Benefit of Behavioral Activation During TMS for Major Depressive Disorder

Transcranial magnetic stimulation
Transcranial magnetic stimulation
The combination of behavioral activation therapy with TMS may be beneficial for the treatment of major depressive disorder.

The integration of behavioral activation therapy into transcranial magnetic stimulation (TMS) was shown to be feasible, well-tolerated, and led to a significant reduction in the symptoms of major depressive disorder, according to a study published in the Journal of Affective Disorders.

Behavioral activation therapy is a form of psychotherapy that supports environmental positive reinforcement for individuals through goal setting and the scheduling of positive reinforcement between-session activities. The TMS staff were trained in behavioral activation therapy, and instructed on how to integrate behavioral activation therapy into a 6-week course of TMS sessions. 

As a part of daily clinical assessment, staff would check in with participants on behavioral activation therapy goal attainment in the first 5 to 10 minutes of TMS sessions before the procedure commenced. After the TMS procedure was complete, staff would then work with participants on selecting and planning the next goal. This protocol offered the unexpected benefit of standardizing the daily clinical assessment required for TMS with specific queries that elicit a richer amount of clinical information from participants than the previous nonspecific queries did, thereby allowing for a more accurate assessment of functional changes.

Six of the 11 outpatients with major depressive disorder who received treatment with behavioral activation therapy +TMS protocol met the study criteria for response following treatment: overall symptom improvement as shown by a ≥50% change in baseline to end point scores on the Inventory of Depressive Symptoms and the 9-item Patient Health Questionnaire. Participants also demonstrated a 77% average behavioral activation therapy goal completion rate. The primary study limitation was its inability to compare the behavioral activation therapy +TMS protocol with the efficacy of TMS alone.

Major depressive disorder is associated with an abnormal neurobiological response to reward, which can be improved with TMS. The present study sought to determine if TMS could make individuals with severe depression more receptive to the positive reinforcement effects of behavioral activation therapy, and thereby improve overall treatment outcomes.

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Study investigators conclude, “[behavioral activation therapy] proved to be highly adaptable to the delivery of TMS in an outpatient setting. Modifications were made without compromising the central therapeutic principles of [behavioral activation therapy] or TMS, and TMS technicians without formal training in psychotherapy or counseling were effective agents in delivering care with this [behavioral activation therapy]+TMS protocol. Combining modified behavioral activation therapy with standard TMS therapy has potential to improve antidepressant outcomes for patients with [treatment resistant depression].”


Russo GB, Tirrell E, Busch A, Carpenter LL. Behavioral activation therapy during transcranial magnetic stimulation for major depressive disorder [published online April 24, 2018]. J Affect Disord. doi: 10.1016/j.jad.2018.04.108