TMS Improves Residential Therapy Outcomes in Combat-Related PTSD
Key Clinical Summary
- Active navigated transcranial magnetic stimulation (TMS) added to intensive residential treatment was associated with greater reduction of symptoms in patients with combat-related posttraumatic stress disorder (PTSD) than sham TMS.
- TMS also demonstrated greater durability of symptom relief compared to sham treatment.
- At 1-month follow-up, clinically significant reductions in PTSD symptoms were found in 85% of active TMS vs 59% of sham recipients.
According to findings from a randomized clinical trial published in JAMA Network Open, the addition of active navigated transcranial magnetic stimulation (TMS) to intensive residential treatment significantly contributed to treatment gains in patients with combat-related posttraumatic stress disorder (PTSD).
Study Findings
The study randomized 119 US veterans with moderate (9 [8%]), severe (56 [47%]), or extreme (54 [45%]) PTSD to receive daily active (n = 60) or sham (n = 59) navigated TMS for up to 20 sessions. Both groups also received intensive residential treatment, which included manualized prolonged exposure twice weekly and day-long psychotherapeutic augmentation for 30 days.
Researchers evaluated symptom-severity change in PTSD Checklist for DSM-5 (PCL-5) scores between baseline and the end of treatment as the primary outcome. Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Patient Health Questionnaire–9 (PHQ-9) depression module scores were also evaluated throughout treatment and 1- and 3-month follow-up.
At the end of the treatment period, active TMS demonstrated greater symptom relief than sham in PCL-5 score (mean difference, −5.94; P = .02) and CAPS-5 score (mean difference, −6.03, P = .008).
Follow-up measures found that active TMS also showed greater durability of symptom relief (PCL-5 mean score difference, −12.30, P = .008 and PHQ-9 mean score difference, −3.45, P = .03). These findings were further confirmed via reliable change indices, which demonstrated superior sustained benefit for active vs sham TMS on the PCL-5 at 1 month follow-up (85% [95% CI, 71%-98%] vs 59% [95% CI, 41%-78%]; P = .03).
Clinical Implications
It is estimated that PTSD affects 4% to 17% of 3 million US veterans who were deployed in Afghanistan and Iraq, underscoring the need for effective therapeutic options in this patient population. While pharmacotherapy and trauma-focused cognitive behavioral therapies are commonly used in PTSD treatment, they may not be suitable or effective in all patients. This study highlights that TMS, which is currently approved by the US Food and Drug Administration (FDA) for the treatment of major depressive disorder (MDD) and obsessive-compulsive disorder (OCD), may be leveraged to augment standard residential PTSD treatment.
Clinicians should note that the study does not establish the efficacy of TMS as a monotherapy or adjunct to other PTSD therapies. Furthermore, most patients included in the study sample had severe to extreme combat-related PTSD, which may limit the findings’ generalizability to nonmilitary populations or individuals with less severe PTSD.
Expert Commentary
“In this [trial], navigated TMS added to residential standard of care resulted in statistically significant and clinically meaningful improvements in PTSD symptoms that persisted during the 1- to 3-month follow-up for most participants,” concluded Peter T. Fox, MD, Research Imaging Institute, University of Texas Health Science Center at San Antonio, and study coauthors. “This study provides important new evidence of the therapeutic efficacy of navigated TMS combined with conventional therapy modalities.”
