PsychotherapyPlus: augmentation of cognitive behavioral therapy (CBT) with prefrontal transcranial direct current stimulation (tDCS) in major depressive disorder—study design and methodology of a multicenter double-blind randomized placebo-controlled trial

Abstract

Major Depressive Disorder (MDD) is one of the most prevalent psychiatric disorders worldwide. About 20-30% of patients do not respond to the standard psychopharmacological and/or psychotherapeutic interventions. Mounting evidence from neuroimaging studies in MDD patients reveal altered activation patterns in lateral prefrontal brain areas. Successful cognitive behavioral therapy (CBT) is associated with a recovery of these neural alterations. Moreover, it has been demonstrated that transcranial direct current stimulation (tDCS) is capable of influencing prefrontal cortex activity and cognitive functions such as working memory and emotion regulation. Thus, a clinical trial investigating the effects of an antidepressant intervention combining CBT with tDCS seems promising. The present study investigates the antidepressant efficacy of a combined CBT-tDCS intervention as compared to CBT with sham-tDCS or CBT alone. A total of 192 patients (age range 20-65 years) with MDD (Hamilton Depression Rating Scale Score ≥ 15, 21-item version) will be recruited at four study sites across Germany (Berlin, Munich, Tuebingen, and Freiburg) and randomly assigned to one of the following three treatment arms: (1) CBT + active tDCS; (2) CBT + sham-tDCS; and (3) CBT alone. All participants will attend a 6-week psychotherapeutic intervention comprising 12 sessions of CBT each lasting 100 min in a closed group setting. tDCS will be applied simultaneously with CBT. Active tDCS includes stimulation with an intensity of 2 mA for 30 min with the anode placed over F3 and the cathode over F4 according to the EEG 10-20 system, if assigned. The primary outcome measure is the change in Montgomery-Åsberg Depression Rating Scale scores from baseline to 6, 18, and 30 weeks after the first session. Participants also undergo pre- and post-treatment neuropsychological testing and functional magnetic resonance imaging (fMRI) to assess changes in prefrontal functioning and connectivity. The study investigates whether CBT can be augmented by non-invasive brain stimulation techniques such as tDCS in the treatment of MDD. It is designed as a proof-of-principle trial for the combined tDCS-CBT treatment, but also allows the investigation of the neurobiological underpinnings of the interaction between both interventions in MDD. Trial registration ClinicalTrials.gov Identifier NCT02633449.

Abnormal functional connectivity of the amygdala is associated with depressive symptoms in patients with multiple system atrophy

“…Repetitive transcranial magnetic stimulation (rTMS) has been proven to be a powerful antidepressant intervention tool and has been widely investigated in the last two decades. 27 , 28 Treatment-resistant depression (TRD) patients show a significant improvement of depressive symptoms after DLPFC high-frequency (5–20 Hz) rTMS treatment. 29 , 30 The above-mentioned results indicate that the middle prefrontal cortex may be a key cortical pathogenesis hub that is associated with depression.…”

Leveraging Neuroplasticity to Enhance Adaptive Learning: The Potential for Synergistic Somatic-Behavioral Treatment Combinations to Improve Clinical Outcomes in Depression

“…One additional, similar randomized controlled trial of tDCS combined with CCT is underway (see Table 1). Finally, three randomized controlled trials examining tDCS combined with CBT for depression are underway, with results anticipated shortly (see Table 1) (135).…”

Precision non-implantable neuromodulation therapies: a perspective for the depressed brain

“…109 In this study, 192 depressed patients are being randomized to 12 sessions of either: 1) CBT + active tDCS (2 mA, 30 minutes); 2) CBT+sham tDCS; or 3) CBT alone. 109 The combination of tDCS with DLPFC activation techniques, such as working memory training or combined cognitive training, has also shown promising results in healthy subjects, 110 schizophrenia, 111 mild cognitive impairment, 112 and cognitive impairment in Parkinson's disease. 113 For combined treatment, tDCS has advantages over rTMS: it does not produce noise, which can be a distracting factor in rTMS sessions, and is portable.…”

“…An ongoing, multicenter study is evaluating the efficacy of tDCS combined with group CBT. 109 In this study, 192 depressed patients are being randomized to 12 sessions of either: 1) CBT + active tDCS (2 mA, 30 minutes); 2) CBT+sham tDCS; or 3) CBT alone. 109 …”