Antidepressant efficacy of administering repetitive transcranial magnetic stimulation (rTMS) concurrently with psychological tasks or interventions: a scoping review and meta-analysis

Current approaches to optimize the efficacy of repetitive transcranial magnetic stimulation (rTMS) for depressive symptoms focus on personalizing targets and parameters. But what should occur during these three-to-forty-minute sessions remains under-investigated. Specific concerns include evidence suggesting brain state modulates the brain response to stimulation, and the potential to boost antidepressant efficacy by administering rTMS concurrently with psychological methods. Thus, conducted a scoping review and meta-analysis, per PRISMA-ScR guidelines, to pool studies that administered rTMS during psychological tasks or interventions. PubMed and Web of Science databases were searched from inception to 10 July 2024. Inclusion criteria: neuropsychiatric patients underwent rTMS; studies assessed depressive symptom severity; psychological tasks or interventions were administered during rTMS, or intentionally did not include a wash-out period. Of 8442 hits, 20 studies combined rTMS with aerobic exercise, bright light therapy, cognitive training or reactivation, psychotherapy, sleep deprivation, or a psychophysical task. Meta-analyses with random effects models pooled the efficacy of these combinations, based on change scores on depressive severity scales. The effect size was large and therapeutic for uncontrolled pretest-posttest comparisons (17 studies, 20 datasets, g=-1.91, SE=0.45, 95%CI= -2.80 to -1.03, p<0.01); medium when studies compared active combinations with sham rTMS plus active psychological methods (8 studies, g=-0.55, SE=0.14, 95%CI= -0.82 to -0.28, p<0.01); and non-significant when active combinations were compared with active rTMS plus sham psychological methods (4 studies, p= 0.96). These findings suggest that the antidepressant efficacy of combining rTMS with psychological methods is promising, but not an improvement over rTMS alone.