## 3 Brain Stimulation Techniques
### Combining tDCS and tMS with Other Therapeutic Approaches in Depression  
Research has shown that tDCS combined with medication therapy (Table 4) can improve the effectiveness of traditional treatment for depression without additional side effects. The combined approach to treating depression with selective serotonin reuptake inhibitors (SSRIs) and tDCS has shown better outcomes than when drug treatments are used alone. A study carried out on patients with moderate to severe, nonpsychotic, unipolar MDD showed that a combination of serntraline with tDCS increased treatment efficacy [25]. [PERSON] et al. [25] interpreted that the lack of a statistically significant interaction between tDCS and medication treatment could be due to an additive clinical effect. Interestingly, the mechanism proposed for this combined therapeutic approach is that tDCS acts primarily through cortical activation, while SSRIs determine the downregulation of limbic hyperactivity [25]. The same group of researchers also tested the combined therapy of tDCS with another SSRI, such as escitalopram, in a single-center, double-blind trial, demonstrating the noninferiority of tDCS to escitalopram in the treatment of depression and side effects, such as skin redness, tinnitus, and nervousness [25]. In another study, researchers conducted a double-blind, randomized clinical trial and demonstrated that different drug therapies (e.g., mood stabilizers, lithium, sodium valproate, or carbamazepine) in combination with tDCS reduced depressive symptoms and improved response inhibition in patients with bipolar depression [83]. Another approach combines tDCS with neurobehavioral therapy, such as cognitive control therapy (CCT). Specifically, several studies showed a reduction in depressive symptoms when tDCS is combined with CCT [10]. Geriatric patients with depression, who are more prone to experience cognitive deficits, showed a significant improvement in cognitive tasks when exposed to tDCS and CCT [10]. Other methods, such as neurofeedback, may be used in conjunction with tDCS in the future to improve the outcome of antidepressant therapy. To date, a recent study indicated that neurofeedback interventions combined with tDCS could improve cognitive performance in healthy volunteers compared to using tDCS alone [84]. Although tMS is not yet widely used, when specialists choose it, it is because of treatment-resistant depression, a situation in which increasing the dose of antidepressants has not worked. In this situation, there is a lack of knowledge regarding optimal dosage and optimal strategy for changing the dosing of the antidepressants. Strategies used include reducing the dose of antidepressants used and introducing tMS, continuing with the same treatment and introducing tMS, or introducing an SNRI or second-generation antipsychotic in the antidepressant treatment along with tMS to accelerate treatment response and remission [85]. tMS is used concomitantly with antidepressants to potentiate changes in neuroplasticity, one of the mechanisms of action of psychiatric treatment. Together with the modulation of neurotransmitters and changes in network connectivity, both tMS and antidepressants address the main causes reported in major depression. Magnetic stimulation helps modify \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Therapeutic Approach** & **Type of Depression 1 ** & **Outcome** & **References** \\ \hline tDCS + Sertraline & MDD & Depressive symptoms \(\succ\) & [25] \\ \hline tDCS + Mood stabilizes; Lithium; Sodium & BD & Depressive symptoms \(\succ\) & [83] \\ valproate; Carbamazepine & & Response inhibition ability \(\
earrow\) & [83] \\ \hline tDCS + serntraline, hydrochloride, & & Depressive symptoms \(\succ\) & [4] \\ and escitalopram & MDD & response rate \(\
earrow\) & [10] \\ \hline tDCS + Cognitive control therapy & MDD & Depressive symptoms \(\succ\) & [10] \\ \hline \hline \end{tabular}
\end{table} 
Table 4: tDCS in combination with other therapeutic approaches in depression.