Table 1.
RCTs of TMS monotherapy for PTSD..
| Study | Participants | n | TMS type | Groups (frequency, target) | MT (%) | Total dose | Outcome measures | Assessment times | Main outcomes |
|---|---|---|---|---|---|---|---|---|---|
| Cohen et al. 29 | PTSD | 24 | rTMS | 1 Hz right DLPFC 10 Hz right DLPFC Sham (coil rotated vertically) |
80% | 10 sessions 1000 pulses (1 Hz) 4000 pulses (10 Hz) |
PCL-5 Treatment Outcome PTSD scale HAM-A HAM-D CAPS |
Baseline Sessions 5 and 10 Follow-up 2 weeks |
Compared with sham and 1 Hz TMS, 10 Hz TMS showed improvement in core PTSD symptoms of re-experiencing and avoiding as well as anxiety, with no significant reduction in depressive symptoms. Effects were stable at 2-week follow-up. |
| Boggio et al. 31 | PTSD | 30 | rTMS | 20 Hz right DLPFC 20 Hz left DLPFC Sham coil |
80% | 10 sessions 16,000 pulses |
PCL-5 Treatment Outcome PTSD scale HAM-A HAM-D |
Baseline Sessions 5 and 10 Follow-up weeks 2, 4, 8, and 12 |
Compared with sham, both 20 Hz TMS to the right and left DLPFC showed improvement in core PTSD symptoms, though the effect was greater effect for the right. Right-sided TMS showed anxiety reduction. Left-sided TMS showed depression reduction. Effects persisted to 12-week follow-up. |
| Watts et al. 32 | PTSD (veterans) | 20 | rTMS | 1 Hz right DLPFC Sham coil |
90% | 10 sessions 4000 pulses |
CAPS PCL BDI STAI BNCE |
Baseline Session 10 Follow-up weeks 4 and 8 |
Compared with sham, 1 Hz TMS improved core PTSD and depressive symptoms. There was no improvement of anxiety over sham. Beneficial effects still present but degraded by 8-week follow-up. |
| Nam et al. 33 | PTSD | 18 | rTMS | 1 Hz right DLPFC Sham (coil rotated vertically) |
100% | 15 sessions Total 18,000 pulses |
CAPS | Baseline Weeks 2, 4, and 8 |
Compared with sham, 1 Hz TMS improved PTSD re-experiencing symptoms and total CAPS scores. Avoidance scores trended toward improvement. There was no improvement in hyperarousal. Effects were not seen until weeks 4 and 8. |
| Ahmadizadeh and Rezaei 34 | PTSD (veterans) | 65 | rTMS | 20 Hz bilateral DLPFC 20 Hz right DLPFC Sham coil |
100% | 10 sessions 24,000 pulses |
PCL-M | Baseline Session 5 Week 4 (endpoint) |
Compared with sham, both 20 Hz bilateral and right-sided stimulation improved PTSD symptoms. Response rates (PCL reduction at least 2 SD below baseline score) were significantly higher in active conditions versus sham (0%) with no significant difference between bilateral (62.5%) and right-sided TMS (41.2%). |
| Kozel et al. 35 | PTSD (veterans) | 44 | rTMS | 1 Hz right DLPFC 10 Hz right DLPFC |
110% | 36 sessions 86,400 pulses |
CAPS-5 PCL-5 IPF MADRS QIDS-SR Pain Score NSI |
Baseline Weekly (6 weeks) End of 3-week taper Follow-up months 1 and 3 |
Both 1 and 10 Hz TMS improved PTSD and depressive symptoms. Only 10 Hz TMS improved function measured on the IPF, though there was no difference on self-report function scores. Effects were sustained at 3 months. Overall, there was no clear advantage for one frequency over the other. |
| Philip et al. 36 | PTSD/MDD | 22 | sTMS | sTMS at IAF Sham coil |
NA | 20–40 sessions | PCL-5 QIDS |
Baseline End of 8 weeks |
This pilot study confirmed feasibility and tolerability of sTMS. There was significant reduction over sham in ‘threshold PTSD’ symptoms on the PCL as well as trends over sham for overall PTSD symptoms on the PCL-5 and depression on the QIDS-SR. There was greater separation between groups with more TMS treatment sessions. |
| Philip et al. 37 | PTSD | 50 | TBS | TBS right DLPFC Sham coil |
80% | 10–20 sessions (10 blinded + 10 unblinded) 18,000–36,000 pulses (1800 pulses per 9.5 min sessions) |
CAPS SOFAS QLESQ PCL IDS-SR |
Baseline Week 2 Follow-up 4 weeks |
At the end of the blinded phase: compared with sham, TBS showed significant improvement in social and occupational functioning only. At 1-month follow-up (included unblinded phase): compared with sham, TBS showed significant improvement in social and occupational functioning, depressive symptoms, and PTSD symptoms. Improvement in PTSD was predicted by greater positive connectivity within the DMN and by greater negative connectivity between the DMN and other external networks. |
| Leong et al. 38 | PTSD | 31 | rTMS | 1 Hz right DLPFC 10 Hz right DLPFC Sham 1 Hz Sham 10 Hz |
120% | 10 sessions 22,500 pulses (1 Hz) 30,000 pulses (10 Hz) |
CAPS-IV HAM-D PCL-C QIDS BAI GAD-7 |
Baseline Endpoint 2 weeks 3-month follow-up |
Compared with sham, 1 Hz TMS significantly improved PTSD symptoms on the CAPS, whereas 10 Hz TMS did not. 10 Hz TMS trended toward improvement in depressive symptoms. There was no significant improvement over sham on anxiety measures. |
BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; BNCE, Brief Neurobehavioral Cognitive Examination; CAPS, Clinician Administered PTSD Scale; DLPFC, dorsolateral prefrontal cortex; DMN, default-mode network; GAD-7, Generalized Anxiety Disorder Assessment; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Depression Rating Scale; IAF, individualized alpha frequency; IPF, Inventory of Psychosocial Functioning; MADRS, Montgomery–Asberg Depression Rating Scale; MDD, major depressive disorder; MT, motor threshold; NA, not available; NSI, Neurobehavioral Symptom Inventory; PCL, PTSD Checklist; PCL-M, PTSD Checklist Military; PTSD, post-traumatic stress disorder; QIDS-SR, Quick Inventory of Depressive Symptomatology–Self Report; QLESQ, Quality of Life Enjoyment and Satisfaction Questionnaire; RCTs, randomized controlled trials; rTMS, repetitive transcranial magnetic stimulation; SOFAS, Social and Occupational Functioning Assessment Scale; STAI, State Trait Anxiety Inventory; sTMS, synchronized transcranial magnetic stimulation; TBS, Theta-burst transcranial magnetic stimulation.