Introduction
Psychiatric disorders are prevalent and debilitating, but are treatable through pharmacological, psychotherapy treatment, or transcranial magnetic stimulation (TMS) approaches. Depression is amongst the most disabling and potentially fatal mental illness (Carpenter et al., 2012, p.1). Depression impairs cognition or rather higher mental processes such as planning, thinking, speaking, and imagining. Studies on Global burden of disease report that major depressive disorder (MDD) is the leading cause of disability, globally. Antidepressant medication is considered the standard of treatment to ease symptoms. But, it is now projected that 20 to 40% of patients cannot tolerate or do not benefit from antidepressant medications, not even with repeated attempts (Carpenter et al., 2012, p.2). For this reason, the use of alternative methods such as psychotherapy and TMS to relieve depression is increasingly becoming critical. Probably, cognitive behavioral therapy (CBT) and antidepressant medications engage similar neural structures, and mechanisms that are distinct to each. Research on mental treatment of mental depression reveals that the use of psychotherapy is as effective as medications in treating mental disorders.
Despite the treatment method, the goal is the same to improve patient outcome by reducing patients’ depressive symptoms. This term paper will examine research articles on TMS therapy and CBT therapy by Carpenter et al. (2012) and Goldapple et al (2004) and how these interventions contrast with antidepressant medication. These scholars hypothesized that if results are based on treatment duration, it is probable that moderator variables are varied in the population. Whereas, Goldapple et al. (2004) studies are aimed at examining changes related to CBT and hypothesis that despite the treatment modality each intervention results in clinical remission. The focus will be to determine if psychotherapy is linked to less relapse than medication treatments. In today’s world, research on depression and related disorders has been facilitated by the advances in the neuroscience due to availability of functional brain imaging. Depressed individuals present mood changes and, as noted by Ward (2015, p.12), mood is a product of brain processes. Notably, a mood is a prolonged emotional state and depressed individuals are impaired in their social and occupational functioning. The studies have demonstrated that nonpharmacological interventions, although costly than medications, resulted in a positive outcome for patients suffering depression.
In a study, 42 US-based clinical practice sites treated 307 patients with MDD and symptoms that persisted despite antidepressant pharmacotherapy. According to Carpenter et al. (2012, p. 2), the initial sample size was 339, but 32 patients failed to meet full eligibility criteria and were not included in the final study population. Out of the 42 clinical practices, 76% (32) were in private settings, 17% (7) in academic medical centers and the remaining 3 patients were in nonacademic institutions. Carpenter et al. (2012, p. 2) argue that transcranial magnetic stimulation (TMS) is a nonsystematic, noninvasive device producing magnetic resonance imaging (MRI) strength delivering magnetic fields that induces an electric current in the cerebral cortex. Therefore, if used as an antidepressant, TMS delivers clinical benefits without adverse cognitive effects and systematic adverse effects linked to medications.
TMS has now replace the direct electrical simulations of the human brain. With TMS, stimulation is done across the skull (transcranially) and not directly on a brain. Current safety and ethical guidelines recommends that TMS should not be used repetitively to children excepting in compelling therapeutic practices such as treatment of depression (Ward, 2015, p. 409). Patients were considered evaluable for TMS study if the primary clinical diagnosis was a single or recurrent major depressive episode consistent with the DSM-IV criteria. Also, eligible patients did present medical conditions precluding the safe application of TMS therapy and had not been treated for depression using this approach. Further, these patients failed to benefit from antidepressants and their psychiatrist suggested TMS as the most suitable clinical treatment option. Arguably, these criteria prove the effectiveness of TMS therapy over antidepressant treatment. Hence, this therapeutic procedure remains effective even in situations where patients exhibit antidepressant treatment resistance with more than one medication.
The NeuroStar TMS therapy system delivered all treatments and the motor threshold (MT) was determined at the initial treatment session over the left hemisphere to define treatment intensity. The system is integrated with an automatic mathematical algorithm or rather an iterative software to determine motor threshold. Stimulation is specified at 120% of MT, active stimulation cycle of 4 sec on, and a pulse frequency of 10 pulses/second. The system generated 75 stimulation cycles leading to 3,000 pulses/treatment session. Besides, all participating sites obtained approval by the Institutional review board (IRB) and the treatment costs were catered for by the patients or their insurer. Both the study physicians and patients received remunerations from study sponsor for preparation and completion of rating scales. Having detailed and described all the study procedures, all subjects obtained a written informed consent. Notably, 86.3% (265) patients successfully completed treatment and registered for a 52-week follow-up study. Outcome evaluation was done at baseline, second week, at time of maximal benefit, and at sixth week. The physicians treated 306 patients through second week, 280 through fourth week as well as 169 and 71 patients through the sixth week and beyond.
In contrast, 17 unmedicated, unipolar depressed individuals (11 women, 6 men) presenting symptoms for mood and anxiety disorders enrolled for the CBT program at the Toronto Center for Addiction and Mental Health. Goldapple et al. (2004, p.35) note that their mean ± SD age was 41 ± 9 and the recruitment was done via a newspaper advertisement. The Structured Clinical Interview for DSM-IV and DSM-III-R was used to clinically diagnose a major depressive disorder (unipolar type). Historically, none of the 17 patients was considered treatment refractory and the exclusion criteria was based on head trauma, history of neurological illness, pregnancy, substance abuse, antidepressant medications in preceding month, and psychotic symptoms. Like in the TMS therapy study, written informed consent was obtained from the 17 participants. Similarly, the study was approved by a recognized institution. In this case, the Center for Addiction and Mental Health Ethics Committee approved the study.
Moreover, all participants received 15-20 personalized outpatient CBT sessions. Therapy was done by 2 CBT trained therapists with 8 and 10 years of experience and the sessions were audiotaped to enable the supervisor psychologist rate treatment fidelity. Therapeutic strategies were employed to moderate automatic reactivity to negative attitudes or thoughts and to counter dysphoric mood. Furthermore, behavioral activation helped to deal with the disruption of routine caused by depression while increasing recurrence of pleasant events such as withdrawal and avoidance. In between the CBT sessions, participants were asked to test their beliefs and interpretations via behavioral experiments and document their thoughts. Using collaborative inquiry, the therapists guided patients to a more evidence-based understanding of their experience. Unlike in the TMS clinical treatment where a longterm (52 weeks) follow-up was required, the CBT sessions was monitored weekly. In this case, a Beck Depression Inventory was used to monitor clinical response. In this case, the methodology also entails use of the Hamilton Depression Rating Scale (HDRS) score to evaluate the CBT sessions. The specificity of identified CBT outcomes were interpreted through a post hoc comparison of 13 patients treated with paroxetine.
Findings Analysis
The findings by Goldapple et al (2004) indicate that CBT results in significant clinical improvements as measured by the HDRS score. For the 14 participants who successfully completed the full CBT treatment course, the mean ± SD scores were 20 ± 3 and 6.7 ± 4 before and after treatment. Nine of the participants met the 50 percent full response decrease criteria after attaining the HDRS final score of 4.7 ± 3.5. All patients, however, were included in both pre-treatment and post-treatment analysis because of the small sample size. Patients in antidepressant (paroxetine) comparison group also had a decrease in severity of symptoms as shown in the mean ± SD HDRS scores of 22.8 ± 3.6 before and 6.0 ± 4.1 post-treatment. Additionally, the outcomes show a significant metabolic changes with CBT treatment. Metabolism increased in the dorsal midcingulate and hippocampus areas (BA 24b/c) but also decreased in ventrolateral prefrontal (BA 11/47), dorsolateral prefrontal (BA 9/46), inferior and superior medial frontal regions as well as inferior parietal, and posterior cingulate (BA 31). Similar metabolism changes were observed even in the 5 patients that failed to meet the 50% full response criteria.
Whereas, the study by Carpenter et al. (2012) found that over 54% of participants met the Antidepressant Treatment Record (ATR) criteria for resistance to 2 or more antidepressant trials. They had received a mean (SD) of 2.5 (± 2.4) attempts at an adequate duration and dosage as required by ATR criteria. The categorical outcomes suggested an improvement on the constant outcome measures. In all the three outcome measures, PHQ-9, CGI-S, and IDS-SR, remission rates and categorical response were compatible in clinical magnitude. The Clinical Global Impressions-Severity of Illness Scale (CGI-S) was the primary outcome measure where 58% responded with a CGI-S ≤ 3 score of mildly ill while 37.1% of participants reached remission. As indicated in the findings, the CGI-S changed significantly from baseline to end of therapy (−1.9 ± 1.4, P < .0001). Further, the results indicate that those with lower pretreatment baseline scores and in a younger age group had better treatment benefits. The study was conducted on 307 patients under acute TMS therapy, results also show a mean ± SD age of 48.6 ± 14.2 years with 66.8% as females. Thus, this data demonstrates that for patients who are incapable of benefiting from initial antidepressant medication, TMS can be an effective treatment.
Comparing the CBT and antidepressants group baseline scans directly showed no significant differences. Across these two groups, there were also no substantial correlations between weeks of treatment and metabolism. Additionally, covarying the post-treatment and pretreatment changes with the HDRS score nullifies the changes in these groups, indicating that the divergent change patterns mirror treatment-specific response effects. The distinct changes in dorsal and anterior midcingulate and orbital frontal demonstrate medial frontal modulation with medications and CBT treatment response. But, according to Goldapple et al. (2004, p. 38), CBT was linked to widespread changes. With CBT, brain pattern variations for several disorders possibly reflect fundamental differences in the basic psychopathology. It also reflects the procedural differences the cognitive technique used to treat each mental condition.
While the TMS therapy is now considered safe and effective in MDD treatment as it works in across a wide range of treatment resistance. Carpenter et al. (2012, p. 6) reveal that the benefits of TMS are consistent even where patients have a history of psychiatric hospitalization or presence of comorbid anxiety disorder. Compared to the preceding methods of treating depression, TMS is more effective as it is highly recommended when other approaches cannot achieve satisfactory results. Though efficacy of TMS in controlled trials is broad and comprises replications of positive outcomes, it has not yet been characterized for its effectiveness and utility in routine clinical practice (Carpenter et al., 2012, p. 2). But, in a number of studies Ward (2015, p. 102) reports that TMS has proved to improve moods in depressed persons when patients are exposed to recurrent frontal lobe stimulations.
The research outcomes, as manifested by the remissions, show that antidepressant medications are symptom-suppressive. Medications can be effective in treating acute depressive episode, it does not reduce future risks if the antidepressants are withdrawn. Compared to the medications, psychotherapy protects patients from potential relapse and recurrence. Cognitive therapy assumes that maladaptive information and inaccurate beliefs have a significant causal role in depression. It focuses on creating changes in the way an individual process emotion relevant information. Thus, the outcomes on CBT show that the method is efficacious as medication, however its effects are more enduring.
Conclusion
A safe and effective nonpharmacological intervention offset the relative cost and inconvenience of the therapy. The researchers in both the CBT and TMS therapy studies are concerned with outcomes and found that their effects are more enduring compared to antidepressant medications. For instance, CBT has been found to affect clinically recovery through modulation of specific areas in cortical and limbic pathways. Relative to paroxetine, Goldapple et al. (2004) concludes that CBT has distinctive directional changes hippocampus, cingulate, and frontal cortex. Hippocampus is specifically crucial to memory and learning (Ward, 2015, p. 27). Unlike with medications where the hippocampal and cingulate decreases, this pattern is unique with CBT. In the cases where patients fail to benefit from medication treatment for depression, TMS is a viable and effective option. The study results affirm that TMS therapy has a highly noteworthy improvement in treating depression and can be well tolerable even in the nonresearch populations. Current neuroscience advancements have played a crucial role in scientific research on depression, particularly the use of psychotherapy interventions. Consequently, psychotherapy methods are evidence-based practice that are less likely to be associated with relapse and recurrence than antidepressant medication.
