The role of rTMS for patients with severe PTSD and depression

### Patient A 27-year-old woman. ### Present illness A 27-year-old female patient with chronic post-traumatic stress disorder (PTSD) and recurrent major depressive sisorder (MDD) is referred for consultation regarding possible repetitive transcranial magnetic stimulation (rTMS) treatment for her medication-resistant depression. She has no other medical diagnoses and had no history of substance abuse. ### Present status At the time of initial consult, psychometrics indicated that both PTSD symptoms and MDD symptoms were severe. While the patient passively endorses suicidal thoughts, she denies active intent or plan to harm herself. She has taken medical leave of absence from her job in order to get treatment for her depression. To review how rTMS may affect their patient’s PTSD symptoms, the consulting team conducts a review of published literature. ### Background PTSD is a severe psychiatric illness characterised by four core symptom clusters: re-experiencing, avoidance, negative cognition and mood and hyperarousal.1 With an estimated lifetime prevalence in community samples of up to 8%, PTSD results in a great deal of personal suffering and escalating social and economic costs.2 Unfortunately, current evidence-based treatments for PTSD leave a high percentage with a significant symptom burden, highlighting the urgent need for novel treatments. The growing acceptance3 of rTMS to the dorsolateral prefrontal cortex (DLPFC) for treatment-resistant MDD has evoked the question of its potential efficacy for PTSD. What effect does excitatory rTMS over the left DLPFC have on symptoms of PTSD in patients undergoing rTMS treatments for depression? Patients: patients with PTSD undergoing rTMS. Intervention: accelerated protocol of rTMS to augment usual care (psychotropic medications±talk therapy). Comparison: sham rTMS or usual care. Outcomes: level of PTSD symptoms after treatment. PubMed, Ovid/Medline, and PsycInfo databases are queried with search terms ‘rTMS’, ‘transcranial magnetic stimulation’, ‘PTSD’ and ‘post-traumatic stress disorder.’ In a 2017 systematic review and meta-analysis4 by Yan and colleagues, pooled data from 13 original studies …