiological signals, which are closely related to changes in emotional arousal and physiological states 33 . Regarding emotional arousal, further research has pointed out that it has its own unique neural network, including regions such as the prefrontal cortex 34 . These studies suggest that there is a close relationship between emotional arousal and brain activity, and applying emotional arousal in the study of psychiatric disorders such as depression is crucial. Following accelerated iTBS treatment, emotion-arousal activation levels in this region showed an increase, a finding consistent with previous research results 35 , 36 . Adolescent depression patients exhibited symptom alleviation on the HAMD scale after iTBS therapy, further demonstrating the therapeutic efficacy of iTBS. However, the observed differences in this study were only marginally significant. This may be attributed to the influence of repeated naturalistic stimuli, where duplicated exposures affected emotion-arousal activation levels during subsequent viewing. Alternatively, the variability could stem from analytical approaches applied to naturalistic stimuli themselves. Compare to conventional task-based paradigms, diverse methodologies are employed for naturalistic stimuli—for instance, Mosley 37 utilized Hidden Markov Models (HMM) to analyze such stimuli, while Xie 27 adopted a sliding window approach. Nevertheless, the present findings partially reveal that naturalistic stimuli can capture changes in emotion-arousal activation among adolescent depression patients, and concurrently corroborate that TMS stimulation of the left prefrontal cortex alleviates depressive disorders. For patients receiving personalized iTBS target treatment (n = 19), we quantified the spatial proximity between individualized stimulation sites and the peak coordinate of the pathological locus (L-SFG) using Euclidean distance in standardized MNI space. ​​Correlation analysis​​ revealed a significant negative relationship between the Euclidean distance to the L-SFG and the percentage reduction in GAD-7 scores. Specifically, as the stimulation target approached the L-SFG coordinate, the GAD-7 symptom reduction rate increased, suggesting ​​anatomical specificity of treatment efficacy for anxiety symptoms​​. No significant correlations were found with other psychological scales. The specific association between stimulation proximity to the L-SFG and improvement in anxiety symptoms, as measured by the GAD-7, aligns with the nature of our naturalistic stimuli. These video clips, validated in a SAD cohort and depicting socially challenging scenarios, are potent in eliciting anxiety-related emotional arousal. This finding suggests that the L-SFG may be a key node in a circuit that processes socially-relevant anxious arousal. The improvement in GAD-7 scores, but not other scales, following stimulation near this region indicates that iTBS may exert part of its therapeutic effect by normalizing the brain's response to such anxiety-provoking contexts. This provides a neurobiological rationale for the frequent comorbidity of depression and anxiety and suggests that targeting the L-SFG could be a strategy for addressing both symptom domains. Due to the inclusion of subjects undergoing different treatment regimens, this study comprised participants receiving iTBS therapy over either two or four days, in addition to some receiving personalized targeted interventions. Although this variation may have reduced the effective sample size and increased inter-subject heterogeneity, the potential impact on the primary outcomes is likely limited, given that the study aimed to investigate brain activity under emotional arousal and all therapeutic stimulations were consistently targeted at the LDLPFC. Future studies should nonetheless seek to control for treatment regimen variables and recruit larger samples to enable large-scale validation. Regarding the use of the GLM for analyzing N-fMRI data, alternative computational approaches—such as HMM and sliding window techniques—could be considered in subsequent work. Finally, caution is warranted when generalizing these findings, as the participant group was restricted to adolescents with depression. Follow-up studies involving adults with depression and patients with other psychiatric disorders are needed to extend the generalizability of the results. 5 Conclusions In summary, this research investigated the variability in treatment outcomes among adolescent depression patients following accelerated iTBS therapy. Utilizing N-fMRI, we observed reduced emotion-arousal activation in the L-SFG and L-MFG among depressed adolescents compared to healthy controls. After accelerated treatment with iTBS, adolescents with depression showed significant reductions in HAMD scale scores and L-MFG activity increased after treatment. Furthermore, we calculated the Euclidean distance between individualized iTBS therapeutic targets and these anomalous brain regions. Correlation analyses revealed that as stimulation targets approached the coordinates of the L-SFG, the GAD-7 symptom reduction rate increased. This suggests a relationship between TMS efficacy variability and stimulation location. Future studies should prioritize monitoring changes in this specific neuroanatomical region in depressed adolescents and explore underlying neural mechanisms. Declarations Conflict of Interests: The authors declare that they have no competing interests or conflict of interest. Funding: The funding for this study was provided by the Tianjin Health Research Project (Grant No. TJWJ2023MS038), Tianjin Education Commission Research Project (Grant No. 2023KJ044) and Tianjin Key Medical Discipline (Specialty) Construction Project (Grant No. TJYXZDXK-3-015B). Author Contribution Z.Z.: Methodology, Software, Formal Analysis, Investigation, Data Curation, Writing - Original Draft, Visualization.Y.L.: Writing - Review & Editing, Validation.J.W.: Investigation, Resources, Data Curation.P.L.: Investigation, Resources, Data Curation.Z.Y.: Supervision, Project Administration, Funding Acquisition.L.S.: Supervision, Project Administration, Funding Acquisition.B.Z.: Conceptualization, Methodology, Supervision, Writing - Review & Editing, Project Administration. Acknowledgment: We thank all the study participants for their cooperation. References Malhi G, Mann J (2018) Depression. Lancet Lond. Engl. 392, 2299–2312 Otte C et al (2016) Major depressive disorder. Nat reviews Disease primers 2(1):1–20 McKetta S, Keyes KM (2019) Oral contraceptive use and depression among adolescents. Ann Epidemiol 29:46–51 Chen ZY, Guo F, Wang XS (2023) 2022 Report on the Mental Health Status of Chinese Adolescents. China National Mental Health Development Report. 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Depression and Anxiety, p 5522658. 1 Bolt T et al (2025) Autonomic physiological coupling of the global fMRI signal. : pp. 1–9 Zhang R et al (2025) A neurofunctional signature of affective arousal generalizes across valence domains and distinguishes subjective experience from autonomic reactivity. 16(1): p. 6492 Berlim M et al (2014) Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials. Psychol Med 44(2):225–239 George MS, Taylor JJ, Short EB (2013) The expanding evidence base for rTMS treatment of depression. Curr Opin Psychiatry 26(1):13–18 Mosley PE et al (2025) Markers of positive affect and brain state synchrony discriminate melancholic from non-melancholic depression using naturalistic stimuli. Mol Psychiatry 30(3):848–860 Additional Declarations No competing interests reported. Supplementary Files SupplementalMaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Feb, 2026 Reviews received at journal 28 Jan, 2026 Reviews received at journal 12 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers agreed at journal 09 Jan, 2026 Reviewers invited by journal 04 Dec, 2025 Editor assigned by journal 05 Nov, 2025 Submission checks completed at journal 05 Nov, 2025 First submitted to journal 02 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8011953","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":556275919,"identity":"76807c57-f241-447f-b651-66b979cae25f","order_by":0,"name":"Zeyang Zhao","email":"","orcid":"","institution":"Chengde Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zeyang","middleName":"","lastName":"Zhao","suffix":""},{"id":556275920,"identity":"b6db0775-b949-4af8-84c3-610a44017882","order_by":1,"name":"Yuan Liu","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Liu","suffix":""},{"id":556275921,"identity":"5a58a9de-803e-43d1-b4cd-e6ef70b35d15","order_by":2,"name":"Jiang Wang","email":"","orcid":"","institution":"Tianjin Anding Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiang","middleName":"","lastName":"Wang","suffix":""},{"id":556275922,"identity":"1ca26e18-6233-4cc8-8102-e7fd860c5f62","order_by":3,"name":"Peiying Li","email":"","orcid":"","institution":"Tianjin Anding Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peiying","middleName":"","lastName":"Li","suffix":""},{"id":556275923,"identity":"7518273e-d52a-4110-a129-60d485eecab5","order_by":4,"name":"Zhi Yang","email":"","orcid":"","institution":"Beijing Anding Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhi","middleName":"","lastName":"Yang","suffix":""},{"id":556275925,"identity":"882eb8ca-1f79-4aee-9827-a7d0abbb1fe5","order_by":5,"name":"Ling Sun","email":"","orcid":"","institution":"Tianjin Anding Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Sun","suffix":""},{"id":556275928,"identity":"9f769abd-e3b3-494c-a814-352d26c41c0b","order_by":6,"name":"Bin Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYDACCTB5gIeBvSH9wwcbEIex8QBxWngOPGOckQbW0kCUFiAj8RkzTxoDjIsbyM9ufvbwC8MdGXOew2mPbRJsEte2HwbaUmMTjUsL45xj5sYyDM94LNvb0o1zEtKMzc4kArUcS8ttwKGFWSLBTFqC4TCPwZkzCdK5Pw7LmR0AamFsOIxTC5tE+jeIlhv5H6QtEg7zmJ1/iF8Lj0SOmeQHsJaENGmGBKAtNwjYIiGRUybNYPAM6LADyYY9IL/cANqSgMcv8jPSt0n+qLhjb3C8IfHBD2CIbTuf/vDBhxobnFrAQcBjgC6UgEc5CDD+IKBgFIyCUTAKRjgAAD8EY0WnqE6WAAAAAElFTkSuQmCC","orcid":"","institution":"Tianjin Anding Hospital","correspondingAuthor":true,"prefix":"","firstName":"Bin","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-11-02 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11:42:53","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":19417,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/06634279bf13fd9154f33daf.png"},{"id":97894102,"identity":"7081c75e-f973-4ef4-ac6c-c7b66c27afbc","added_by":"auto","created_at":"2025-12-10 15:31:56","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23367,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/45b70a30338a1bd233d05427.png"},{"id":97697339,"identity":"e69f69aa-76f3-4f6f-b816-04bb68d653d4","added_by":"auto","created_at":"2025-12-08 11:42:53","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88883,"visible":true,"origin":"","legend":"","description":"","filename":"d9edc40c2b3f454bae99be829af96e261structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/be4d00049a01858009b9bb0b.xml"},{"id":97697340,"identity":"a7765f53-fd11-4bc2-a73a-f8f06056a35a","added_by":"auto","created_at":"2025-12-08 11:42:53","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101684,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/757097b37ce270cf7d17a52b.html"},{"id":97894398,"identity":"e4e0d4db-2bde-41f1-9ca0-0fc75d61fd30","added_by":"auto","created_at":"2025-12-10 15:32:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":445142,"visible":true,"origin":"","legend":"\u003cp\u003eIn the second-level analysis of N-fMRI, after FWE correction at the cluster level, significantly surviving clusters (control \u0026gt; patient, FWE \u0026lt; 0.05) were identified in the L-SFG and L-MFG within the High-Medium levels of the emotional arousal dimension. The MNI coordinates of the significant peaks passing correction were (-20, 34, 34) and (-32, 34, 28).​\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/60f983c76cadf99ee41f24b7.png"},{"id":97893280,"identity":"e04e9fc1-fc58-4abb-9169-eb1786333a63","added_by":"auto","created_at":"2025-12-10 15:29:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60167,"visible":true,"origin":"","legend":"\u003cp\u003eA spherical ROI with a 6-mm radius was centered at the L-MFG coordinate (-32, 34, 28). Beta values were extracted from this ROI in adolescent depression patients before and after iTBS treatment. Paired-sample t-tests revealed a marginally significant increase in neural activation (before \u0026gt; after, \u003cem\u003et\u003c/em\u003e= -1.69, \u003cem\u003ep\u003c/em\u003e= 0.098).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/d1a4590f05e8c1506e3390dc.png"},{"id":97894424,"identity":"111cefd0-8a09-4303-b3fc-8ac43d404d4b","added_by":"auto","created_at":"2025-12-10 15:32:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":157867,"visible":true,"origin":"","legend":"\u003cp\u003e(A) The target sites for 19 adolescent depression patients were derived from standard space coordinates calculated based on the most negative functional connectivity between the L-DLPFC and pgACC. (B) For each subject, the Euclidean distance between their individual target coordinate and the peak activation coordinate (-20, 34, 34) in the L-SFG was calculated. These distance values were then correlated with GAD-7 improvement rates. A significant negative correlation was observed between Euclidean distance to the L-SFG locus and clinical improvement (\u003cem\u003er\u003c/em\u003e= -0.468, \u003cem\u003ep\u003c/em\u003e\u0026lt; 0.05).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/5334338eb6155ce800e7bb5e.png"},{"id":97902415,"identity":"a88a3731-5c70-4dd0-bbd1-a24a5c7e7720","added_by":"auto","created_at":"2025-12-10 15:52:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1300888,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/f14c41c5-b558-4032-b41f-5d4ed05b16ac.pdf"},{"id":97697330,"identity":"ec8b59ca-fa34-4c5f-926f-83cc0762cc32","added_by":"auto","created_at":"2025-12-08 11:42:53","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20130,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-8011953/v1/64da3370f07569921f2aeb1d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intermittent theta-burst stimulation (iTBS) Modulates Abnormal Brain Activity During Emotional Arousal in Adolescent Depression","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eDepressive disorder is a prevalent psychiatric condition characterized by high prevalence, recurrence rates, and disability\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, imposing a considerable economic burden worldwide\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Notably, adolescents face elevated risks of depression due to incomplete psychological development and limited capacity to cope with stress\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In China, the prevalence of adolescent depressive disorder has shown a persistent upward trend, with 14.8% of adolescents exhibiting varying degrees of depression risk\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. These studies highlight the need for attention to adolescent patients with depression. Given the academic pressures adolescents often face, both they and their parents may prefer faster treatment plans.\u003c/p\u003e\u003cp\u003eAs a treatment modality with longer-lasting effects and shorter treatment durations\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, accelerated intermittent theta-burst stimulation (iTBS) effectively meets the needs of adolescent depression patients and their families. Stanford Neuromodulation Therapy (SNT) has demonstrated\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e that accelerated and high-dose iTBS protocols exhibit favorable tolerability, safety, and efficacy in treating treatment-resistant depression patients. Accelerated iTBS has also proven to be safe and effective for adolescents with depression\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. However, there are variations in therapeutic outcomes among different individuals after treatment. This variability in treatment efficacy may stem from abnormalities in patients' brain activity, especially brain circuits underlying emotion processing.\u003c/p\u003e\u003cp\u003eAdolescents with depressive disorders frequently exhibit significant deficits in emotional regulation. Emotion, as conceptualized by Russell's circumplex model\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, is not a monolithic entity but is constructed from two fundamental dimensions: valence (the pleasantness or unpleasantness of an emotion) and arousal (the intensity or activation level of the emotional state). The regulation of arousal is a critical component of healthy emotional functioning. Given that pronounced dysregulation of the arousal system is a transdiagnostic feature across various psychiatric conditions, including depression and post-traumatic stress disorder (PTSD), it has become a key objective of antidepressant treatment research to investigate its neural correlates\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. To accurately capture the brain dynamics underlying these real-world emotional challenges in adolescents, it is therefore essential to employ paradigms that can evoke and measure brain activity during states of heightened emotional arousal.\u003c/p\u003e\u003cp\u003eThe naturalistic functional magnetic resonance imaging(N-fMRI) is a parallel approach to resting-state functional magnetic resonance imaging(rs-fMRI), in which subjects are often told to watch movies that could evoke various emotional states and thoughts, allowing monitoring of brain response to close-to-real-life conditions\u003csup\u003e\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. N-fMRI presents a particularly well-suited methodological approach for adolescence. N-fMRI can effectively convey social and emotional contexts, eliciting corresponding brain responses\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This ecological validity is crucial for studying the nuanced social and emotional deficits characteristic of adolescent depression\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Furthermore, N-fMRI has demonstrated robust test-retest reliability\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and is more effective at mitigating head motion control in children and adolescents\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Compared to traditional task-based paradigms that focus on specific condition contrasts, naturalistic paradigms offer opportunities to integrate data across different spatiotemporal scales\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. By allowing for the integrated analysis of brain activity across multiple spatiotemporal scales, N-fMRI offers distinct advantages for identifying the subtle, distributed neural abnormalities\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e that may underlie the variable treatment outcomes observed in adolescent depression.\u003c/p\u003e\u003cp\u003eThe naturalistic video stimuli used in this study were adopted from Zhang et al.'s prior work, which demonstrated high validity of naturalistic fMRI metrics in identifying social anxiety disorder (SAD) in children and adolescents using a similar paradigm\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. These video clips, depicting scenarios of social stress and emotional interactions, are particularly effective in evoking anxiety-related symptoms in the context of emotional arousal. Given that anxiety is a highly prevalent comorbidity in depression and that the chosen stimuli are potent in eliciting anxiety-related arousal, we specifically utilized the Generalized Anxiety Disorder-7 (GAD-7) scale to quantify this relevant symptom dimension. This approach allowed us to investigate whether neural responses to socially challenging content were linked to clinical measures of anxiety in our depressed adolescent cohort. The present study was designed to investigate the neural substrates underlying the inter-individual variability in accelerated iTBS treatment response among adolescents with depression. Leveraging a N-fMRI paradigm previously validated to elicit emotional arousal\u003csup\u003e\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, we sought to identify pre-treatment neural markers that are predictive of clinical outcomes. By examining whole-brain activation patterns using a general linear model (GLM), we formulated two primary hypotheses:\u003c/p\u003e\u003cp\u003eWe hypothesized that, at baseline, adolescents with depression would exhibit aberrant neural activation within key emotion-regulation circuits during the emotional arousal task compared to healthy controls. Furthermore, we predicted that this dysfunctional activation would be significantly modulated\u0026mdash;trending towards normalization\u0026mdash;following a full course of iTBS treatment. Crucially, we hypothesized that the magnitude of this baseline neural dysfunction, and/or its modulation post-treatment, would significantly correlate with the degree of clinical improvement, thereby serving as a potential biomarker for treatment efficacy.\u003c/p\u003e\u003cp\u003eBy linking aberrant brain function during emotional arousal to treatment response, this research aims to provide a neurobiological basis for personalizing neuromodulation therapies in this vulnerable population.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Participants\u003c/h2\u003e\u003cp\u003e This study recruited 58 adolescent patients with depression and 29 healthy adolescent participants from Tianjin Anding Hospital. Healthy subjects were recruited via posters, with physical and mental illnesses excluded. These patients were diagnosed with depressive disorder by psychiatrists using DSM-5 as the diagnostic criterion, and this diagnosis was confirmed through MINI-KID interviews conducted by evaluators on the recruited participants. The participants with organic brain disorders (such as brain tumors, traumatic brain injuries and neurodegenerative diseases), physical disabilities, severe visual or hearing impairments, a history of severe head trauma, substance and/or alcohol addiction or severe suicidal tendency were excluded. After meeting the inclusion and exclusion criteria, the participants signed informed consent forms to be included in this study. Among them, 43 adolescent patients with depression completed TMS treatment and underwent natural stimulus fMRI scans. Of these 43 patients who completed TMS treatment, 19 received personalized target treatment. Detailed inclusion and exclusion criteria can be found in the supplementary materials. This study was approved by the Ethics Committee of Tianjin Anding Hospital.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Experimental procedure\u003c/h2\u003e\u003cp\u003e First, after participants signed the informed consent form, the collection of scale data and MRI scans commenced. Among them, the psychological scales included the Montgomery-Asberg Depression Rating Scale ​​(MADRS​), Hamilton Depression Rating Scale (​​HAMD), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). Some subjects were not captured on the GAD-7 and PHQ-9 scales. Following TMS treatment, participants completed repeat scale evaluations and MRI scanning. This resulted in two MRI scans for the patient group. Healthy control participants underwent MRI scanning only once.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 TMS Treatment\u003c/h2\u003e\u003cp\u003eThe AIM-III Magnetic Stimulation Robot (Mag TD; Yiruide Medical Equipment New Technology Co., Ltd., Wuhan, China) was used to administer iTBS. The device was fitted with an active, 70-mm figure-of-eight, air-cooled coil. After the initial cranial MRI scan, researchers specialized in data analysis calculated the target coordinates and then transmitted them to the TMS treatment team.\u003c/p\u003e\u003cp\u003eThe subjects in this study comprised participants receiving two treatment regimens: one involving two days of treatment\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and another involving four days of treatment. Among the four-day treatment group, 19 subjects received personalised targeted therapy, while the remaining subjects received treatment targeting the standard location. The personalized targets were standard space coordinates derived from the most negative functional connectivity between Left Dorsolateral Prefrontal Cortex(L-DLPFC) and pregenual anterior cingulate cortex(pgACC)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The remaining patients were treated using standard space coordinates (-41, 16, 54)\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, which were subsequently transformed to individual space.\u003c/p\u003e\u003cp\u003eFollowing the completion of the second day's treatment within the four-day accelerated therapy programme, a rest period of five to seven days is required before proceeding with the remaining two days of transcranial magnetic stimulation therapy. Each treatment session lasted 10 minutes with 50-minute intervals between sessions, repeated 5 times daily, totaling 20 sessions of iTBS. The stimulation parameters were set at 100% resting motor threshold (RMT), However, because adolescents are less tolerant, the RMT was reduced to 70%-100%, with an intra-burst frequency of 50Hz and inter-burst frequency of 5Hz, consisting of 2-second stimulation periods followed by 8-second rest periods, delivering 1800 pulses per treatment session. A total of 36,000 pulses were administered throughout the entire treatment period.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Naturalistic Stimulus Video\u003c/h2\u003e\u003cp\u003eThis study utilized video materials from our previous research \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e to elicit emotional responses in participants and observe corresponding brain activity. The video consisted of four public service announcements and cartoon clips edited into a 7\u0026rsquo;50\u0026rsquo;\u0026rsquo;s compilation. The selection criteria for these materials were: ability to evoke positive or negative emotions, comprehensibility without audio or subtitles, and representation of engaging contexts. To account for the potential influence of language on participants' comprehension, the audio track and subtitles of the experimental stimuli were removed \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, and the videos were presented without sound.\u003c/p\u003e\u003cp\u003eThe video content depicted scenarios of school-related social stress and emotional interactions between children and parents. After fMRI scanning during video viewing, participants completed a post-scan assessment to evaluate their engagement and comprehension through questionnaire responses. The entire video is divided into 59 segments, each lasting 8s, with the last segment lasting 6s. After excluding those with emotional disorders, 33 raters were obtained. Before the experiment, the assessors were led to practice to ensure that they were familiar with the scoring rules and accurately understood the difference arousal. Based on the responses of 33 raters to natural stimulus videos, we established normative values for emotional arousal based on their ratings of video segments. These were then categorized into three levels each (arousal: low, medium, high). After excluding segments that contained overlapping video clips, each level was composed of the top, middle, and bottom 15% of the average scores, resulting in 9 segments for each level.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 MRI Data Acquisition\u003c/h2\u003e\u003cp\u003eMRI data were acquired using a Siemens 3.0 Tesla scanner (Siemens Healthineers, Erlangen, Germany) at Tianjin Anding Hospital. Participants were instructed to attentively watch the video while maintaining head stillness. The video was presented without sound. The N-fMRI scans were acquired using a GE-EPI sequence with the following parameters: TR\u0026thinsp;=\u0026thinsp;800 ms, TE\u0026thinsp;=\u0026thinsp;30 ms, FOV\u0026thinsp;=\u0026thinsp;208 \u0026times; 208 mm\u0026sup2;, matrix size\u0026thinsp;=\u0026thinsp;104 \u0026times; 104, flip angle\u0026thinsp;=\u0026thinsp;56\u0026deg;, slice thickness\u0026thinsp;=\u0026thinsp;2 mm, number of slices\u0026thinsp;=\u0026thinsp;72, voxel size\u0026thinsp;=\u0026thinsp;2 \u0026times; 2 \u0026times; 2 mm\u0026sup3;, number of time points\u0026thinsp;=\u0026thinsp;614.\u003c/p\u003e\u003cp\u003eT1-weighted structural images were acquired using an MP-RAGE sequence with the following parameters: TR\u0026thinsp;=\u0026thinsp;2000 ms, TE\u0026thinsp;=\u0026thinsp;2.32 ms, FOV\u0026thinsp;=\u0026thinsp;230 \u0026times; 230 mm\u0026sup2;, matrix size\u0026thinsp;=\u0026thinsp;256 \u0026times; 256, flip angle\u0026thinsp;=\u0026thinsp;8\u0026deg;, slice thickness\u0026thinsp;=\u0026thinsp;0.90 mm, number of slices\u0026thinsp;=\u0026thinsp;208, voxel size\u0026thinsp;=\u0026thinsp;0.9 \u0026times; 0.9 \u0026times; 0.9 mm\u0026sup3;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 MRI Data Analysis\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.6.1 Data Preprocessing\u003c/h2\u003e\u003cp\u003ePreprocessing was performed using DPARSF software (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://rfmri.org/DPARSF\u003c/span\u003e\u003cspan address=\"http://rfmri.org/DPARSF\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) following the standard preprocessing pipeline recommended by the software, Which is implemented in Matlab R2020a (Mathworks, Inc., Sherborn, MA). For each participant's fMRI scan data, the last 27 volumes were discarded, retaining only 587 volumes. Preprocessing included realignment to correct for head motion during functional acquisition and coregistration of the high-resolution T1 structural image to the mean realigned functional volume. Segmentation of the T1 image and normalization of all images to Montreal Neurological Institute (MNI) space were then performed using the DARTEL method, resampling to 2\u0026times;2\u0026times;2 mm\u0026sup3; voxels. Nuisance covariates \u0026ndash; comprising white matter (WM) and cerebrospinal fluid (CSF) signals, the global signal, head motion parameters (Friston 24), and polynomial trends \u0026ndash; were regressed out. Finally, the normalized functional images underwent spatial smoothing with a Gaussian kernel (6 mm full width at half maximum (FWHM)).​\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e2.6.2 Whole-Brain Analysis\u003c/h2\u003e\u003cdiv id=\"Sec11\" class=\"Section4\"\u003e\u003ch2\u003e2.6.2.1 Individual-level Analysis​​\u003c/h2\u003e\u003cp\u003eSubject-specific General Linear Models (GLMs) were implemented in SPM12 to model the Blood Oxygenation Level-Dependent (BOLD) response to naturalistic video stimuli. The design matrix incorporated separate regressors for each video, convolved with SPM12\u0026rsquo;s canonical hemodynamic response function (HRF), to model condition-specific responses. Both emotional arousal ratings provided by participants were explicitly modeled within the GLM framework. To mitigate low-frequency signal drift, a high-pass filter with a cutoff period of 128 seconds was applied. The GLMs were estimated subject to standard linear assumptions (linearity, independence, and homogeneity of variance). During the analysis, covariates such as gender, age, and head movement were excluded to eliminate confounding effects. A total of six first-level directional contrasts were computed representing pairwise differences between rating levels: High\u0026thinsp;\u0026gt;\u0026thinsp;Low, Low\u0026thinsp;\u0026gt;\u0026thinsp;High, High\u0026thinsp;\u0026gt;\u0026thinsp;Medium, Medium\u0026thinsp;\u0026gt;\u0026thinsp;High, Medium\u0026thinsp;\u0026gt;\u0026thinsp;Low, Low\u0026thinsp;\u0026gt;\u0026thinsp;Medium.\u003c/p\u003e\u003cp\u003e​​\u003cb\u003e2.6.2.2 Group-level Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo identify significant neural emotion-arousal activation differences between adolescents with depression (MDD) and healthy controls (HC), a series of two-sample t-tests were performed on each of the twelve contrast images (i.e., one group-level model per contrast). ​​Crucially, to control for the family-wise error (FWE) rate arising from massive univariate testing across the whole brain, statistical inference was performed using cluster-based correction​​ (implemented within SPM12). Cluster-forming was initiated at a voxel-wise threshold of ​​\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The significance of spatially contiguous clusters resulting from this initial threshold was then assessed based on their extent under Gaussian Random Field Theory. Only clusters surviving a ​​cluster-level Family-Wise Error (FWE) corrected threshold of \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05​​ were considered statistically significant.\u003c/p\u003e\u003cp\u003e​​\u003cb\u003e2.6.2.3 Follow-up ROI Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor adolescents with depressive disorders patients who underwent fMRI scanning both before and after treatment (n\u0026thinsp;=\u0026thinsp;43), secondary small volume analyses\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e were conducted on regions demonstrating significant between-group differences in the whole-brain analyses. For the extraction of effect size we used Marsbar-0.45 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.sourceforge.net/projects/marsbar\u003c/span\u003e\u003cspan address=\"http://www.sourceforge.net/projects/marsbar\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Spherical regions of interest (ROIs) with a 6mm radius were defined bilaterally centered on the peak coordinates (-20, 34, 34; -32, 34, 28) identified in the whole-brain MDD vs HC contrasts relevant to therapeutic change. Mean beta parameter estimates from these ROIs for the key contrasts (High\u0026thinsp;\u0026gt;\u0026thinsp;Medium) were extracted for each patient\u0026rsquo;s pre-treatment and post-treatment scans. Potential treatment-related changes in emotion-arousal activation levels within these MDD patients were assessed using paired-sample t-tests.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Euclidean Distance Calculation\u003c/h2\u003e\u003cp\u003eFor patients undergoing personalized targeted therapy, we calculated the Euclidean distance between the coordinates of their treatment targets in standard space and the peak activation coordinates identified in the whole-brain analysis. After excluding one individual due to missing questionnaire data, IBM SPSS Statistics Version 27.0 (IBM Corp., Armonk, NY, USA) was used to analyze the correlation between these Euclidean distances and the psychological scale scores.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e\u003cp\u003eThe demographic information of the adolescent patients with depression and the healthy participants is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Chi-square tests or independent samples t-tests revealed no significant differences between the patient group and the control group in terms of gender (\u003cem\u003eχ\u003c/em\u003e\u0026sup2; = 0.66, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.417) or age (\u003cem\u003et\u003c/em\u003e = -1.08, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.288). Patients exhibited significant clinical improvement: HAMD scores decreased substantially after iTBS treatment (pre\u0026thinsp;\u0026gt;\u0026thinsp;post, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.009, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of the participants (M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMDD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eafter\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSample size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex(M/F)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17/41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15/28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14/22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAMD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.53\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGAD-7\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eHAMD, Hamilton Depression scale; M, male; F, female; GAD-7\u003csup\u003ea\u003c/sup\u003e means some subjects were not captured on the GAD-7 scales.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Whole-Brain Analysis Results\u003c/h2\u003e\u003cp\u003eIn the group-level analysis of naturalistic stimulus data, significant clusters demonstrating between-group differences were identified ​​after applying cluster-level Family-Wise Error (FWE) correction​​ (voxel-level threshold: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; significance threshold: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 FWE-corrected). Specifically, for the ​​High vs Medium Arousal contrast​​, two clusters survived correction: one in the left superior frontal gyrus (L-SFG; peak MNI coordinates: -20, 34, 34) and another in the left middle frontal gyrus (L-MFG; peak MNI coordinates: -32, 34, 28), as visualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Adolescent depression patients (MDD) exhibited significantly reduced emotion-arousal activation in these regions relative to healthy controls (HC) (HC\u0026thinsp;\u0026gt;\u0026thinsp;MDD, L-SFG: \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.27, FWE-corrected \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; L-MFG: \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.16, FWE-corrected \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.3 ROI Small Voxel Analysis Results\u003c/h2\u003e\u003cp\u003eBuilding upon whole-brain analysis findings, spherical ROIs (6mm radius) were centered on the L-MFG (peak MNI: -32, 34, 28) and L-SFG (peak MNI: -20, 34, 34) coordinates identified in the ​​High vs Medium Arousal contrast​​. Beta values extracted from these regions in adolescent depression patients pre- and post-iTBS treatment revealed differential responses.\u003c/p\u003e\u003cp\u003e​​For the L-MFG, paired-sample t-tests indicated a trend-level increase in emotion-arousal activation after treatment (​​post\u0026thinsp;\u0026gt;\u0026thinsp;pre​​, \u003cem\u003et\u003c/em\u003e = -1.69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.098). Although not meeting conventional significance thresholds, this directional effect suggests ​​elevated​​ neural responsiveness in the L-MFG following TMS intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Critically, concomitant with this neural change, patients exhibited significant clinical improvement​​ on the HAMD: HAMD scores decreased substantially after iTBS treatment (​​pre\u0026thinsp;\u0026gt;\u0026thinsp;post​​, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.009, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant treatment-related changes​​ were observed in the L-SFG.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Euclidean Distance Calculation Results\u003c/h2\u003e\u003cp\u003eThe target coordinates in standard space, derived from the most negative functional connectivity between L-DLPFC and pgACC, are shown in Fig.\u0026nbsp;4(A). We calculated the Euclidean distance between each subject's target coordinates and the peak emotion-arousal activation coordinates in the L-SFG (-20, 34, 34) and L-MFG (-32, 34, 28).\u003c/p\u003e\u003cp\u003eCorrelational analysis between these Euclidean distances and psychological scale scores revealed a significant negative correlation between GAD-7 reduction rates and the distance to the L-SFG (\u003cem\u003er\u003c/em\u003e = -0.468, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as illustrated in Fig.\u0026nbsp;4(B). This indicates that closer proximity of the treatment target to the L-SFG was associated with greater anxiety symptom relief and better treatment efficacy in adolescent depression patients. No significant correlations were found with other psychological scales.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study investigated the neural correlates of emotional processing deficits in adolescent depression and their therapeutic modulation by iTBS. Whole-brain analyses comparing patients and healthy controls revealed significantly ​​reduced emotion-arousal activation​​ within the left frontocortical circuitry\u0026mdash;specifically in the L-SFG and L-MFG\u0026mdash;during high versus medium arousal processing. Subsequent accelerated treatment with iTBS triggered significant clinical symptom improvement accompanied by a marginal enhancement of L-MFG emotion-arousal activation. This pattern of convergent neurobehavioral changes suggests that iTBS may engage prefrontal compensatory mechanisms, partially reversing task-specific hypoactivation implicated in emotional arousal dysregulation. In this study, N-fMRI and iTBS were combined and used in adolescent depressed patients for the first time, and N-fMRI was used to explore the abnormal brain activity of adolescent depressed patients in the presence of emotional arousal. The question of the difference in efficacy of patients after accelerated iTBS treatment was explored in depth.\u003c/p\u003e\u003cp\u003eThe significantly reduced emotion-arousal activation in the L-SFG and L-MFG in adolescent depression patients compared to healthy controls, suggests these regions may serve as critical neurophysiological substrates for depression. Over the past two decades, a widely accepted theoretical framework posits that depression results from dysregulation in these prefrontal-limbic circuits\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. The present study investigated abnormal brain activity in depressed patients using the relatively novel N-fMRI technique, and the results are consistent with previous findings, both of which indicate the importance of the frontal lobes in depressed patients. In addition, studies have indicated that fluctuations in the global fMRI signal are synchronized with physiological signals, which are closely related to changes in emotional arousal and physiological states\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Regarding emotional arousal, further research has pointed out that it has its own unique neural network, including regions such as the prefrontal cortex\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. These studies suggest that there is a close relationship between emotional arousal and brain activity, and applying emotional arousal in the study of psychiatric disorders such as depression is crucial.\u003c/p\u003e\u003cp\u003eFollowing accelerated iTBS treatment, emotion-arousal activation levels in this region showed an increase, a finding consistent with previous research results\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Adolescent depression patients exhibited symptom alleviation on the HAMD scale after iTBS therapy, further demonstrating the therapeutic efficacy of iTBS. However, the observed differences in this study were only marginally significant. This may be attributed to the influence of repeated naturalistic stimuli, where duplicated exposures affected emotion-arousal activation levels during subsequent viewing. Alternatively, the variability could stem from analytical approaches applied to naturalistic stimuli themselves. Compare to conventional task-based paradigms, diverse methodologies are employed for naturalistic stimuli\u0026mdash;for instance, Mosley\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e utilized Hidden Markov Models (HMM) to analyze such stimuli, while Xie\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e adopted a sliding window approach. Nevertheless, the present findings partially reveal that naturalistic stimuli can capture changes in emotion-arousal activation among adolescent depression patients, and concurrently corroborate that TMS stimulation of the left prefrontal cortex alleviates depressive disorders.\u003c/p\u003e\u003cp\u003eFor patients receiving personalized iTBS target treatment (n\u0026thinsp;=\u0026thinsp;19), we quantified the spatial proximity between individualized stimulation sites and the peak coordinate of the pathological locus (L-SFG) using Euclidean distance in standardized MNI space. ​​Correlation analysis​​ revealed a significant negative relationship between the Euclidean distance to the L-SFG and the percentage reduction in GAD-7 scores. Specifically, as the stimulation target approached the L-SFG coordinate, the GAD-7 symptom reduction rate increased, suggesting ​​anatomical specificity of treatment efficacy for anxiety symptoms​​. No significant correlations were found with other psychological scales.\u003c/p\u003e\u003cp\u003eThe specific association between stimulation proximity to the L-SFG and improvement in anxiety symptoms, as measured by the GAD-7, aligns with the nature of our naturalistic stimuli. These video clips, validated in a SAD cohort and depicting socially challenging scenarios, are potent in eliciting anxiety-related emotional arousal. This finding suggests that the L-SFG may be a key node in a circuit that processes socially-relevant anxious arousal. The improvement in GAD-7 scores, but not other scales, following stimulation near this region indicates that iTBS may exert part of its therapeutic effect by normalizing the brain's response to such anxiety-provoking contexts. This provides a neurobiological rationale for the frequent comorbidity of depression and anxiety and suggests that targeting the L-SFG could be a strategy for addressing both symptom domains.\u003c/p\u003e\u003cp\u003eDue to the inclusion of subjects undergoing different treatment regimens, this study comprised participants receiving iTBS therapy over either two or four days, in addition to some receiving personalized targeted interventions. Although this variation may have reduced the effective sample size and increased inter-subject heterogeneity, the potential impact on the primary outcomes is likely limited, given that the study aimed to investigate brain activity under emotional arousal and all therapeutic stimulations were consistently targeted at the LDLPFC. Future studies should nonetheless seek to control for treatment regimen variables and recruit larger samples to enable large-scale validation. Regarding the use of the GLM for analyzing N-fMRI data, alternative computational approaches\u0026mdash;such as HMM and sliding window techniques\u0026mdash;could be considered in subsequent work. Finally, caution is warranted when generalizing these findings, as the participant group was restricted to adolescents with depression. Follow-up studies involving adults with depression and patients with other psychiatric disorders are needed to extend the generalizability of the results.\u003c/p\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eIn summary, this research investigated the variability in treatment outcomes among adolescent depression patients following accelerated iTBS therapy. Utilizing N-fMRI, we observed reduced emotion-arousal activation in the L-SFG and L-MFG among depressed adolescents compared to healthy controls. After accelerated treatment with iTBS, adolescents with depression showed significant reductions in HAMD scale scores and L-MFG activity increased after treatment. Furthermore, we calculated the Euclidean distance between individualized iTBS therapeutic targets and these anomalous brain regions. Correlation analyses revealed that as stimulation targets approached the coordinates of the L-SFG, the GAD-7 symptom reduction rate increased. This suggests a relationship between TMS efficacy variability and stimulation location. Future studies should prioritize monitoring changes in this specific neuroanatomical region in depressed adolescents and explore underlying neural mechanisms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of Interests:\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests or conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe funding for this study was provided by the Tianjin Health Research Project (Grant No. TJWJ2023MS038), Tianjin Education Commission Research Project (Grant No. 2023KJ044) and Tianjin Key Medical Discipline (Specialty) Construction Project (Grant No. TJYXZDXK-3-015B).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.Z.: Methodology, Software, Formal Analysis, Investigation, Data Curation, Writing - Original Draft, Visualization.Y.L.: Writing - Review \u0026amp; Editing, Validation.J.W.: Investigation, Resources, Data Curation.P.L.: Investigation, Resources, Data Curation.Z.Y.: Supervision, Project Administration, Funding Acquisition.L.S.: Supervision, Project Administration, Funding Acquisition.B.Z.: Conceptualization, Methodology, Supervision, Writing - Review \u0026amp; Editing, Project Administration.\u003c/p\u003e\u003ch2\u003eAcknowledgment:\u003c/h2\u003e\u003cp\u003eWe thank all the study participants for their cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMalhi G, Mann J (2018) \u003cem\u003eDepression. 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J Neurosci 32(44):15277\u0026ndash;15283\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRedcay E, Moraczewski D (2020) Social cognition in context: A naturalistic imaging approach. NeuroImage 216:116392\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaarim\u0026auml;ki H (2021) Naturalistic stimuli in affective neuroimaging: A review. Front Hum Neurosci 15:675068\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBartels A, Zeki S (2004) Functional brain mapping during free viewing of natural scenes. Hum Brain Mapp 21(2):75\u0026ndash;85\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFinn ES, Bandettini PA (2021) Movie-watching outperforms rest for functional connectivity-based prediction of behavior. NeuroImage 235:117963\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKauttonen J et al (2018) Brain mechanisms underlying cue-based memorizing during free viewing of movie Memento. 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BMJ open 14(11):e081520\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFox MD et al (2012) Efficacy of transcranial magnetic stimulation targets for depression is related to intrinsic functional connectivity with the subgenual cingulate. Biol Psychiatry 72(7):595\u0026ndash;603\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePoldrack RA (2007) Region of interest analysis for fMRI. Soc Cognit Affect Neurosci 2(1):67\u0026ndash;70\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLu F et al (2021) Prefrontal-limbic-striatum dysconnectivity associated with negative emotional endophenotypes in bipolar disorder during depressive episodes. J Affect Disord 295:422\u0026ndash;430\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLei X et al (2023) Characterizing Unipolar and Bipolar Depression by Alterations in Inflammatory Mediators and the Prefrontal-Limbic Structural Network, vol 2023. Depression and Anxiety, p 5522658. 1\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBolt T et al (2025) \u003cem\u003eAutonomic physiological coupling of the global fMRI signal.\u003c/em\u003e : pp. 1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang R et al (2025) \u003cem\u003eA neurofunctional signature of affective arousal generalizes across valence domains and distinguishes subjective experience from autonomic reactivity.\u003c/em\u003e 16(1): p. 6492\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerlim M et al (2014) Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials. Psychol Med 44(2):225\u0026ndash;239\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGeorge MS, Taylor JJ, Short EB (2013) The expanding evidence base for rTMS treatment of depression. Curr Opin Psychiatry 26(1):13\u0026ndash;18\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMosley PE et al (2025) Markers of positive affect and brain state synchrony discriminate melancholic from non-melancholic depression using naturalistic stimuli. Mol Psychiatry 30(3):848\u0026ndash;860\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"brain-topography","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"btop","sideBox":"Learn more about [Brain Topography](http://link.springer.com/journal/10548)","snPcode":"10548","submissionUrl":"https://submission.nature.com/new-submission/10548/3","title":"Brain Topography","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Adolescent depression, Naturalistic fMRI, iTBS, emotional arousal","lastPublishedDoi":"10.21203/rs.3.rs-8011953/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8011953/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe rising incidence of adolescent depression in China causes significant impairments, necessitating rapid treatments such as accelerated Intermittent theta-burst stimulation(iTBS). However, responses to treatment vary. We used naturalistic functional magnetic resonance imaging(N-fMRI) to investigate the impact of depression on the neural processing of emotional arousal. The objectives of this study were: 1) to identify brain regions associated with treatment response, and 2) to correlate these neural signatures with clinical outcomes following accelerated iTBS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eFifty-eight adolescents with depression and twenty-nine healthy controls underwent fMRI while viewing emotion-evoking videos. Forty-three patients completed accelerated iTBS treatment, with pre- and post-treatment fMRI scans. Statistical analysis of the MRI data was performed in SPM12, employing cluster-based family-wise error correction at a significance threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWhole-brain analysis revealed that adolescents with depression exhibited significantly reduced emotion-arousal activation in the left superior frontal gyrus (L-SFG) and left middle frontal gyrus (L-MFG) compared to healthy controls during high-to-medium emotional arousal. Hamilton Depression Scale scores significantly decreased after iTBS treatment. L-MFG showed a marginally significant increase in emotion-arousal activation after iTBS. Correlation analysis between the Euclidean distance of treatment targets to the L-SFG and psychological scale scores revealed a significant negative association between the Euclidean distance and Generalized Anxiety Disorder-7 reduction rate.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis exploratory study suggests that abnormal activity in the L-SFG and L-MFG underlies the variable efficacy of accelerated iTBS in adolescent depression. Our findings indicate that proximity to the L-SFG is correlated with treatment response, and L-MFG beta values showed slightly increased post-treatment. These regions represent potential neuroanatomical targets for future investigation as biomarkers for iTBS mechanisms.\u003c/p\u003e","manuscriptTitle":"Intermittent theta-burst stimulation (iTBS) Modulates Abnormal Brain Activity During Emotional Arousal in Adolescent Depression","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 11:42:48","doi":"10.21203/rs.3.rs-8011953/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-04T23:25:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T14:27:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-12T17:20:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15586552952498219370846048326123902908","date":"2026-01-11T01:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310579499271054265989001213031739759887","date":"2026-01-09T09:02:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-04T14:56:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-05T15:00:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-05T08:53:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Brain Topography","date":"2025-11-02T15:35:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"brain-topography","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"btop","sideBox":"Learn more about [Brain Topography](http://link.springer.com/journal/10548)","snPcode":"10548","submissionUrl":"https://submission.nature.com/new-submission/10548/3","title":"Brain Topography","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b27af19f-c325-4261-8a70-c3028b76d379","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T09:14:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 11:42:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8011953","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8011953","identity":"rs-8011953","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}