1. Transcranial direct current stimulation (tDCS) combined with repetitive transcranial magnetic stimulation (rTMS) had greater efficacy in reducing depressive symptoms in participants with major depressive disorder than either tDCS + rTMS alone. 

Evidence Rating Level: 1 (Excellent)

Noninvasive brain-stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) have each been found to be effective in treating depression when applied individually. However, it remains unclear whether the combination of rTMS and tDCS offers greater efficacy in treating major depressive disorder (MDD). This study thus examined the efficacy and safety of rTMS and tDCS, both individually and in combination, in patients with MDD. This double-blind, sham-controlled randomized clinical trial included adults aged 18-65 diagnosed with MDD from three hospitals in China. Participants were randomly assigned 1:1:1:1 to one of four interventions: active tDCS + active rTMS, sham tDCS + active rTMS, active tDCS + sham rTMS, and sham tDCS + sham rTMS. Treatments were given were 5 times a week for 2 weeks and followed up for another 2 weeks. The 24-item Hamilton Depression Rating Scale (HDRS-24) was used to assess depressive symptoms (higher score indicating more severe symptoms) at baseline, end of the 2-week treatment, and during the 2-week follow-up period. Out of the 240 participants included in the study (mean [SD] age, 32.50 [15.18] years, 139 females (57.9%), 219 patients (91.3%) completed both the 2-week intervention and 2-week follow-up. From baseline to week 2, participants who received active tDCS + active rTMS had a greater reduction in mean [SD] HDRS-24 total scores compared with participants in the other three groups (active tDCS + active rTMS: 18.33 [5.39], sham tDCS + active rTMS: 14.86 [5.59], active tDCS + sham rTMS: 9.21 [4.61], and sham tDCS + sham rTMS: 10.77 [5.67]; F3,236 = 35.79; η2 = 0.31 [95% confidence interval (CI), 0.21-0.39]). Although response rates at week 4 were similar across groups, remission rates were higher for participants treated with active tDCS + active rTMS (50 [83.3%]) compared to those in the other groups (p < 0.001). No serious adverse events occurred during treatment and follow-up. Overall, this study found that the combination of tDCS + rTMS was safe and had greater efficacy in reducing depressive symptoms in participants with MDD than tDCS + rTMS alone. Future studies are needed to confirm study findings and elucidate the mechanisms underlying the synergistic effect tDCS + rTMS.

Click to read the study in JAMA Network Open

Image: PD

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