Rationale for Combining TMS and Psychotherapy

One of every four patients with a psychiatric disorder does not adequately respond to or tolerate standard treatment (Bajbouj and Padberg 2014). The burden of insufficiently treated mental illness manifests in decreased quality of life, increased socioeconomic burden, and higher risk of morbidity and mortality. As Bajbouj and Padberg (2014) point out, a multimodal approach should be chosen for patients with treatment-refractory disorders. Although psychotherapy and psychopharmacological combinations are often used together for moderately to severely ill patients, studies find that this approach is not effective for about 30% of major depressive episodes (Rush et al. 2006; Serafini et al. 2015). Adjunctive brain stimulation interventions may facilitate psychotherapeutic processes and are already being used to treat various psychiatric disorders. Patients are increasingly interested in nonmedication treatments because medications are not always effective and have significant side effects. Additionally, psychotherapeutic treatments may take time to yield effect and can be burdensome on individuals due to the time commitment involved and expensive out-of-pocket costs. It is important to keep in mind, however, that TMS does not replace psychotherapeutic or psychopharmacological interventions; rather, it represents another treatment option as part of a multimodal approach for these complex disorders.

Although psychotherapy is a well-established approach in the treatment of depression, researchers are now investigating whether brain stimulation combined with therapeutic interventions can enhance patient outcomes. Not only does TMS improve depressed mood, but it is also a promising modality to enhance cognition (Guse et al. 2010; Serafini et al. 2015). Evidence suggests that plasticity in the brain in response to stimulation depends on the state of the brain or the activation of the circuit during stimulation, inferring that brain plasticity may be impacted by how activated neural circuits are during TMS sessions (Vedeniapin et al. 2010). There is also evidence that psychotherapy induces neuroplastic changes in brain function and structure (Figure 5–1). The fact that both modalities have this capacity raises the distinct possibility that engaging the brain via psychotherapy during a TMS session (in which the brain is being stimulated) may magnify the benefits of both treatments. In other words, while undergoing TMS a more engaged brain (i.e., during psychotherapy) may be more receptive to the benefits of TMS than a less engaged brain (i.e., while watching TV). Thus, combining the two interventions may, in fact, have a synergistic effect by modulating mood circuits in complementary ways. Although TMS may prime and/or augment psychotherapy if treatments are administered in succession (“offline” treatment), it is also practical to coadminister psychotherapy during TMS sessions (“online” treatment) because patients are coming to the clinic 5 days/week and on average are in a treatment session for 35–45 minutes. Figure 5–2 provides a visual overview of various ways to administer TMS with psychotherapy.

Can a patient’s specific brain state be changed or supported during TMS sessions such that there are improved outcomes? Isserles et al. (2011) hypothesized that the antidepressant outcome of TMS treatment is affected by a cognitive-emotional procedure performed during stimulation. Patients received 4 weeks of daily TMS and 4 weeks of maintenance TMS. Two subgroups of patients received either positive or negative cognitive-emotional reactivation along with the stimulation sessions. These states, either positive or negative, were induced by patients reading short directive paragraphs describing personalized positive or negative emotional states prior to and during the treatments.

Across all of the groups, 21 of 46 patients (46%) who received at least 10 stimulation sessions achieved response (improvement of ≥50% on the Hamilton Depression Rating Scale [HDRS]), and 13 (28%) achieved remission (HDRS ≤10) by the end of the daily treatment phase. Improvements were smaller in the negatively reactivated group, and Beck Depression Inventory (BDI) scores were not significantly improved in this group, signifying that negative cognitive-emotional reactivation may disrupt the therapeutic effects of deep TMS. These results suggest that topics of discussion and focus during TMS treatment sessions may affect response to treatment, although more studies with larger sample sizes are needed. Investigators at Duke University plan to further test this hypothesis by engaging a specific brain network, using cognitive restructuring (a cognitive-behavioral therapy [CBT] technique), and enhancing learning by using TMS (Neacsiu 2015). The results are likely to add to the growing body of evidence that what happens while patients are in the treatment chair impacts treatment outcomes.

Review of Literature

Although the benefits of combining TMS and psychotherapy are promising, the use of TMS in conjunction with psychotherapy has not been well studied. It is not clear whether patients in outpatient, open-label effectiveness trials (Carpenter et al. 2012) received psychotherapy while in treatment. In our own TMS centers, the decision to combine psychotherapy with TMS is an individualized treatment decision. We find that some patients prefer to temporarily stop psychotherapy because of the time commitment with TMS, whereas others who have started to benefit from TMS resume therapy and report improved effectiveness. Nonetheless, a literature review of TMS and psychotherapy provides insight into this promising multimodal approach. Although many questions remain unanswered, a growing body of evidence supports coalescing therapeutic modalities and TMS for both psychiatric and neurological disorders. Table 5–1 provides an overview of the various therapeutic modalities studied in combination with TMS.

Combining Therapy, Behavioral Skills, and Exercises With TMS

There are several depression-specific therapies and behavioral skills that can be combined with TMS both during and outside of treatment sessions (Strunk 2017). As highlighted earlier, when psychotherapies or exercises are prescribed outside of the TMS therapy session, they are referred to as “offline” interventions, but when administered during the TMS therapy session, they are referred to as “online” interventions. Behavioral activation, cognitive therapy, and interpersonal psychotherapy have strong research support as monotherapies for patients with depression. These treatments are used in clinical practice and should be thought of as optimal modalities to combine with TMS for patients with TRD.

Before therapy is initiated, it is important to understand the patient’s history of therapy; this helps to determine the individual’s level of treatment resistance and provides an inventory of prior therapies. Histories should document the approximate start and stop dates of treatment, frequency of sessions, type of psychotherapy or skills taught, treatment focus, and therapist’s name and degree. If validated instruments were used to measure change in depressive symptoms, then pretreatment and posttreatment scores should be documented. Patients can usually report a subjective sense of whether a treatment was helpful, partially helpful, or unhelpful. Some patients are hesitant to restart therapy or continue therapy in conjunction with TMS because they may have a perception that therapy “did not work” or may reference time constraints as a barrier to pursing both treatments. Building motivation, establishing goals, and exploring negative perceptions about therapy are instrumental for patients to have success when combining TMS with therapy.