In the ever-evolving field of mental health care, the search for effective treatments for various psychiatric disorders persists. Transcranial Magnetic Stimulation (TMS) has emerged as a promising therapy for conditions like Post-traumatic Stress Disorder (PTSD), depression, anxiety, and other mood disorders. TMS is a non-invasive neurostimulation technique that uses magnetic fields to induce electrical currents within specific regions of the brain. This targeted stimulation can modulate neural activity and has shown promise in treating various psychiatric disorders. In recent years, the integration of TMS with other therapeutic modalities and psychiatric treatments has gained increasing attention. This article delves into supporting research about combining TMS with these therapies, highlighting the synergistic effects that can enhance outcomes for patients with PTSD.

Psychotherapy and TMS: A Synergistic Approach

 

The combination of  TMS and psychotherapy has been found to be more effective in treating PTSD than either treatment alone. This is particularly true when compared to other psychiatric conditions such as anxiety and depression. The relationship between psychotherapy and TMS has been more extensively and rigorously studied in relation to PTSD than in other mental health conditions. It is believed that TMS promotes neuroplasticity, which is the brain’s ability to change and adapt in response to new experiences. TMS has been shown to bring about changes in neuronal activity in brain regions linked to mood regulation, such as the prefrontal cortex. Psychotherapy, on the other hand, is a form of counseling that helps people with mental health disorders by providing a safe and supportive environment for them to discuss their thoughts, feelings, and behaviors. Specifically, people with PTSD who, as a result of exposure to traumatic events, experience symptoms such as flashbacks, nightmares, and avoidance. Psychotherapy aims to help people cope with their symptoms and the related emotional and behavioral challenges. Prolonged exposure (PE) and cognitive processing (CPT) are two types of psychotherapies that are recommended as first-line treatments for PTSD. They both help people process their traumatic experiences and reduce their negative emotions and beliefs. PE involves gradually confronting the traumatic memories, feelings, and situations that the person has been avoiding, while CPT focuses on identifying and challenging the unhelpful thoughts, or “stuck points,” that the person has developed as a result of the trauma. Both PE and CPT have been shown to be effective in reducing PTSD symptoms and improving quality of life in many studies, including randomized controlled trials.

Together, these two methods—psychotherapy and TMS—can enhance each other’s effects and provide better outcomes than either alone. The evidence suggests that this combination can reduce the severity of PTSD symptoms and improve the quality of life for patients.

Both psychotherapy and TMS may be effective for PTSD, as they can both target the brain networks involved in the disorder. PTSD is linked to a dysfunctional “fear circuitry” that consists of brain regions including the hippocampus, amygdala, and medial pre-frontal cortex (mPFC). These brain regions are responsible for regulating fear responses and extinguishing fear memories. However, in PTSD, the mPFC fails to control the amygdala, leading to exaggerated and persistent fear reactions to stress-related cues. This is supported by brain imaging studies that show lower mPFC activity and higher amygdala activity in PTSD patients compared to healthy people. Moreover, successful PTSD treatment with psychotherapy has been shown to reduce amygdala activity, which is correlated with less severe PTSD symptoms. However, not all PTSD patients respond well to conventional treatments, such as medication or therapy. Therefore, TMS therapy could offer a novel and promising alternative for treatment, and even better outcomes when combined with psychotherapy.

However, further research is needed to fully understand the mechanisms underlying this combined treatment strategy and to optimize its use in clinical practice.

Examining the Research

 

Several studies, including randomized controlled trials, have explored psychotherapy combined with TMS.

One study combined low frequency TMS to the pre-frontal cortex and exposure therapy for nine treatment-resistant PTSD patients.¹ The patients received either real or sham (fake) TMS for 30 minutes, then talked about their traumatic experiences, and then received another 20 minutes of real or sham TMS. The study measured the changes in PTSD symptoms and hormones related to stress and arousal. The results showed that the patients who received real TMS and exposure therapy had more improvement in their hyperarousal symptoms and lower levels of stress-related hormones than the patients who received sham TMS and exposure therapy. This suggests that TMS and exposure therapy together can have positive effects on PTSD symptoms and physiology.

In another study, researchers gave low frequency TMS to the prefrontal cortex of veterans who had long-lasting PTSD from combat.² The TMS was done before weekly sessions of Cogntive Processing Therapy (CPT). The study compared the effects of real TMS and CPT with sham TMS and CPT. The results showed that the veterans who got real TMS and CPT had more improvement in their PTSD symptoms during and after the therapy than the veterans who got sham TMS and CPT.

These studies indicate that TMS, especially when combined with exposure therapy or CPT, can enhance the treatment outcomes for PTSD patients who are resistant to conventional therapies.

As such, TMS is a promising addition to psychotherapy for PTSD, but it still faces challenges and limitations in the current research.³ Some of the unresolved issues include the uncertainty around optimal parameters of TMS, such as the frequency, intensity, duration, and location of stimulation, and how they affect different brain regions and networks involved in PTSD. Another issue is the choice of clinically relevant outcome measures, such as which PTSD symptoms are most responsive to TMS, and which ones are most stable and durable over time. Furthermore, the current research needs more examination of the effects of TMS when combined with well-established psychotherapy protocols, such as PE or CPT, and how they interact and enhance each other. Finally, the current research would benefit from a better understanding of the neurobiological markers related to PTSD, such as brain activity, hormones, and genes, and how they change in response to both psychotherapy and TMS. These issues are important for advancing the knowledge and application of TMS for PTSD treatment.

Integrating TMS with Other Psychiatric Treatments

 

Expanding Treatment Options

Beyond psychotherapy and medication, TMS can be integrated into various other psychiatric treatments. For instance, TMS can be used in conjunction with electroconvulsive therapy (ECT) or ketamine therapy to provide a broader range of options for patients. This flexibility allows clinicians to tailor treatment plans to individual needs and preferences.

Precision Psychiatry

The integration of TMS with other psychiatric treatments aligns with the growing concept of precision psychiatry. By combining treatments based on a patient’s unique biological, psychological, and social factors, clinicians can optimize therapeutic outcomes. This personalized approach may improve psychiatric care by increasing treatment efficacy and reducing the trial-and-error often associated with mental health treatments.

Other Considerations

 

Patient Suitability

While the integration of TMS with other therapies offers exciting prospects, it is crucial to assess each patient’s suitability for such combined treatments. Factors like the severity of the condition, treatment history, and potential contraindications must be considered before implementing an integrated approach.

The integration of TMS with other therapies, such as cognitive-behavioral therapy (CBT), medication, and various psychiatric treatments, holds significant promise in the field of mental health care. By combining these approaches, clinicians can offer a more comprehensive and personalized treatment strategy for individuals suffering from psychiatric disorders. However, careful patient selection, informed consent, and ethical considerations are essential to ensure the responsible and effective use of integrated treatments. As our understanding of these approaches continues to evolve, the future of psychiatric care may see remarkable advancements in improving patient outcomes and quality of life.

References

1. Osuch, E. A., Benson, B. E., Luckenbaugh, D. A., Geraci, M., Post, R. M., & McCann, U. (2009). Repetitive TMS combined with exposure therapy for PTSD: a preliminary study. Journal of anxiety disorders, 23(1), 54-59.
2. Kozel, F. A., Motes, M. A., Didehbani, N., DeLaRosa, B., Bass, C., Schraufnagel, C. D., … & Hart Jr, J. (2018). Repetitive TMS to augment cognitive processing therapy in combat veterans of recent conflicts with PTSD: a randomized clinical trial. Journal of Affective Disorders, 229, 506-514.
3. Petrosino, N. J., Cosmo, C., Berlow, Y. A., Zandvakili, A., van’t Wout-Frank, M., & Philip, N. S. (2021). Transcranial magnetic stimulation for post-traumatic stress disorder. Therapeutic advances in psychopharmacology, 11, 20451