Combining psychotherapy with non-invasive neuromodulation can enhance the treatment of depression and other neuropsychiatric diseases, with positive results even in the long term. This is confirmed in the recent article "Boosting psychological change: Combining non-invasive brain stimulation with psychotherapy," which presents an overview of evidence to date on the effectiveness of integrated treatments with psychotherapy and brain stimulation, for more personalized and effective treatment.
We spoke with Professor Simone Rossi, co-author of the study and Professor of Physiology at the University of Siena. Professor Rossi is also Scientific Director with the neurocare group in Italy and was able to speak to the evidence of brain stimulation as a treatment pathway for depression.
Depression is rising worldwide, and not everyone responds to medication
Depression and other mental health disorders are among the leading causes of morbidity and mortality and a major challenge for health care systems throughout the world. The COVID-19 pandemic, social restrictions and growing feelings of insecurity have caused a 27 percent increase in the incidence of depression and anxiety worldwide.1
Despite advances in the knowledge and management of neuropsychiatric disorders, treatment pathways are not effective for everyone. In fact, "not all people with depression or other psychiatric disorders, such as obsessive-compulsive disorder, respond positively to first-line treatments" says Professor Rossi.2
"Indeed, it has been estimated that less than 50 percent of people with major depression respond to pharmacological treatments or psychotherapy."
Noninvasive neuromodulation, a new therapeutic frontier for neuropsychiatric disorders
In recent decades, noninvasive neuromodulation techniques, such as Transcranial Magnetic Stimulation (TMS)and Transcranial Electric Stimulation (TES), have emerged as promising nonpharmacological treatment options for depression, obsessive-compulsive disorder, and other disorders, such as pathological addictions. In particular, it has been shown that neuromodulation techniques may also be effective in patients who have not responded to medication and are considered 'treatment resistant'.
"Neuromodulation treatments can be administered relatively quickly," Professor Rossi continues, "and can bring rapid and lasting benefits because they act directly on the impaired neural circuits underlying some disorders, such as depression." Moreover, brain stimulation can be easily integrated with psychotherapy to enhance its benefits.
In fact, "in the Boosting Psychological Change study, we compared the results of research that included the administration of magnetic or electrical stimulation along with psychotherapy as a treatment for drug-resistant depression. The analysis showed that the therapies reinforce each other and that combining brain stimulation and psychotherapy could become the first-line treatment option for treating depression and other neuropsychiatric disorders in the future," he concludes.3
How Psychotherapy positively affects and "changes" the brain
Psychotherapy is a set of techniques centered around the therapist-patient interaction which can alleviate a patient's psychological distress through learning, emotional, cognitive and behavioral changes.
The scientific literature has now shown that psychotherapy influences the functioning of neuronal activity in various mental health conditions. In the 'Boosting Psychological Change' study, imaging techniques were used to demonstrate that psychotherapy, particularly cognitive behavioral therapy (CBT), is able to induce long-lasting changes in brain activity, promoting neural plasticity and inducing neurogenesis.
Studies on major depression, anxiety, and post-traumatic stress disorder have shown that psychotherapy-mediated changes occur in regions of the brain devoted to emotional regulation, decision making, and memory, key regions for coping with symptoms and achieving psychological change.
In particular, cognitive behavioral psychotherapy acts on the skills of problem-solving, self-representation and self-regulation of emotions. The areas of the brain in which significant changes have been demonstrated during and after psychotherapy are precisely those on which CBT intervenes.
Transcranial Magnetic Stimulation is effective, safe and painless
Transcranial Magnetic Stimulation or TMS is a noninvasive, nonpharmacological neuromodulation technique. TMS works by placing a magnetic coil on the patient's head to electrically stimulate specific areas of the brain. The therapy is also sometimes called rTMS, repetitive transcranial magnetic stimulation, because the protocols involve multiple sessions repeated over time.
TMS "delivers accurate stimulation limited to a target region, localized by a neuronavigation system that provides immediate feedback on coil position and orientation. By stimulating selected brain areas, one is able to directly intervene on dysfunctional neural circuits, alleviating the symptomatology of certain neuropsychiatric disorders," explains Professor Rossi.
TMS "is a completely painless treatment and does not require anesthesia or hospitalization. To date, no side effects have been reported, apart from a mild focal headache that resolves after a few minutes. Unlike Electroconvulsive Therapy (ECT), TMS does not cause seizures there is no risk of inducing memory loss," Rossi concludes.
TMS and Psychotherapy, the optimal treatment for Depression
Major Depression is a mood disorder characterized by a persistent feeling of sadness, loss of interest, fatigue, and difficulty concentrating. Those suffering from depression show alterations in the processing of negative emotions and reduced dopamine release in response to rewards. Transcranial Magnetic Stimulation acts directly on brain areas impaired by depressive disorders, restoring their regular functioning.
TMS can be useful in the management of depressive symptoms precisely because of its direct action on neural activity.
"Combining magnetic stimulation and psychotherapy aims to enhance the benefits of both therapies to optimize the course of treatment," says Professor Rossi.
"Overall, the studies reviewed in the publication suggest that integrated protocols with brain stimulation and cognitive-behavioral psychotherapy are very viable and effective treatment options even in the long term."
Rossi makes an example of the 2018 Donse study which looked into accumulative data of 2019 patients with medication-resistant depression.
"About 66 percent achieved a positive response to integrated treatment of TMS and cognitive behavioral psychotherapy," says Rossi.
"The study reported that 56 percent of patients went into complete remission of symptoms, and 60 percent of patients maintained beneficial effects 6 months after treatment".4
The effectiveness of TMS has also been proven in previous research. "In Isserles' 2011 study, about 46 percent of patients who underwent TMS treatment combined with cognitive behavioral psychotherapy achieved excellent results and 30 percent achieved complete remission of symptoms," Rossi concludes.5
The best therapy for depression is integrated and individualized
Current treatment standards approach depression and neuropsychiatric disorders by proposing pathways based mostly on pharmacotherapy or psychotherapy. However, it has been seen how multidisciplinary and integrated interventions with neuromodulation can provide greater and longer lasting benefits, especially for those who do not respond positively to medication.
Studies investigating the effectiveness of a therapeutic approach based on the combination of psychotherapy and brain stimulation techniques are increasing, with the aim of formulating optimal clinical protocols to provide targeted interventions. An individualized treatment program, calibrated to the patient's unique profile, can result in faster recovery that is also effective in the long term.
Brain stimulation and cognitive-behavioral psychotherapy reinforce each other's beneficial effects. So, a course tailored to the individual's needs and integrated with psychotherapy and neuromodulation treatments could become the first-line treatment option for depression and other neuropsychiatric disorders in the future.