What’s the Evidence for Using Transcranial Magnetic Stimulation (TMS) or Spravato in Combination With Psychotherapy?

The past twenty years have seen dramatic changes in our approach to mental health and mental health treatment: clinicians now use new therapies – based on solid clinical evidence – such as transcranial magnetic stimulation (TMS) and Spravato in combination with psychotherapy.

And with every passing day – with the help of innovative clinicians and others – we reduce stigma around mental health diagnoses, normalize seeking mental health treatment and support, and convince more and more people that experiencing mental health challenges is nothing to hide or be ashamed of.

It’s part of being human. No one is immune.

Most of us have family or friends with some type of diagnosis: anxiety, depression, substance misuse – these are things people we know and love deal with every day. The more we understand mental health disorders and mental health treatment, the better we can support people who need help. With effective, evidence-based treatment, we can improve their lives, the lives of their family members and loved ones, and, by extension, the overall quality of life in our communities.

Transcranial Magnetic Stimulation (TMS), Spravato, and Psychotherapy

Two important new developments in mental health treatment are the use of brain stimulation therapies (BSTs) like transcranial magnetic stimulation (TMS) and the use of psychedelic medications like Spravato to support people with treatment resistant disorders. A treatment-resistant condition can be frustrating. When patients try standard treatments that work for most people – but don’t see any progress and still experience uncomfortable, disruptive symptoms, even after more than one attempt at treatment with more than one medication – it’s easy to become discouraged, lose confidence in the treatment process, and lose hope their symptoms will improve.

That’s one reason TMS and Spravato are important in the evolution of mental health treatment: they can offer symptom relief when other medications don’t, and a positive treatment effect often appears more quickly than with standard medications for diagnoses like treatment-resistant depression, anxiety, or obsessive-compulsive disorder (OCD).

Now there’s new evidence that shows us when we combine TMS or Spravato with psychotherapy, specifically approaches like cognitive behavioral therapy (CBT), outcomes improve even more.

Medication and Psychotherapy: Alone or Together?

When antidepressant medication first became available to the general public, providers did not always combine those medications with psychotherapy. That makes sense: in the late 20^th century, we still embraced an old paradigm: diagnose, prescribe medication, wait for results. If one medication didn’t work, we’d repeat the process. When we applied this approach – often perfectly effective for physical injury or illness – to mental health, we learned it didn’t always work.

Around the turn of the century, combined psychotherapy and medication became the gold-standard treatment for diagnoses from major depressive disorder to anxiety to obsessive-compulsive disorder.

And now, research shows that combining cutting-edge treatments like TMS or Spravato with psychotherapeutic techniques like cognitive behavioral therapy (CBT) may be more effective than monotherapy with TMS, Spravato, or psychotherapy. A paragraph in an article called “Integrating Psychotherapy and Psychopharmacology: Psychedelic-Assisted Psychotherapy and Other Combined Treatments” is intriguing:

“Just as the mechanism of action of antidepressants is more psychological than may appear at first glance, psychotherapy acts more biologically than might be expected. Introspection, challenging dysfunctional thoughts, cultivating self-compassion, practicing adaptive behaviors, and healing inter-actions with a therapist may all remodel dysfunctional neural circuits.”

What that means is that the combination of medication and psychotherapy is not merely additive. The outcomes are more than the sum of their constituent parts. The techniques are mutually reinforcing, interactive, synergistic, and lead to improvements neither medication nor talk therapy could achieve in isolation.

That new paper indicates the same thing is true of combining psychedelic therapy with psychotherapy like CBT. Pairing the therapies works in a synergistic manner – on psychological and biological levels – and for some patients, leads superior symptom reduction, compared to a monotherapy with one or the other.

Clinical Research: TMS, Spravato, and Psychotherapy

You don’t have to take our word for it, though. An abundance of clinical research published recently demonstrates the benefits of combining these two new treatment approaches with a standard psychotherapeutic approach like CBT. These studies include benefits and important considerations for ongoing improvement.

The Latest Data on TMS + CBT

• The paper “The Dynamic Duo: Combining Noninvasive Brain Stimulation With Cognitive Interventions” discusses how to get the most out of combining these two approaches through appropriate patient preparation.
• The study “Simultaneous rTMS And Psychotherapy In Major Depressive Disorder” shows a significant reduction of symptoms and sustained remission of symptoms at 6 months follow up after participating in a combined rTMS and CBT treatment program.
• The study ”Audio-Guided Mindfulness Meditation During Transcranial Magnetic Stimulation Sessions for the Treatment of Major Depressive Disorder: A Pilot Feasibility Study” shows us two things: it’s almost impossible to meditate during a TMS session – but for those who can, MBCBT during TMS can lead to symptom improvement.

We include that last study to show we’re not cherry -picking data: that study shows significant benefit to TMS + MBCBT, but suggests that mindfulness components happen during TMS treatment overall, but not during an individual TMS session.

The Latest Data on Spravato + CBT

• The paper “Psychedelic-Assisted Psychotherapy—A Systematic Review of Associated Psychological Interventions” indicates psychedelic psychotherapy + CBT  is effective in reducing symptoms of treatment resistant depression, effective in facilitating smoking cessation, effective in reducing symptoms of post-traumatic stress disorder, beneficial in reducing opioid dependence, and beneficial for opioid tapering.
• The paper “Psychedelics and Psychotherapy: Cognitive-Behavioral Approaches as Default” offers evidence supporting the case for cognitive-behavioral approaches in general – including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT) – becoming the standard concurrent psychiatric approach to support and improve outcomes in patients engaging in psychedelic therapy.
• The clinical review “Psychedelics and The New Behaviorism: Considering The Integration Of Third-Wave Behavior Therapies With Psychedelic-Assisted Therapy” discusses the evidence supporting the combination of psychedelic psychotherapy + Third Wave Therapies – like DBT, ACT, and MBCBT – for patients with mood disorders, suicidality, self-injury behavior, and substance use.

Holistic Treatment: All of the Above, Tailored for Each Patient

Here’s our takeaway from this recent research:

Evidence shows TMS and psychedelic therapy work – and for some patients, TMS + psychotherapy or Spravato + psychotherapy works even better.

In our work with patients, we collaborate to find the best path forward, based on their individual needs and treatment goals. With this new information, we can offer options: they can choose a monotherapy with behavioral therapy or a new approach like TMS/psychedelic therapy, or they can choose a combination of TMS or psychedelic therapy with a cognitive-based behavioral therapy. Both approaches work, and we can let the patient decide which they prefer.

That’s a win-win situation, where everyone benefits: the best kind.