Introduction:
Depression is frequently accompanied by neurotic, stress-related and somatoform disorders (F4 diagnoses, ICD-10), which are linked to greater severity and poorer treatment outcomes. Transcranial magnetic stimulation (TMS) is a non-invasive neuromodulation technique used for treatment-resistant depression. We investigated whether comorbid F4 diagnoses affect the antidepressant efficacy of different TMS protocols under real-world conditions.

Methods:
We retrospectively analyzed data from 416 in- and outpatients with unipolar or bipolar depression at a German tertiary hospital between 2019 and 2024, of whom 107 had an F4 comorbidity. All patients received left prefrontal TMS: intermittent theta-burst stimulation (iTBS) with 600 (n = 138), 1200 (n = 98), or 1800 pulses per session (n = 104), or tonic repetitive TMS (rTMS) at 20 Hz with 2000 pulses (n = 76). Depressive symptoms were assessed before and after treatment using the HAMD-21 and MDI.

Results:
Depression scores improved significantly in both groups, with no significant difference between patients with or without F4-comorbidity. Remission rates were lower in patients with comorbid F4-diagnoses. No significant differences were observed between TMS protocols in patients with F4-comorbidity. Network analyses revealed similar symptom profiles in both groups.

Conclusion:
Comorbid F4-diagnoses do not affect the antidepressant efficacy of TMS. iTBS is as effective as other protocols, but shorter and more cost-efficient, making it preferable for patients and providers.