Department of Psychiatry, 70401University of Calgary, Alberta, Canada.
Hotchkiss Brain Institute, 70401University of Calgary, Alberta, Canada.
Can J Psychiatry. 2021 Sep;66(9):763-773. doi: 10.1177/0706743720982432. Epub 2020 Dec 23.
Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment modality for Post-traumatic stress disorder (PTSD). Several targets and stimulation parameters have been investigated, and while previous meta-analyses have suggested that rTMS is efficacious, these have pooled different stimulation parameters and targets, and the relative efficacy of each is unknown.
We therefore performed a systematic review and network meta-analysis of randomized controlled trials (RCTs) by searching MEDLINE, EMBASE, CENTRAL, and PsycINFO and retaining RCTs with at least 5 individuals per arm and clinician-rated PTSD symptoms (PROSPERO CRD42019134984). We adhered to PRISMA guidelines, and 2 independent reviewers screened studies for eligibility and extracted the primary outcome of clinician-rated PTSD symptoms. Dropouts were extracted as a proxy for acceptability. Random effects pairwise meta-analyses and a network meta-analysis were performed.
We synthesize data from 10 RCTs with a total of 421 participants. Two rTMS interventions targeting the right dorsolateral prefrontal cortex (DLPFC) improved PTSD symptoms relative to sham: low-frequency stimulation (SMD = 0.70; 95% CI, 0.22 to 1.18) and high-frequency stimulation (SMD = 0.71; 95% CI, 0.11 to 1.31). Medial PFC dTMS, right DLPFC intermittent theta-burst stimulation, and left DLPFC high-frequency stimulation did not separate from sham. Dropouts as a proxy for acceptability revealed no differences between any of the active conditions or sham nor did any of the active conditions differ from each other.
The current literature does not support efficacy differences between interventions; however, protocols stimulating the right DLPFC appear superior to sham. It is unclear whether this reflects heterogeneity in pathology requiring a personalized medicine approach or nonspecific mechanisms of rTMS.
重复经颅磁刺激（rTMS）是治疗创伤后应激障碍（PTSD）的一种很有前途的治疗方法。已经研究了多个靶点和刺激参数，尽管之前的荟萃分析表明 rTMS 是有效的，但这些分析汇总了不同的刺激参数和靶点，并且每个靶点的相对疗效尚不清楚。
因此，我们通过搜索 MEDLINE、EMBASE、CENTRAL 和 PsycINFO 进行了一项系统评价和网络荟萃分析，纳入了至少每臂 5 名参与者和临床医生评定的 PTSD 症状的随机对照试验（RCT）（PROSPERO CRD42019134984）。我们遵循 PRISMA 指南，两名独立的审查员筛选研究的合格性并提取临床医生评定的 PTSD 症状的主要结局。辍学率作为可接受性的替代指标进行提取。进行了随机效应成对荟萃分析和网络荟萃分析。
我们综合了 10 项 RCT 的数据，这些 RCT 共纳入了 421 名参与者。两种针对右侧背外侧前额叶皮质（DLPFC）的 rTMS 干预措施改善了 PTSD 症状，与假刺激相比：低频刺激（SMD = 0.70；95%CI，0.22 至 1.18）和高频刺激（SMD = 0.71；95%CI，0.11 至 1.31）。内侧前额叶皮层 dTMS、右侧 DLPFC 间歇性 theta 爆发刺激和左侧 DLPFC 高频刺激与假刺激无差异。作为可接受性的替代指标的辍学率表明，任何一种活性条件与假刺激之间均无差异，并且任何一种活性条件之间也无差异。
目前的文献不支持干预措施之间的疗效差异；然而，刺激右侧 DLPFC 的方案似乎优于假刺激。目前尚不清楚这是否反映了需要个性化医疗方法的病理异质性，还是 rTMS 的非特异性机制。
