Transcranial Magnetic Stimulation and Psychotherapy


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Transcranial Magnetic Stimulation and Psychotherapy


Sasha Bergeron, M.S.N., PMHNP-BC
Richard A. Bermudes, M.D.


In the overall management of any illness, a clinician should consider an approach that yields high efficacy with comparatively few side effects. Complex psychiatric disorders often require a multimodal treatment model to improve outcomes, especially for patients with treatment-resistant disorders. In this chapter, we review nonpharmacological interventions used in conjunction with transcranial magnetic stimulation (TMS) for the treatment of psychiatric and neurological disorders. A number of studies, ranging from case reports to randomized controlled trials, support the use of such an integrated approach. The combination of TMS with therapeutic interventions is rooted in both practical and biological rationale. We review evidence-based psychotherapies for treatment-resistant depression (TRD) and explore the feasibility of implementing them over the course of TMS therapy. Rather than totally replacing ongoing psychological treatments, TMS should be used in conjunction with other well-established modalities to enhance outcomes for difficult-to-treat populations.


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.



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Figure 5–1. Psychotherapy and transcranial magnetic stimulation induction of neuroplastic changes that normalize neural networks instrumental in mood regulation.


(A) Theoretically, psychotherapy and transcranial magnetic stimulation (TMS) may be combined to target prefrontal cortex function, resulting in improved cognitive control and improved emotional regulation (“top down”). (B) Certain psychotherapeutic practices may target limbic network functioning and may be combined with TMS, resulting in improved emotional functioning (“bottom up” and “top down”).



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Figure 5–2. “Online” and “offline” administration of psychotherapy plus transcranial magnetic stimulation.


Transcranial magnetic stimulation and psychotherapy can be administered (A) during the same session (“online”); (B) sequentially, so as to prime one intervention (“offline”); or (C) randomly, but during the same treatment course (“offline”).



CLINICAL VIGNETTE


The patient is a 57-year-old man receiving bilateral TMS for his severe, recurrent TRD and comorbid generalized anxiety disorder. He previously underwent two courses of CBT and multiple antidepressant medication trials, each of which was ineffective. Over the course of his TMS treatment (42 sessions total), he received concurrent psychotherapy during his TMS sessions one to two times weekly (“online” treatment) as well as one “offline” session weekly that occurred either immediately before or after a TMS session. His treatment provider administered psychotherapy and managed the psychotropic medications. Various therapeutic modalities that were incorporated into sessions included behavioral activation and cognitive restructuring (a CBT approach); relaxation training using a progressive muscle relaxation exercise; problem-focused therapy to correct sleep and appetite disturbances; mindfulness meditation techniques, such as awareness of breath and purposeful attention to the present moment; and supportive therapy, including empathetic listening, reassurance, and encouragement.


Practical implementation involved the selection of specific, effective therapeutic interventions. The components necessary to foster a good therapeutic rapport included eye contact, positioning, volume of speech, and privacy. These were maintained utilizing a variety of techniques: The provider sat directly in front of the patient, at a height that was comfortable to maintain eye contact, because the patient was in a fixed position during treatment. Both the provider and the patient were sensitive to the auditory interruptions of the TMS pulse trains, and during the right-sided low-frequency treatment (1 pulse per second), each spoke at a slightly higher than normal amplitude over the metronomic pulse delivery. For the left-sided high-frequency treatment (10 pulses per second for 4 seconds), speech was paused, even if mid-sentence, and resumed during the intertrain interval (10 seconds). Privacy was maintained with white noise machines throughout the office. The patient agreed to participate in therapy knowing a technician would be present; the technician maintained discretion during sessions and had a good rapport with the patient. Ultimately, the patient achieved a 63% reduction in depressive symptoms as measured by the 9-item Patient Health Questionnaire (PHQ-9) and a 66% reduction in anxiety symptoms as measured by the Generalized Anxiety Disorder 7-item scale (GAD-7). In his final session, the patient reflected that the combination of psychotherapy and TMS was particularly helpful in identifying triggers and improving coping skills. In summary, practical barriers to implementing concurrent TMS and psychotherapy were easily identified and adjusted to provide a successful course of “online” therapy with TMS.


Though more research is needed on the topic, evidence is building that this simultaneous treatment approach may have enhanced outcomes for a patient with severe TRD.


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.























































Table 5–1. Overview of psychotherapeutic modalities used with transcranial magnetic stimulation (TMS) for various disorders


Condition


Therapy


Delivery


Reference


Depression


Cognitive-behavioral therapy


Online


Vedeniapin et al. 2010


Posttraumatic stress disorder


Exposure therapy


Online


Osuch et al. 2009


Obsessive-compulsive disorder


Exposure and response prevention therapy


Offline


Grassi et al. 2015


Poststroke


Speech and language therapy


Offline


Yoon et al. 2015



Virtual reality training


Online


Zheng et al. 2015



Occupational therapy


Offline


Kakuda et al. 2010


Alzheimer’s disease


Cognitive training


Offline


Rabey et al. 2013


Note. Online=therapy delivered simultaneously with TMS treatment; offline=therapy delivered outside of TMS treatment session but over the course of TMS treatment.


TMS AND PSYCHOTHERAPY FOR MAJOR DEPRESSIVE DISORDER


Although research combining TMS with psychotherapy for the treatment of major depression is limited, there is a case report describing the use of CBT with TMS in a patient with TRD. Vedeniapin et al. (2010) treated a female patient who had severe TRD with simultaneous CBT and left prefrontal TMS (“online” treatment). Prior to the study, the patient had responded to a course of TMS, but a mild relapse 1 year later necessitated a subsequent series of 14 TMS sessions. Symptoms gradually worsened again, even with medication management and weekly psychotherapy. At the time of this study, the patient’s depressive symptoms were severe. She was first educated on the basics of CBT and then received 14 excitatory (10 Hz) TMS-CBT sessions, interspersed with 25 TMS-only sessions over an 8-week course of treatment. She experienced a gradual reduction in symptoms, ultimately achieving remission, with fewer sessions overall during this course of treatment (39 total sessions) than in her initial course of TMS (59 total sessions). She maintained remission for at least 3 months. This case report suggests that CBT can be combined with TMS to improve symptoms and maintain remission from depression, although more research with controlled studies is needed (Vedeniapin et al. 2010).


Functional neuroimaging research suggests that mindfulness exercises activate a number of brain structures implicated in regulating emotions and reappraisal, including the dorsolateral prefrontal cortex (DLPFC) (Chiesa et al. 2013; Ochsner et al. 2002). A related question is whether TMS can be used to prime for psychotherapeutic interventions. In a retrospective chart review, Leong et al. (2013) examined the change in four components of mindfulness in individuals with major depression who had received a course of TMS. The investigators reported that patients’ scores significantly improved on the Nonreactivity to Inner Experience subscale of Baer’s Five Facet Mindfulness Questionnaire (BFFMQ) (P<0. 05) and on the Decentering subscale of the Experience Questionnaire (EQ) (P<0.05). Of note, scores on these components of mindfulness showed improvement after TMS and were independent of changes in depression scores. The subjects showed improvement in emotional regulation normally seen in individuals who practice mindfulness. Although in this study mindfulness exercises were not prescribed during the TMS treatment course, one wonders if the combination of TMS and mindfulness may enhance or speed up achieving better emotional regulation. Referring practitioners may consider prescribing mindfulness exercises to be used alongside a course of TMS therapy.


TMS AND PSYCHOTHERAPY FOR OTHER PSYCHIATRIC DISORDERS


Evidence is emerging regarding the benefits of using psychotherapy and TMS to treat disorders other than major depressive disorder. For example, Marin and Milad (2015) hypothesized that augmentation with TMS could facilitate the consolidation process of learning during exposure-based therapies and improve responses for patients with treatment-resistant posttraumatic stress disorder (PTSD). In a crossover study, Osuch et al. (2009) randomly assigned nine adults with treatment-refractory PTSD to imaginal exposure therapy combined with 1-Hz TMS over the right DLPFC or a sham procedure. Prior to treatment, patients developed an individual exposure hierarchy consisting of 10 cues for use during sessions. The hierarchy began with an item 0, chosen by the subject to be calming, with subsequent experiences eliciting incrementally increasing levels of distress. During the sessions, patients could control how much of the traumatic experience they were exposed to, could talk about any of the traumatic cues, or could remain silent. All patients completed the 4-week protocol of imaginal exposure therapy during TMS (“online” therapy). Although this was a small study, active TMS treatment showed a large, but not significant, effect on hyperarousal symptoms compared with sham TMS (P=0.08). Furthermore, 24-hour urinary norepinephrine and serum thyroxine levels increased, and prolactin levels decreased. The authors concluded that TMS therapy with imaginal exposure therapy was well tolerated and feasible and had symptomatic as well as physiological effects in patients with severe, treatment-refractory PTSD (Osuch et al. 2009). These results, although preliminary, support conducting larger studies in the future to clarify the effects of combining exposure therapy with TMS for PTSD.


In an individual case report, TMS enhanced the results of exposure and response prevention therapy for a patient with treatment-resistant obsessive-compulsive disorder (OCD) (Grassi et al. 2015). The subject in this report was a 32-year-old woman with severe OCD (since age 10) and concurrent mild depression. She experienced a low level of daily functioning and had failed to respond to multiple serotonergic drugs, augmentation with second-generation atypical antipsychotics, and two different CBT trials at specialized OCD centers. As described in this case report, she underwent 16 sessions of CBT, with the latter 10 centered on exposure and response prevention exercises. Prior to each exposure session, she was given a high-frequency TMS session over the left DLPFC. A score reduction of 32.14% from her baseline score on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was observed after the final treatment session and was maintained at 6-, 12-, and 24-month follow-ups. The patient also reported significantly improved quality of life and daily functioning. Grassi et al. (2015) concluded that TMS might enhance extinction learning because of its durable effects on neuroplasticity, although further systematic studies are required to establish reliability.


TMS AND REHABILITATIVE THERAPIES FOR NEUROCOGNITIVE DISORDERS


In addition to being combined with psychotherapy, TMS can be combined with other nonpharmacological interventions to treat various neurocognitive disorders. Neurocognitive illnesses and injuries are disabling and negatively impact physical functioning, mental capacity, relationships, and employment. Furthermore, standard treatments such as rehabilitative therapy and pharmacological treatment rendered in community settings do not fully restore affected patients. Research has recently examined the combination of TMS with rehabilitative therapies to treat neurocognitive disorders. Table 5–2 provides an overview of the literature on integrating TMS with rehabilitative therapies in the treatment of select neurocognitive disorders.


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.














































Table 5–2. A selective literature review concentrating on transcranial magnetic stimulation (TMS) and rehabilitative therapies in the treatment of neurocognitive disorders


Rehabilitative therapy


Treatment-focused problem


Study design


Methods


Summary of findings


Speech and language therapy (SLT)


(Yoon et al. 2015)


Poststroke nonfluent aphasia


Case study


Experimental group (n=10): 1-Hz TMS 5 days a week with 2 days followed by SLT for 4 weeks.


Control group (n=10): SLT 2 times a week for 4 weeks.


TMS+SLT group showed significant improvement over SLT-only group in repetition and naming.


TMS prior to SLT could precondition brain to be more responsive to intensive training programs for aphasia and help facilitate neural activity, although more research is required.


Cognitive training (COG)


(Rabey et al. 2013)


Alzheimer’s disease (AD)


Double-blind RCT


Treatment group (n=7): 1-Hz daily TMS-COG.


Control group (n=8): sham TMS-COG.


Both groups received 5 sessions/week for 6 weeks, followed by biweekly sessions for 3 months.


Primary outcome was significantly improved cognitive scores for the treatment group.


Secondary outcomes included significant improvement in score on the Clinical Global Impression of Change (CGIC) and nonsignificant improvement in score on the Neuropsychiatric Inventory (NPI) for the treatment group.


TMS-COG was found to be safe and efficacious for improving cognitive function in AD.


Virtual reality (VR) training


(Zheng et al. 2015)


Upper limb functioning for poststroke hemiplegia


Double-blind RCT


Experimental group (n=55): low-frequency TMS+VR training.


Control group (n=53): sham TMS+VR training.


Both groups received therapy 6 days/week for 4 weeks.


Upper limb motor function was significantly increased in the experimental group compared with the control group.


Results suggest that low-frequency TMS+VR training is a promising rehabilitative treatment for effectively improving upper limb function in patients with hemiplegia following subacute stroke.


Occupational therapy (OT)


(Kakuda et al. 2010)


Upper limb hemiparesis poststroke


Case study


Inpatient combination treatment provided for 5 poststroke patients with upper limb hemiparesis.


Over 6 consecutive days, each patient received 10 sessions of 1-Hz TMS and intensive OT.


All patients completed treatment protocol, and none showed adverse effects.


At the end of treatment, scores assessing motor function in the affected upper limb had improved in all patients.


No deterioration of improved upper limb function was observed at 4 weeks posttreatment.


Combination treatment seems safe and feasible, but larger studies are required for validation.


Note. RCT=randomized controlled trial.



“OFFLINE” PSYCHOTHERAPEUTIC INTERVENTIONS AND TMS


CBT is well studied for patients with TRD (Wiles et al. 2013). This approach utilizes a systematic method to analyze and evaluate negative thought patterns. Patients receiving TMS can do cognitive therapy while in treatment (i.e., “online”) and over the course of treatment (i.e., “offline”). CBT can also be introduced to patients as they improve over a course of TMS or after they achieve acute response or remission because CBT can support remission maintenance (Biesheuvel-Leliefeld et al. 2015). Basic cognitive and behavioral skills can be taught to patients during a course of TMS therapy with Internet-based programs such as the MoodGYM training program (moodgym.com.au). Table 5–3 provides a list of popular computer-based and facilitated psychotherapeutic interventions. For most common anxiety and mood disorders, computer-based CBT programs can be as effective as face-to-face therapy, provided periodic check-ins with a therapist are maintained (Cuijpers et al. 2010). There are also several applications available for mobile phone users based on CBT, and preliminary studies indicate that these applications are comparable to computer-based CBT programs (Watts et al. 2013). In addition, mobile system applications may improve adherence and access, because users can learn or practice skills when it is most convenient for them.


Behavioral activation (BA) is an empirically supported therapy for patients with moderate to severe depression (Strunk 2017). Depressed patients experience decreasing positive emotions in their environments, and in an effort to cope with these negative emotions, they often withdraw and isolate themselves, leading to increased maladaptive behaviors. Through BA, patients identify these behaviors and develop activities and actions that lead to more positive emotions, thus increasing positive reinforcement. BA has research support for its use in both the acute and maintenance phases of depression (Dimidjian et al. 2006; Dobson et al. 2008). BA or behavioral techniques, which target avoidance and withdrawal behaviors, are practical for patients who are “cognitively shut down” by their depression, and they are validated as stand-alone treatments for major depressive disorder. For patients with TRD who are undergoing a course of TMS, BA techniques may be utilized in a variety of ways, including simple coaching by the TMS treatment team and “offline” delivery with a separate therapist.


Mindfulness-based CBT has research support for use with patients with TRD (Eisendrath et al. 2008). It was one of the first therapy systems to demonstrate that patients receiving the treatment, specifically during the remission phase of depression, had reduced relapse rates compared with patients receiving usual care (Teasdale et al. 2000). Mindfulness-based CBT combines cognitive techniques and mindfulness practices to help patients better recognize catastrophic cognitions regarding their moods, which predispose them to depressive relapse. Patients practice specific exercises and learn to direct their attention to what is happening in the present moment, while taking a nonjudgmental approach to their experiences. Mindfulness-based CBT is becoming more readily available, and there have been several patient self-help books published (e.g., Williams et al. 2007).










































Table 5–3. Computer-facilitated psychotherapeutic interventions


Product name


Description


Link


MoodGYM


Free Web-based CBT for depression


moodgym.com.au


Headspace


Subscription smartphone/tablet app; guided meditation for stress and anxiety


www.headspace.com


myCompass


CBT self-help program for managing depression, stress, and anxiety; free and available on any type of device


www.mycompass.org.au


Sleepio


CBT self-help insomnia program; subscription-based program with Internet and mobile applications


www.sleepio.com


E-couch


Free Web-based self-help program for depression and anxiety; draws from CBT and IPT


ecouch.anu.edu.au


MoodKit


CBT-based mobile platform for tracking mood and mood-boosting activities and skills


www.thriveport.com


Note. CBT=cognitive-behavioral therapy; IPT=interpersonal psychotherapy.


Interpersonal therapy (IPT), another modality of psychotherapy, was initially studied for the treatment of major depression. The basis for this therapy lies in the theory that changes in interpersonal relationships often trigger depression. Depressive symptoms can also change or negatively impact interpersonal relationships. Over the course of 12–16 sessions, IPT therapists focus on improving problematic interpersonal relationships that directly relate to the patient’s current depressive episode. Patients receiving IPT during the acute phase of depression or after achieving remission have improved durability of remission (Cuijpers et al. 2016). Thus, IPT can be started in conjunction with TMS or after patients have achieved response or remission and are tapering TMS therapy.


There is research supporting the use of IPT for patients with other conditions, such as eating disorders (Cuijpers et al. 2016). Therefore, several clinical considerations may influence the decision to use this therapy, including the impact of depressive symptoms on interpersonal functioning, depression precipitated by a significant interpersonal change, a diagnosis of unipolar or bipolar depression, and comorbidity with an eating disorder. There is also an Internet-based IPT program, E-couch (ecouch.anu.edu.au; see Table 5–3), which can be easily incorporated into TMS sessions and reinforced by the TMS treatment team.


Engaging in healthy behaviors and activities between TMS treatment sessions can benefit patients. Table 5–4 lists multiple activities, such as exercise, yoga, and journaling, that can assist the patient in countering the symptomatic isolation and withdrawal of severe depression. Patients can be encouraged by their TMS provider and TMS technician to engage in such activities over the course of TMS therapy. Anecdotally, patients who engage in healthy behaviors early in their treatment course have greater and more durable reductions in depressive symptoms; however, no systematic research has been done on the combination of these activities with TMS.


“ONLINE” PSYCHOTHERAPEUTIC INTERVENTIONS AND TMS


A number of psychotherapeutic interventions can be used by the treatment team during TMS treatment sessions. These include the use of self-help manuals, Internet therapies, and brief coping skills, which may be taught or coached by TMS technicians while the patient is in the TMS chair. These treatments are considered low-tech in the sense that they can be delivered during the treatment session by a TMS technician or with the use of readily accessible technology, such as a TV or tablet. High-tech treatments are less common during the TMS session because they require a licensed therapist trained in depression-specific therapies. Because patients come to treatment 5 days/week for 4–6 weeks, and treatments typically last 35–40 minutes, it is important to plan and discuss how to best utilize patients’ time in the treatment chair. Each TMS treatment provides an opportunity to use a multimodal treatment approach within the same session (“online”), pairing brain stimulation with daily, assisted therapeutic work.





































Table 5–4. “Offline” therapeutic activities to augment antidepressant effects of transcranial magnetic stimulation


Walking at least 30 minutes/day


Yoga


Meditation practice


Hiking


Tennis and other sports


Hobbies such as knitting


Good sleep hygiene


Healthy eating (e.g., reducing or eliminating sugar or gluten)


Joining jogging or running groups


Reestablishing friendships


Journaling


Moderating caffeine and alcohol intake


Increasing natural light exposure


Volunteering/community service


Religious or spiritual activities



Internet therapies are widely available and are tools that can be easily incorporated into the TMS treatment room via a smart TV or handheld tablet. TMS technicians can “coach” or cue patients in certain exercises or skills, as prescribed by the treating provider. While in the TMS chair, patients could have the option to complete programs directed at specific diagnoses, such as depression or anxiety, or to select programs targeting specific symptoms, such as sleep or cognitive function. Programs that target anxiety, for example, can be used to address comorbidities, such as ruminating or catastrophizing thoughts. Although research on combining computerized therapy with TMS is limited, the combination is typically proven effective in treating cognitive conditions; in our experience, patients are accepting of these applications and, upon completion, report the programs as helpful. Furthermore, the successful implementation of these programs can bolster patients’ skill sets, empowering them to pursue continued mental health treatment, such as individual face-to-face therapy, following the completion of TMS.


Many brief psychotherapeutic skills can be taught or reinforced by the TMS technician during treatment sessions. Table 5–5 lists strategies that can be implemented while the patient is in the treatment session. For example, negative thinking about oneself, others, and one’s future (Beck’s negative triad; Beck et al. 1987) is pervasive in depression; learning to identify the triggers for one’s negative thinking, maladaptive thought patterns, and typical cognitive errors can be easily accomplished with some basic training and reinforcement from the TMS technician. Acquisition of this type of skill is a neurobehavioral intervention with specific functional impact on the DLPFC, which correlates with improved functioning and “top-down” control of the limbic system (Ritchey et al. 2011).


Other behavioral skills that can be taught to depressed patients include brief mindfulness exercises, such as breathing mindfulness and a body scan (Kabat-Zinn 2013). Protocols lasting 10 and 20 minutes are readily available on several music streaming services and mobile applications. Meditation exercises are associated with greater top-down control in the short term and with downregulation of the limbic system over the long term (“bottom-up”) (Chiesa et al. 2013). Having patients practice these skills while simultaneously receiving neuromodulation may facilitate faster acquisition, leading to a more durable antidepressant response. Research on such combinations is ongoing, but prospects appear promising and feasible to implement across TMS clinics.


Befriending is a treatment that increases social support for patients with depression, and NICE clinical guidelines suggest a role for this type of therapy for patients with chronic depression (Middleton et al. 2005). Befriending can be utilized during TMS to engage patients in an ongoing discussion of everyday topics and current events in a neutral, friendly, and nonconfrontational manner, without the expectation of solving problems or working through conflicts or emotions. Befriending is typically administered by unlicensed volunteers with 2–3 days of training (Mead et al. 2010). Harris et al. (1999) demonstrated the efficacy of befriending using volunteers for individuals with chronic depression. A meta-analysis of befriending therapy for depressive symptoms suggests the intervention has significant effects on depressive symptoms compared with usual care or no treatment (Mead et al. 2010). Befriending therapy has not been studied with TMS, but given its brief training period and application by unlicensed volunteers, it could be easily administered during treatment sessions.










































Table 5–5. Brief “online” therapeutic activities for use during a transcranial magnetic stimulation therapy session


Goal setting


Positive imagery


Body scan mindfulness exercise


Mindfulness of the breath exercise


Progressive muscle relaxation


Psychoeducation about depression


Creating a sleep diary


Creating a nutrition diary


Breathing retraining to cope with anxiety


Identifying automatic thoughts and cognitive errors


Modifying negative thinking


Identifying triggers for depression


Activity scheduling


Psychoeducation regarding sleep


Psychoeducation regarding exercise


Creating symptom diaries


Leisure activities (e.g., listening to music or podcasts, watching TV)



Conclusion


The research supporting the combination of TMS with psychotherapy is still in its infancy. However, the importance of the combination of TMS with rehabilitative therapies, such as cognitive exercises, physical therapy, or occupational therapy, appears to be well documented for treating certain neurological disorders. We hypothesize that a patient’s brain state matters while he or she is in the TMS treatment chair and that supporting treatment sessions with “online” therapeutic interventions may enhance outcomes. Furthermore, what a patient does with his or her time between TMS treatments (“offline”) may also impact improvement. Thus, assessing a patient’s psychotherapy history and prescribing psychotherapeutic activities is necessary when prescribing TMS for a patient with treatment-resistant depression.



KEY CLINICAL POINTS


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• Patients prescribed TMS should be prescribed therapies delivered “offline” (i.e., therapies occurring over the course of TMS therapy but separately from the TMS treatment session). These include cognitive-behavioral therapy, behavioral activation, mindfulness-based cognitive-behavioral therapy, and interpersonal therapy.


• Patients prescribed TMS should be prescribed therapies delivered “online” (i.e., during the TMS treatment session). These include Internet-based therapies, mindfulness meditation, and befriending therapy.


• TMS technicians can provide brief therapeutic activities that do not require a licensed clinician and offer options to improve the use of patients’ time in the treatment chair.


• Patients should be encouraged to engage in healthy behaviors, lifestyles, and relationships when prescribed TMS.



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Mar 17, 2020 | Posted by in PSYCHIATRY | Comments Off on Transcranial Magnetic Stimulation and Psychotherapy
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