Combining Transcranial Magnetic Stimulation with Antidepressants: A Systematic Review and Meta-Analysis.

Major depressive disorder (MDD) imposes significant disability on patients. In addition to antidepressants, brain stimulation modalities such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) have been helpful in treatment of MDD. Novel TMS paradigms like theta burst stimulation (TBS) have rapidly become popular due to their effectiveness. Given that both antidepressants and TMS are commonly used together and affect neuroplasticity, we reviewed studies that administered both these as treatments for MDD. Unlike ECT wherein previous trials have shown that continuing pharmacotherapy is useful while giving ECT, there are no consensus guidelines on what to do with antidepressants when starting TMS. So, we reviewed two groups of studies - 1) those that administered TMS and antidepressant pharmacotherapy concurrently and 2) those wherein TMS augmented antidepressants or were an adjunctive intervention to antidepressants. We performed a meta-analysis for randomized clinical trials (RCTs) that administered TMS and antidepressants concurrently. We found ten RCTs fulfilling criteria 1 and compared uniformly titrated antidepressant regimens combined with active versus sham TMS. We also found twenty studies fulfilling criterion 2, that used TMS as an augmenting or adjunctive intervention. Both groups of studies showed TMS combined with antidepressants had greater efficacy for treatment of MDD. We advocate for laboratory studies examining the interaction between TMS and antidepressants in a parametric fashion; in addition to randomized controlled trials that examine this combination to expedite remission in MDD.