Document Type : Research articles


1 Department of Clinical Psychology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 PhD, Associate Professor, Department of Clinical Psychology, Faculty of Medicine, Shahid Beheshti University, Tehran, Iran

3 PhD, Professor, Department of Psychology, Faculty of Educational Sciences and Psychology, University of Tehran, Tehran, Iran

4 PhD, Associate Professor, Department of Psychology, Faculty of Medicine, Shahid Beheshti University, Tehran, Iran

5 Medicine, Quran and Hadith Research Center & Department of Community Medicine, Faculty of Medicine, Tehran, Iran


Background: Repetitive transcranial magnetic stimulation (rTMS) is recommended as an effective treatment for both major depressive disorder (MDD) and treatment-resistant depression.
Objectives: According to the possible impact of rTMS on cognitive psychological characteristics, this study aimed to determine the effectiveness of rTMS in meta-worry and neuropsychological functions among MDD patients.      
Methods: This quasi-experimental study was conducted on 30 patients with MDD referring to Atieh Clinical Neuroscience Center, Tehran, Iran, in 2019. The participants were randomly divided into two groups of intervention and control (n=15 each). The data collection tools included the Beck Depression Inventory, meta-worry subscale of the Anxious Thoughts Inventory, and Cambridge Neuropsychological Test Automated Battery.
Results: The comparison between the two groups showed that the scores of the meta-worry scale improved after the intervention in patients undergoing rTMS, compared to those in the control group (Z=-3.41; P=0.002); however, no difference was observed between the two groups in the follow-up (Z=-2.02; P=0.053). The assessment of neuropsychological functions among the patients undergoing rTMS and those in the control demonstrated that neuropsychological functions (i.e., Minimum Spanning Tree, Rapid Visual Information Processing, and Spatial Working Memory) were significantly different immediately after the intervention and in the follow-up (P<0.05) except for the Difficulty Maintaining Sleep (DMS) subtest. In addition, the mean depression score was significantly different between the two groups (Z=-4.17; P<0.005). There was a significant relationship between depression and all the subtests of neuropsychological functions except for DMS (P>0.05).
Conclusion: In summary, the results of the current study indicated that the use of rTMS was an effective method in the improvement of neuropsychological functions except for DMS in patients with depression. However, the obtained findings did not demonstrate the persistent effect of multiple rTMS on meta-worry.


  1. World Health Organization. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017.
  2. Lim GY, Tam WW, Lu Y, Ho CS, Zhang MW, Ho RC. Prevalence of depression in the community from 30 countries between 1994 and 2014. Sci Rep. 2018;8(1):2861. doi: 10.1038/s41598-018-21243-x. [PubMed: 29434331].
  3. Masoumi SZ, Poorolajal J, Keramat A, Moosavi SA. Prevalence of depression among infertile couples in Iran: a meta-analysis study. Iran J Public Health. 2013;42(5):458-66. [PubMed: 23802102].
  4. Piwoński J, Piwońska A, Sygnowska E. Do depressive symptoms adversely affect the lifestyle? Results of the WOBASZ study. Kardiol Pol. 2010;68(8):912-8. [PubMed: 20730723].
  5. Disu TR, Anne NJ, Griffiths MD, Mamun MA. Risk factors of geriatric depression among elderly Bangladeshi people: a pilot interview study. Asian J Psychiatr. 2019;44:163-9. doi: 10.1016/j.ajp.2019.07.050. [PubMed: 31382211].
  6. Xie Y, Kong Y, Yang J, Chen F. Perfectionism, worry, rumination, and distress: a meta-analysis of the evidence for the perfectionism cognition theory. Personal Individ Differ. 2019;139:301-12. doi: 10.1016/j.paid.2018.11.028.
  7. Kanchanatawan B, Thika S, Anderson G, Galecki P, Maes M. Affective symptoms in schizophrenia are strongly associated with neurocognitive deficits indicating disorders in executive functions, visual memory, attention and social cognition. Prog Neuropsychopharmacol Biol Psychiatry. 2018;80(Pt C):168-76. doi: 10.1016/j.pnpbp.2017.06.031. [PubMed: 28666826].
  8. Haenisch B, Bönisch H. Depression and antidepressants: insights from knockout of dopamine, serotonin or noradrenaline re-uptake transporters. Pharmacol Ther. 2011;129(3):352-68. doi: 10.1016/j.pharmthera.2010.12.002. [PubMed: 21147164].
  9. Richardson-Jones JW, Craige CP, Guiard BP, Stephen A, Metzger KL, Kung HF, et al. 5-HT1A autoreceptor levels determine vulnerability to stress and response to antidepressants. Neuron. 2010;65(1):40-52. doi: 10.1016/j.neuron.2009.12.003. [PubMed: 20152112].
  10. Gloster AT, Rinner MT, Ioannou M, Villanueva J, Block VJ, Ferrari G, et al. Treating treatment non-responders: a meta-analysis of randomized controlled psychotherapy trials. Clin Psychol Rev. 2020;75:101810. doi: 10.1016/j.cpr.2019.101810. [PubMed: 31884147].
  11. McClintock SM, Brandon AR, Husain MM, Jarrett RB. A systematic review of the combined use of electroconvulsive therapy and psychotherapy for depression. J ECT. 2011;27(3):236-43. doi: 10.1097/YCT.0b013e3181faaeca. [PubMed: 21206376].
  12. Kellner CH, Greenberg RM, Murrough JW, Bryson EO, Briggs MC, Pasculli RM. ECT in treatment-resistant depression. Am J Psychiatry. 2012;169(12):1238-44. doi: 10.1176/appi.ajp.2012.12050648. [PubMed: 23212054].
  13. Al-Harbi KS. Treatment-resistant depression: therapeutic trends, challenges, and future directions. Patient Prefer Adherence. 2012;6:369-88. doi: 10.2147/PPA.S29716. [PubMed: 22654508].
  14. Strawbridge R, Arnone D, Danese A, Papadopoulos A, Vives AH, Cleare A. Inflammation and clinical response to treatment in depression: a meta-analysis. Eur Neuropsychopharmacol. 2015;25(10):1532-43. doi: 10.1016/j.euroneuro.2015.06.007. [PubMed: 26169573].
  15. Croarkin PE, Wall CA, McClintock SM, Kozel FA, Husain MM, Sampson SM. The emerging role for rTMS in optimizing the treatment of adolescent depression. J ECT. 2010;26(4):323-9. doi: 10.1097/YCT.0b013e3181dd17eb. [PubMed: 20418774].
  16. Hanley JR, Young AW. ELD revisited: a second look at a neuropsychological impairment of working memory affecting retention of visuo-spatial material. Cortex. 2019;112:172-9. doi: 10.1016/j.cortex.2018.10.029. [PubMed: 30527927].
  17. Rahimi M. The effects of repetitive transcranial magnetic stimulation (rTMS) over the left DLPFC on neuropsychological function in women with depression. L'Encéphale. 2019;45:S68-9. doi: 10.1016/j.encep.2019.04.014.
  18. Pirmoradi M, Dolatshahi B, Rostami R, Mohammadkhani P, Dadkhah A. Effect of repetitive transcranial magnetic stimulation (rTMS) in reducing severity of the signs and symptoms, such as cognitive, bodily and negativity-worthlessness of depression in patients with recurrent major depression disorder. J Ardabil Univ Med Sci. 2013;13(2):174-86.
  19. Durmaz O, Ebrinc S, Ates MA, Algul A. Evaluation of repetitive transcranial magnetic stimulation for treatment-resistant major depression and the impact of anxiety symptoms on outcome. Psychiatry Clin Psychopharmacol. 2017;27(1):14-8. doi: 10.1080/24750573.2017.1293239.
  20. Mohabbat-Bahar S, Moradi-Joo M, Rayegani SM, Mashhadi A, Bigdeli I. Effectiveness of repetitive transcranial magnetic stimulation on working memory of patients with treatment-resistant major depression disorder. Res Med. 2017;41(2):77-85.
  21. Vanderhasselt MA, De Raedt R, Namur V, Lotufo PA, Bensenor IM, Boggio PS, et al. Transcranial electric stimulation and neurocognitive training in clinically depressed patients: a pilot study of the effects on rumination. Progr Neuropsychopharmacol Biol Psychiatry. 2015;57:93-9. doi: 10.1016/j.pnpbp.2014.09.015. [PubMed: 25455589].
  22. Mahdavi A, Yazdanbakhsh K, Sharifi M. The effectiveness of mindfulness-based cognitive therapy in reducing psychological symptoms, meta-worry and thought fusion of multiple sclerosis patients. Annl Mil Health Sci Res. 2016;14(1):16-21.
  23. Serafini G, Pompili M, Murri MB, Respino M, Ghio L, Girardi P, et al. The effects of repetitive transcranial magnetic stimulation on cognitive performance in treatment-resistant depression. A systematic review. Neuropsychobiology. 2015;71(3):125-39. doi: 10.1159/000381351. [PubMed: 25925699].
  24. Kaser M, Deakin JB, Michael A, Zapata C, Bansal R, Ryan D, et al. Modafinil improves episodic memory and working memory cognition in patients with remitted depression: a double-blind, randomized, placebo-controlled study. Biol Psychiatry Cogn Neurosci Neuroimaging. 2017;2(2):115-22. doi: 10.1016/j.bpsc.2016.11.009. [PubMed: 28299368].
  25. Cirillo P, Gold AK, Nardi AE, Ornelas AC, Nierenberg AA, Camprodon J, et al. Transcranial magnetic stimulation in anxiety and trauma‐related disorders: a systematic review and meta‐analysis. Brain Behav. 2019;9(6):e01284. doi: 10.1002/brb3.1284. [PubMed: 31066227].
  26. Wu MJ, Passos IC, Bauer IE, Lavagnino L, Cao B, Zunta-Soares GB, et al. Individualized identification of euthymic bipolar disorder using the Cambridge Neuropsychological Test Automated Battery (CANTAB) and machine learning. J Affect Disord. 2016;192:219-25. doi: 10.1016/j.jad.2015.12.053. [PubMed: 26748737].
  27. Asbaghi E, Rafieinia P, Hosseini SM, Sabahi P. The effectiveness of rTMS on working memory and symptoms of bipolar disorder. Neuropsychology. 2017;3(2):29-49.
  28. TaheriFard M, Alizadeh GJ. The effectiveness of transcendental direct electric stimulation (TDCS) on improving cognitive functions and problem solving skills of students. J Sch Psychol. 2019;7(4):20-38.
  29. Chen JJ, Zhao LB, Liu YY, Fan SH, Xie P. Comparative efficacy and acceptability of electroconvulsive therapy versus repetitive transcranial magnetic stimulation for major depression: a systematic review and multiple-treatments meta-analysis. Behav Brain Res. 2017;320:30-6. doi: 10.1016/j.bbr.2016.11.028. [PubMed: 27876667].
  30. Kozel FA, Johnson KA, Nahas Z, Nakonezny PA, Morgan PS, Anderson BS, et al. Fractional anisotropy changes after several weeks of daily left high-frequency repetitive transcranial magnetic stimulation of the prefrontal cortex to treat major depression. J ECT. 2011;27(1):5-10. doi: 10.1097/YCT.0b013e3181e6317d. [PubMed: 20559144].
  31. Yang LL, Zhao D, Kong LL, Sun YQ, Wang ZY, Gao YY, et al. High-frequency repetitive transcranial magnetic stimulation (rTMS) improves neurocognitive function in bipolar disorder. J Affect Disord. 2019;246:851-6. doi: 10.1016/j.jad.2018.12.102. [PubMed: 30795490].