Mental Illness Research, Education, and Clinical Center, VA Palo Alto Healthcare System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, CA, USA.
Department of Behavioral Sciences and Social Medicine, Florida State University, Tallahassee, FL, USA; Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
J Affect Disord. 2022 Jan 15;297:671-678. doi: 10.1016/j.jad.2021.10.025. Epub 2021 Oct 20.
Repetitive transcranial magnetic stimulation (TMS) is an evidence-based treatment for pharmacoresistant major depressive disorder (MDD), however, the evidence in veterans has been mixed. To this end, VA implemented a nationwide TMS program that included evaluating clinical outcomes within a naturalistic design. TMS was hypothesized to be safe and provide clinically meaningful reductions in MDD and posttraumatic stress disorder (PTSD) symptoms.
Inclusion criteria were MDD diagnosis and standard clinical TMS eligibility. Of the 770 patients enrolled between October 2017 and March 2020, 68.4% (n = 521) met threshold-level PTSD symptom criteria. Treatments generally used standard parameters (e.g., left dorsolateral prefrontal cortex, 120% motor threshold, 10 Hz, 3000 pulses/treatment). Adequate dose was operationally defined as 30 sessions. MDD and PTSD symptoms were measured using the 9-item patient health questionnaire (PHQ-9) and PTSD checklist for DSM-5 (PCL-5), respectively.
Of the 770 who received at least one session, TMS was associated with clinically meaningful (Cohen's d>1.0) and statistically significant (all p<.001) reductions in MDD and PTSD. Of the 340 veterans who received an adequate dose, MDD response and remission rates were 41.4% and 20%, respectively. In veterans with comorbid PTSD, 65.3% demonstrated clinically meaningful reduction and 46.1% no longer met PTSD threshold criteria after TMS. Side effects were consistent with the known safety profile of TMS.
Include those inherent to retrospective observational cohort study in Veterans.
These multisite, large-scale data supports the effectiveness and safety of TMS for veterans with MDD and PTSD using standard clinical approaches.
重复经颅磁刺激（TMS）是一种治疗药物难治性重度抑郁症（MDD）的循证治疗方法，但在退伍军人中的证据参差不齐。为此，VA 实施了一项全国性的 TMS 计划，其中包括在自然设计中评估临床结果。TMS 被假设为安全，并提供 MDD 和创伤后应激障碍（PTSD）症状的临床有意义的减轻。
纳入标准为 MDD 诊断和标准临床 TMS 资格。在 2017 年 10 月至 2020 年 3 月期间招募的 770 名患者中，68.4%（n=521）符合 PTSD 症状阈值标准。治疗通常使用标准参数（例如，左背外侧前额叶皮层，120%运动阈值，10Hz，3000 脉冲/治疗）。足够的剂量操作上定义为 30 个疗程。使用 9 项患者健康问卷（PHQ-9）和 DSM-5 创伤后应激障碍检查表（PCL-5）分别测量 MDD 和 PTSD 症状。
在至少接受一次治疗的 770 名患者中，TMS 与 MDD 和 PTSD 的临床意义（Cohen's d>1.0）和统计学意义（均 p<.001）降低相关。在接受足够剂量的 340 名退伍军人中，MDD 反应和缓解率分别为 41.4%和 20%。在患有共病 PTSD 的退伍军人中，65.3%表现出有临床意义的减少，46.1%在 TMS 后不再符合 PTSD 阈值标准。副作用与 TMS 的已知安全性特征一致。
包括退伍军人回顾性观察队列研究中固有的局限性。
这些多站点、大规模数据支持使用标准临床方法对患有 MDD 和 PTSD 的退伍军人进行 TMS 的有效性和安全性。
