Integrating Mindfulness Into TMS and tDCS for Depression Improves Outcomes

For patients with major depressive disorder (MDD), integrating medication and mindfulness psychotherapy into transcranial magnetic stimulation (TMS) and/or transcranial direct current stimulation (tDCS) results in better symptom improvement than either neuromodulation therapy alone. These findings from a systematic review were published in the Harvard Review of Psychiatry.

Previous research has established that noninvasive neuromodulation therapies – like TMS and tDCS – have demonstrated efficacy for treating some individuals with MDD. However, relatively little is known about how these neuromodulation therapies interact with psychotropic medications or psychotherapies for depression.

To address this knowledge gap, investigators conducted a systematic literature review to investigate whether combining medication and/or psychotherapy with TMS and tDCS is superior to neuromodulation therapy alone. The investigators searched publication databases from inception to December 5, 2023 for clinical research or open-label trials that evaluated the combination of TMS and tDCS with other therapies.

After screening and full-text review, the investigators included 58 studies for the present analysis. By neuromodulation type, 7 studies investigated the combination of TMS with psychotherapy, 32 evaluated TMS with psychopharmacological interventions, 7 studies examined tDCS with psychotherapy, and 12 investigated tDCS with medications.

For TMS, the investigators found that combining TMS and medications generally resulted in improved symptom reduction – especially when TMS was added to stable, ongoing medications or newly initiated citalopram. However, the evidence supporting the use of SNRIs, atypical antidepressants, or tricylic antidepressants with TMS for improved outcomes was weaker among patients with MDD, possibly due to the use of other medications in the studies, such as benzodiazepines or antipsychotics, which can have detrimental effects on MDD symptoms. Existing evidence also indicates that mindfulness plus TMS may be more effective than either modality alone. 

Similar to TMS, the combination of tDCS with mindfulness may be beneficial, but these results are preliminary and additional studies are needed to support its utility. Most of the tDCS plus medication studies evaluated stable doses of ongoing medications in combination with tDCS, showing a benefit over either modality alone. It remains unclear if antipsychotics interfere with tDCS responses as they do with TMS.

These findings indicate that combining TMS and tDCS with other therapies (ie, mindfulness and psychotropic medications) may benefit patients with MDD more than neuromodulation alone. The investigators concluded, “Future studies need to enroll larger samples, include randomized controlled study designs, create more uniform protocols for combined treatment delivery, and explore mechanisms and predictors of change.”

Limitations of the studies analyzed in the review include the predominance of open-label trials and/or those that lack a control group. Additionally, many of the studies had small sample sizes and the TMS studies had multiple different stimulation protocols.

Disclosure: Some of the study author(s) declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Psychiatry Advisor