Neuromodulation treatments for post-traumatic stress disorder: A systematic review and network meta-analysis covering efficacy, acceptability, and follow-up effects

Neuromodulation treatments are novel interventions for post-traumatic stress disorder (PTSD), but their comparative effects at treatment endpoint and follow-up and the influence of moderators remain unclear. We included randomized controlled trials (RCTs) that explored neuromodulation, both as monotherapy and in combination, for treating patients with PTSD. 21 RCTs with 981 PTSD patients were included. The neuromodulation treatment was classified into nine protocols, including subtypes of transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), cervical vagal nerve stimulation (VNS), and trigeminal nerve stimulation (TNS). This Bayesian network meta-analysis demonstrated that (1) dual-tDCS (SMD = -1.30), high-frequency repetitive TMS (HF-rTMS) (SMD = -0.97), intermittent theta burst stimulation (iTBS) (SMD = -0.93), and low-frequency repetitive TMS (LF-rTMS) (SMD = -0.76) were associated with significant reductions in PTSD symptoms at the treatment endpoint, but these effects were not significant at follow-up; (2) no difference was found between any active treatment with sham controls; (3) regarding co-morbid additions, synchronized TMS (sTMS) was significantly associated with reductions of depression symptoms at treatment endpoint (SMD = -1.80) and dual-tDCS was associated with reductions in anxiety symptoms at follow-up (SMD = -1.70). Findings suggested dual-tDCS, HF-rTMS, iTBS, and LF-rTMS were effective for reducing PTSD symptoms, while their sustained efficacy was limited.