Navigated TMS significantly boosts combat PTSD recovery rates

An advanced version of a procedure using magnetic fields to stimulate brain nerve cells in treating depression was significantly effective for 85% of active military and veterans suffering from combat post-traumatic stress disorder enrolled in a recent study, when added to psychotherapy.

The breakthrough study led by UT Health San Antonio researchers used their patented MRI-guided, robotic-controlled form of transcranial magnetic stimulation, or TMS, which they termed “navigated TMS.” They added navigated TMS to the treatment plan for one of two groups of a total 119 active-duty military and veteran participants with combat PTSD – 92% with severe or extremely severe conditions – during a 30-day residential program at Laurel Ridge Treatment Center in San Antonio.

Those who received the navigated TMS treatment in addition to the highest level of psychotherapy for PTSD had more clinically significant symptom reductions a month after completion – enough to greatly improve their quality of life – compared with those receiving a “sham” TMS resembling the procedure but not delivering the treatment. Also, those receiving the TMS add-on were more likely to maintain their treatment gains over time.

These are exciting findings for the hundreds of thousands of U.S. service members and veterans suffering from combat-related PTSD, including many here in Military City USA and throughout South Texas. This randomized clinical trial demonstrates that navigated TMS can effectively reduce PTSD symptoms when added to behavioral therapy.”

Peter T. Fox, MD, director of the Research Imaging Institute at UT Health San Antonio, the academic health center of The University of Texas at San Antonio, and professor of radiology, and of psychiatry and behavioral sciences

Fox was the leader and principal investigator of the study, titled, “Residential Therapy with Navigated TMS for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial,” published today in the journal JAMA Network Open. He created and patented the navigated method of TMS which, using MRI and a robot, guides the placement of the TMS device to the exact spot that should be targeted based on the person’s unique anatomy and brain structure. It’s the first known report of a registered clinical trial using image-guided, robotic delivery of TMS for any disorder.

The study was part of the work of the Consortium to Alleviate PTSD (CAP), a multi-institutional network established in 2013 and jointly funded by the Department of Defense and Department of Veterans Affairs to launch a group of studies on PTSD and related conditions to aid in prevention, diagnosis and successful treatment. The CAP was led by UT Health San Antonio and VA’s National Center for PTSD.

“As we continue to strive for additional ways to improve PTSD care and help more people recover, these study findings give us another valuable tool in the clinician’s toolbox,” said Alan Peterson, PhD, professor of psychiatry and behavioral sciences at UT Health San Antonio, and director of the CAP, and of the STRONG STAR research consortium housed at the university.

A debilitating disorder

The study paper notes that PTSD is a debilitating disorder afflicting 4% to 17% of nearly 3 million U.S. military personnel – up to roughly 500,000 – who deployed to Iraq and Afghanistan alone. The ongoing war in Ukraine has heightened international awareness of the impact of combat-related PTSD on military personnel and civilians and the need for more effective treatments.

Drug therapy is widely prescribed, but often is ineffective or has harmful side-effects, or both. Trauma-focused, cognitive-behavioral therapies, including “prolonged exposure,” or PE, are effective, but can have high dropout rates.

A compressed version of PE with sessions twice per week and at an intensive residential program, like that at Laurel Ridge, is considered the current highest standard of care. PE involves a safe, repeated “exposure” to the person’s trauma through the retelling of one’s traumatic experience in addition to conducting activities that might trigger memories or feelings related to the trauma.

Over time, as patients process the experience, they gain greater control over their emotional and physiological response to the memories, and their symptoms reduce.

Still, while this evidence-based psychotherapy is effective and can help the majority of people recover from PTSD, not everyone gets better, and those who do still may have some remaining symptoms. Also, combat PTSD has proven to be more difficult to treat than PTSD in civilians.

So, researchers have been looking for ways to augment treatment to improve efficacy rates. Combination therapies that add medication, or the use of medical devices in the case of the new study, are seen as promising.

Already FDA-approved for depression

TMS is a form of electric brain stimulation with an extremely mild side-effect profile. An electromagnet placed on the scalp generates pulsing magnetic fields that pass painlessly through the scalp and skull, inducing electrical currents in the underlying brain. The electrical currents engage and modify brain networks implicated in mental health disorders, much like a defibrillator is used to reset heart arrhythmias.

TMS therapy is Food and Drug Administration-approved for major depressive disorder and obsessive-compulsive disorder, but is not yet approved for PTSD. Several small-sample studies suggested that TMS might also work for PTSD, while other studies showed no benefit.

But conventional TMS does not take advantage of the targeting precision possible with magnetic resonance imaging. To make TMS as effective as possible, Fox and his research team developed their MRI-guided, robotic-controlled TMS delivery system. Both their navigated TMS system and the way MRI is used to target PTSD are patented.

“This personalized targeting strategy likely underlies the treatment effects seen in this study,” Fox said.

The study’s structure and findings

While all participants in the study at Laurel Ridge received the same standard of psychotherapy treatment, they were randomized into one of two treatment arms for the TMS portion. One group received the navigated TMS for 20 consecutive days while the other group received the sham version.

One month after treatment completion, 85% of those in the active TMS group showed significant symptom relief, both self-reported and clinically, compared to just less than 60% in the sham group. And at their three-month follow-up, 73% in the active TMS group still showed clinically significant improvement compared to less than 30% in the sham group.

The researchers note that more investigation with regular and navigated TMS needs to be done, and those studies already are being designed. Still, they see strong potential for similar success with other protocols that combine TMS with other cognitive-behavioral therapies, with other types of PTSD patients and in settings that do not require hospitalization. And if that’s the case and TMS is approved for PTSD treatment, it could become broadly accessible and make a big impact on PTSD care.

Other authors of the study are from the South Texas Veterans Health Care System, San Antonio; Texas Department of Information Resources; iKare Mood Trauma Recovery Clinic, San Antonio; FIRST-MD, San Antonio; Laurel Ridge Treatment Center, San Antonio; the Behavioral Science Division of the VA’s National Center for PTSD, Boston; VA Boston Healthcare System, Boston; Boston University School of Medicine, Boston; and the Department of Psychiatry, UT San Antonio.