Does mental health coaching improve efficacy of transcranial magnetic stimulation for major depression? A pilot randomized controlled trial and benchmarking study

Major Depressive Disorder (MDD) is common and burdensome. Repetitive Transcranial Magnetic Stimulation (rTMS) is recommended for individuals who do not respond to first-line treatments. Coach-supported digital mental health programs are scalable strategies for delivering therapeutic content. This randomized controlled trial tested whether digital mental health programs bolster rTMS for MDD. N = 36 depressed adults completed a six-week course of rTMS. Of this group, n = 18 were randomized to digital cognitive behavioral therapy (iCBT with Coaching), and n = 18 were randomized to digital narrative stories of hope (iNarratives with Coaching). Multilevel models tested group differences in treatment outcomes over time. Principal outcomes focused on the Hamilton Rating Scale for Depression. Exploratory analyses compared outcomes versus a Benchmarking Sample of N = 29 patients who received rTMS without coaching. There was a main effect of time (p < .001), indicating an overall reduction in depression symptoms during the trial. Contrary to hypotheses, there was no Group x Time interaction (p = .662), and groups did not differ on clinical response rates (p = .654). Secondary analyses found that the iNarratives group showed greater improvement in positive emotion and functional impairment, whereas the iCBT group showed less dropout from the coaching intervention. Exploratory analyses found a Group x Time interaction (p = .039), potentially suggesting that participants in iCBT or iNarratives showed steeper symptom reduction versus the Benchmarking Sample. The coach-supported iCBT and iNarratives approaches are comparable as adjuncts to rTMS for depression and may yield lower depression scores versus rTMS alone. iNarratives effects appeared specific to increases in positive emotions and decreases in functional impairment.