Bifrontal-transcranial direct current stimulation as an early augmentation strategy in major depressive disorder: A single-blind randomised controlled trial

A Review of Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation Combined with Medication and Psychotherapy for Depression

LEARNING OBJECTIVES

After participating in this CME activity, the psychiatrist should be better able to:• Compare and contrast therapies used in combination with transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) for treating MDD.

BACKGROUND

Noninvasive neuromodulation, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), has emerged as a major area for treating major depressive disorder (MDD). This review has two primary aims: (1) to review the current literature on combining TMS and tDCS with other therapies, such as psychotherapy and psychopharmacological interventions, and (2) to discuss the efficacy, feasibility, limitations, and future directions of these combined treatments for MDD.

METHOD

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched three databases: PubMed, PsycInfo, and Cochrane Library. The last search date was December 5, 2023.

RESULTS

The initial search revealed 2,519 records. After screening and full-text review, 58 studies (7 TMS plus psychotherapy, 32 TMS plus medication, 7 tDCS plus psychotherapy, 12 tDCS plus medication) were included.

CONCLUSIONS

The current literature on tDCS and TMS paired with psychotherapy provides initial support for integrating mindfulness interventions with both TMS and tDCS. Adding TMS or tDCS to stable doses of ongoing medications can decrease MDD symptoms; however, benzodiazepines may interfere with TMS and tDCS response, and antipsychotics can interfere with TMS response. Pairing citalopram with TMS and sertraline with tDCS can lead to greater MDD symptom reduction compared to using these medications alone. 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.

Efficacy of non-invasive brain stimulation combined with antidepressant medications for depression: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Antidepressants, noninvasive brain stimulation (NIBS), and their combination are commonly used in routine clinical practice. Nevertheless, there is a continuous dispute regarding whether the effectiveness of NIBS in combination with antidepressants exceeds that of antidepressants alone. This meta-analysis aimed to evaluate the existing evidence and draw a definitive conclusion on this issue.

METHODS

We conducted a comprehensive search of five databases: Embase, PubMed, Web of Science, SinoMed, and the Cochrane Database of Randomized Controlled Trials. The search was conducted until October 6, 2023. The primary outcomes were the pre- and post-intervention depression and anxiety scores. Secondary outcomes included dropout rates, response rates, and certain levels of neurotransmitters [ 5-hydroxytryptamine (5-HT), dopamine (DA), and gamma-aminobutyric acid (GABA)] at the end of the intervention. Subgroup, meta-regression, and sensitivity analyses were performed to explore the sources of heterogeneity. The data were analysed using R 4.2.2.

RESULTS

We included 18 RCTs [1357 participants; 11 studies used repetitive transcranial magnetic stimulation (rTMS) and 7 studies used transcranial direct current stimulation (tDCS)]. The follow-up duration varied from two weeks to three months. Overall, whether in combination with rTMS or tDCS, antidepressants proved more effective in alleviating depressive symptoms compared to when used as monotherapy. However, this advantage was not evident during the follow-up period. (p > 0.05). And the combination's efficacy in improving anxiety was found to be lacking. Post-treatment serum levels of 5-HT, DA, and GABA were higher in the rTMS group were higher than antidepressant medication group (p < 0.05). Furthermore, subgroup analysis results indicated that only the rTMS + antidepressant medication treatment significantly improved remission and remission rates. The meta-regression results showed that the type of antidepressant and the sex of the participants had a significant association with the depression score.

CONCLUSION

Combination treatment with NIBS was significantly more effective in improving depression symptoms than medication alone. rTMS combined with antidepressants appears to be more effective in improving response and remission rates. However, efficacy may be influenced by the type of medicine used in combination, and long-term efficacy data is lacking.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023388259.

Research on treatment-related aspects of depression from India in the preceding decade (2014-2023): An updated systematic review

Background

The National Mental Health Survey reports a prevalence of 2.7% for depressive disorders in India. The services for depression patients may be organized differently in India as compared to Western countries. It is important to consider studies conducted in India to determine effective interventions for depression catered specifically to the needs of the Indian population. We intended to systematically review the articles studying the usefulness of various treatment modalities in the management of depression in the Indian context.

Materials and Methods

We searched PubMed, Google Scholar, and ScienceDirect to identify studies published in peer-reviewed English language journals. All articles from India evaluating the clinical efficacy of anti-depressants, electro-convulsive therapy, repetitive transcranial magnetic stimulation, and psychological interventions for the management of depression were evaluated. Data were extracted using standard procedures.

Results

A total of 36 studies were included in the review. Out of those, 15 were studies on drug efficacy, five on neuro-modulation, nine on psycho-social interventions, four on adverse effects, and three on miscellaneous studies. Innovations were seen in the field of neuro-modulation and psycho-social intervention. Trials on drug efficacy and adverse drug reactions require larger sample sizes, more studies on newer agents, and more robust study designs.

Conclusion

More research is needed to understand the effectiveness and potential negative effects of depression treatments in India. Studies on ketamine have been inconclusive, and existing research on pharmacological agents is limited. Neuro-modulation studies show promise, but larger-scale studies are needed. Innovative psychological interventions tailored to the Indian population include community-based and digital technology-driven care.