Letter to the Editor
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jun 16, 2022; 10(17): 5929-5933
Published online Jun 16, 2022. doi: 10.12998/wjcc.v10.i17.5929
Repetitive transcranial magnetic stimulation for post-traumatic stress disorder: Lights and shadows
Carmen Concerto, Giuseppe Lanza, Francesco Fisicaro, Manuela Pennisi, Alessandro Rodolico, Giulia Torrisi, Rita Bella, Eugenio Aguglia
Carmen Concerto, Alessandro Rodolico, Giulia Torrisi, Eugenio Aguglia, Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Catania 95124, Italy
Giuseppe Lanza, Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania 95123, Italy
Giuseppe Lanza, Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Troina 94018, Italy
Francesco Fisicaro, Manuela Pennisi, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania 95123, Italy
Rita Bella, Department of Medical and Surgical Sciences and Advanced Technologies “G. F. Ingrassia”, University of Catania, Catania 95123, Italy
Author contributions: Concerto C and Lanza G contributed equally to this work; Concerto C, Lanza G, Fisicaro F, and Rodolico A conceived the study; Pennisi M and Torrisi G performed the literature search; Concerto C and Lanza G wrote the first draft of the manuscript; Bella R and Aguglia E revised the manuscript and supervised the research group; and all authors have read and approve the final manuscript.
Conflict-of-interest statement: The authors declared no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Giuseppe Lanza, MD, MSc, PhD, Associate Professor, Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, Catania 95123, Italy. giuseppe.lanza1@unict.it
Received: January 2, 2022
Peer-review started: January 2, 2022
First decision: January 23, 2022
Revised: January 27, 2022
Accepted: May 12, 2022
Article in press: May 12, 2022
Published online: June 16, 2022
Processing time: 157 Days and 19.4 Hours
Abstract

We have read with interest the publication that describes the available data related to the use of neuromodulation strategies for the treatment of post-traumatic stress disorder (PTSD). Despite treatment advances, however, a substantial proportion of PTSD patients receiving psychological and/or pharmacological treatment do not reach an adequate clinical response. In their paper, the authors draw attention to the current understanding of the use of repetitive transcranial magnetic stimulation (rTMS) as a potential treatment for PTSD. Most of the previous studies indeed applied both inhibitory (1 Hz) and excitatory (> 1 Hz, up to 20 Hz) rTMS to the right and/or left dorsolateral prefrontal cortex. Despite larger therapeutic effects observed when high-frequency stimulation was applied, the question of which side and frequency of stimulation is the most successful is still debated. The authors also reported on the after-effect of rTMS related to neuroplasticity and identified the intermittent theta burst stimulation as a technique of particular interest because of it showed the most effective improvement on PTSD symptoms. However, although numerous studies have highlighted the possible beneficial use of rTMS protocols for PTSD, the exact mechanism of action remains unclear. In their conclusions, the authors stated that rTMS has been demonstrated to be effective for the treatment of PTSD symptoms. Nevertheless, we believe that further research with homogeneous samples, standardized protocols, and objective outcome measures is needed to identify specific therapeutic targets and to better define significant changes when active and sham stimulation procedures are compared.

Keywords: Post-traumatic stress disorder; Neuromodulation; Repetitive transcranial magnetic stimulation; Translational neuroscience; Neuroplasticity; Metaplasticity

Core Tip: The interesting publication of the basic principle, current applications, and future directions of repetitive transcranial magnetic stimulation for the non-pharmacological treatment of post-traumatic stress disorder (PTSD) have been summarized. Therapeutic effects on core PTSD symptoms, such as avoidance, hyperarousal, and intrusions, appear to be larger when high-frequency stimulation over the right dorsolateral prefrontal cortex was used. However, although the technique has demonstrated safety and efficacy, several concerns remain related to the mechanisms of action and protocols to be adopted, including the heterogeneity in the sample selection, stimulation procedures, and outcome measures.