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Posttraumatic Stress Disorder (PTSD) is highly prevalent among US Military Veterans (Hoge et al., 2008)(Magruder et al., 2005). PTSD is not a problem all its own; major depressive disorder (MDD) has also been commonly associated with this condition. Furthermore, PTSD can lead to complications in social functioning, employment, and even physical health (Thomas et al., 2010). While there are medications and therapies to aid in the treatment of PTSD, novel approaches are needed for this population.  

Repetitive Transcranial Magnetic Simulation (rTMS) is a fairly new intervention that was FDA approved for treatment-resistant MDD in 2008. rTMS is a non-invasive treatment that stimulates the brain using magnetic pulses. While its precise mechanism of action is unknown, it is thought to induce antidepressant effects by inducing neuronal depolarization in the dorsolateral prefrontal cortex, a part of the brain implicated in mood and anxiety disorders.  The most common side effects from rTMS are discomfort under the stimulation site, and a small chance of seizure induction.  However, in contrast to medications, there are no systemic side effects (i.e., no weight gain, diabetes risk, or impact on sexual function) from rTMS, and there are no effects on cognition as seen in electroconvulsive therapy. Standard treatment for MDD includes daily sessions of 10Hz stimulation for up to 6 weeks. To date, rTMS has been widely used for depression, but only a few studies have evaluated the use of rTMS for PTSD, and these studies have used a wide variety of different device settings, suggesting that patients with PTSD and MDD may require different stimulation parameters than patients with only MDD.

We selected 5 Hz stimulation based on our previous experience with this parameter in a group of patients with MDD and comorbid anxiety (Philip et al., 2015), and sought to apply it to Veterans with PTSD in order to address mood, anxiety, and sleep.  In this brief report, we reviewed the charts from 10 patients with comorbid PTSD and MDD, who received 5Hz rTMS treatment at the Psychiatric Neuromodulation Clinic at the Providence VA Medical Center, Providence RI, from 2012 to October 2014.  All Veterans were referred to the clinic based on failure of previous treatments for PTSD and MDD.  As part of standard clinic protocol, self-reported symptoms of PTSD and MDD, PTSD Checklist (PCL) (Weathers et al., 2013) and Quick Inventory of Depressive Symptoms (QIDS-SR) (Rush et al., 2003) were gathered prior to treatment, every 5 treatments, and then at treatment endpoint.

The patients in the clinic largely mirrored Veteran populations nationwide, with most (80%) being male, and in middle age, and symptoms that were in the moderate-to-severe range for both PTSD and MDD prior to treatment.  They had a variety of trauma exposures, inclusive of combat-related PTSD, non-combat related PTSD, and military sexual trauma. On average, Veterans received 27 treatments (range 18-36).  Veterans reported statistically significant and clinically meaningful reductions in both PTSD and MDD symptoms. There was good safety and tolerability; there were no seizures, and no Veterans stopped treatment from side effects or lack of efficacy.

In summary, 5Hz rTMS was found to be efficacious and safe overall in 10 patients with comorbid PTSD and depression, suggesting that this stimulation frequency may be an alternative option for Veterans with comorbid PTSD and MDD. Larger, controlled studies are needed to confirm this efficacy as well as the durability of improvement.

Reference Article

Philip, N. S., Ridout, S. J., Albright, S. E., Sanchez, G., & Carpenter, L. L. (2016). 5-Hz Transcranial Magnetic Stimulation for Comorbid Posttraumatic Stress Disorder and Major Depression. Journal of Traumatic Stress, n/a-n/a. doi: 10.1002/jts.22065

Discussion Questions

  1. What is repetitive Transcranial Magnetic Stimulation (rTMS)?
  2. Do you think other interventions along with rTMS would help Veterans even more?
  3. When would be a good time to implement rTMS?

Author Biography

Noah S. Philip, MD
specializes in the use of technology to understand and treat severe mood and anxiety disorders, focusing on PTSD and MDD. Clinically, he directs the Psychiatric Neuromodulation Clinic, where he delivers rTMS therapy to veterans with treatment-resistant psychiatric illnesses. His current research includes the use of functional magnetic resonance imaging (FMRI) to characterize brain changes associated with PTSD, and pioneering the use of novel brain stimulation approaches at the Providence VA Center for Excellence in Neurorestoration and Neurotechnology.


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