Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study

Lana Donse; Frank Padberg; Alexander T Sack; A John Rush; Martijn Arns

doi:10.1016/j.brs.2017.11.004

Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study

Brain Stimul. 2018 Mar-Apr;11(2):337-345. doi: 10.1016/j.brs.2017.11.004. Epub 2017 Nov 11.

Authors

Lana Donse¹, Frank Padberg², Alexander T Sack³, A John Rush⁴, Martijn Arns⁵

Affiliations

¹ Dept. of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands; Research Institute Brainclinics, Nijmegen, The Netherlands.
² Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany.
³ Dept. of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands; Maastricht Brain Imaging Center, Maastricht, The Netherlands.
⁴ Duke-National University of Singapore, Singapore; Duke Medical School, Durum, NC, USA; Texas Tech University Health Sciences Center, Permian Basin, TX, USA.
⁵ Research Institute Brainclinics, Nijmegen, The Netherlands; Dept. of Experimental Psychology, Utrecht University, Utrecht, The Netherlands; neuroCare Group, Munich, Germany. Electronic address: martijn@brainclinics.com.

PMID: 29174304
DOI: 10.1016/j.brs.2017.11.004

Abstract

Background: Repetitive transcranial magnetic stimulation (rTMS) is considered an efficacious non-invasive neuromodulation treatment for major depressive disorder (MDD). However, little is known about the clinical outcome of combined rTMS and psychotherapy (rTMS + PT). Through common neurobiological brain mechanisms, rTMS + PT may exert enhanced antidepressant effects compared to the respective monotherapies.

Objective: The current naturalistic study aimed to evaluate feasibility and clinical outcome of rTMS + PT in a large group of MDD patients. The second aim was to identify clinical predictors of response and remission.

Methods: A total of 196 patients with MDD were treated with at least 10 sessions of simultaneous rTMS and PT. rTMS was applied over the DLPFC, either 10 Hz left or 1 Hz right. Psychotherapy was based on principles of cognitive behavioral therapy (CBT). Symptoms were measured using the BDI each fifth session until end of treatment and at 6-month follow-up. Comparisons were made between responders and non-responders, as well as between the 10 Hz and 1 Hz protocol. Additionally, baseline variables and early BDI change were evaluated as predictors of response/remission.

Major findings and conclusions: 1) Combining rTMS and PT resulted in a 66% response and a 56% remission rate at the end of treatment with 60% sustained remission at follow-up. Compared to previous findings in RCTs, these rates are relatively high; 2) No differences were found between the 10 Hz and 1 Hz TMS regarding clinical outcome; 3) Clinical baseline variables were not predictive of treatment outcomes; 4) Early symptom improvement (at session 10) was highly predictive of response, and may therefore be used to guide rTMS + PT continuation; 5) Based on the current findings in a large naturalistic study, future studies employing a more standardized method are warranted to draw solid conclusions on the unique effect of rTMS + PT.

Keywords: Clinical predictors; Cognitive-behavioral therapy (CBT); Major depressive disorder (MDD); Treatment outcome; repetitive transcranial magnetic stimulation (rTMS).

Publication types

Clinical Study

MeSH terms

Adult
Depressive Disorder, Major / therapy*
Female
Humans
Male
Middle Aged
Psychotherapy / methods*
Transcranial Magnetic Stimulation / methods*