Journal: Brain Stimulation (2026)
Authors: Berlow, Y; Cilli, S; Kozel, F; Zandvakili, A; Marcotullio, N; Cosmo, C; Goldberg, M; Wicklund, B; Madore, M, Philip,N.
Background:
Transcranial magnetic stimulation (TMS) is increasingly used off-label for posttraumatic stress disorder (PTSD), often applying protocols developed for depression. While prior studies suggest high-frequency TMS can improve PTSD symptoms, few have been adequately powered to compare protocols. We examined whether three common TMS protocols yield equivalent outcomes for PTSD in a large, multisite cohort of veterans.
Objective:
This study examined whether three common TMS protocols yield equivalent outcomes for PTSD in a large, multisite cohort of veterans.
Methods:
Clinical outcomes were analyzed from 756 veterans with comorbid PTSD and depression treated with antidepressant TMS across multiple VA sites. Protocols included left prefrontal 10 Hz TMS (n = 526), left prefrontal intermittent theta burst TMS (iTBS; n = 71), and deep TMS (dTMS; n = 61). PTSD symptoms were measured with the PTSD symptom checklist for DSM-5 (PCL-5). Primary outcomes included PTSD response (>10-point reduction) and remission (PCL-5 <33). Propensity score matching adjusted for baseline differences. Equivalence was set at 10 % for categorical outcomes and Cohen’s d = 0.25 for continuous outcomes. Depression outcomes were also analyzed.
Results:
All three TMS protocols produced substantial PTSD symptom reductions (18-22 points). PTSD response rates were 63 % (10 Hz), 65 % (iTBS), and 78 % (dTMS); remission rates were 47 %, 48 %, and 49 %, respectively. Both iTBS and dTMS were noninferior to 10 Hz (all ps < 0.05). Depression outcomes demonstrated similar patterns.
Conclusions:
These findings support the effectiveness of TMS for PTSD, and protocol selection based on patient-specific or logistical considerations rather than efficacy differences.
