More Conditions Treated With TMS

Post Traumatic Stress Disorder-PTSD, is a psychiatric condition that follows a direct or indirect traumatic event.  It typically presents with a number of problematic symptoms to be reviewed in more detail below and a chronically heightened stress state. Problems with mood and anxiety regulation occur and the mind and body struggle to reset and stay out of a fight or flight mode. Many of the symptoms of PTSD would be expected and normal in a life-threatening situation, but not in everyday life.

PTSD is most often associated with service personnel or veterans who have experienced active-duty combat and associated traumatic experiences. PTSD can occur in many other situations as well, however. Trauma can occur in small doses over many years or from one traumatic event. It can stem from things like abuse, an assault, or an accident. Some 7-9% of all people will experience PTSD in their lifetimes.¹

When experiencing a real or perceived life-threatening situation, the brain will shift into ‘reptilian brain,’ prioritizing pure instinct and survival. It enters into the fight or flight mode and activates basic brain structures that keep the brain in a heightened sense of awareness and safety.

Once the threat has passed, the brain will typically down-regulate itself and return to its everyday default mode. Depending on the severity and repetitiveness of the stressful trauma, however, and the genetic predisposition of the individual, this may not occur effectively. Similar to circuits that become stuck and dysfunctional in clinical depression, certain pathways become fixed in a fight or flight response in PTSD.

We all have different reactions to stressful and traumatic events and anyone can develop PTSD depending on the circumstances. Increased risk factors include:

Recurrent or longer-lasting trauma.

Suffering a physical injury or threat to life during trauma.

Lack of a support network.

Concurrent stress factors such as financial issues, homelessness, bereavement, or imprisonment.

History of depression and anxiety disorders.

Experiencing trauma in childhood.

Working in emergency services.

Refugee status.

The aftermath of a potentially life-threatening incident or repeated trauma typically manifests with natural reactions such as brief confusion, dissociation from one’s surroundings, exhaustion, a feeling of numbness, or acute anxiety or agitation. These expected reactions can support mental recovery and typically fade away. Continuing to struggle with symptoms to follow, however, indicate PTSD. PTSD symptoms have four distinct clusters:

Intrusive thoughts:

Flashbacks

Nightmares

Distressing memories.

Acute distress psychologically or physiologically at triggering reminders.

Negative mood and cognitions

Dissociative Amnesia - inability to recall aspects of the trauma.

Persistent negative emotions such as fear, anger, guilt, and/or shame.

Inability to experience positive emotions.

Feeling detached or estranged from surroundings and others.

Negativity and symptoms similar to depression such as lack of interest in activities.

Hypervigilance

Agitation and aggression.

Reckless or self-destructive behavior.

Startle response with panic attacks.

Insomnia

Difficulty concentrating.

Avoidance

Repeated effort to avoid memories or triggers related to the trauma.

Research has shown the brain actually changes biologically following traumatic experiences. Three significant brain areas become ‘dysregulated’ in PTSD:

The amygdala, responsible for recognizing and responding to threat, as well as attaching emotion to memory, becomes overactive and remains in an emergency and hypervigilant state.

The hippocampus, responsible for cells supporting neural connections that embed memory, shrinks. In reaction to the amygdala’s hypervigilance, stress hormones destroy the formation of new cells and memories that would ordinarily confirm that the threat has passed, solidifying the ‘high alert’ or reactive mode.

An area labeled the ventromedial prefrontal cortex no longer inhibits the hyperactive amygdala, thus reinforcing the inability of the hippocampus to form new memories and distinguish emotions connected to past from present. 

Unsurprisingly, a combination of any of the above symptoms can severely interfere with everyday activities resulting in:

Low self-care.

Difficulties with performing and retaining a job.

Conflict in relationships and friendships.

Inability to make decisions.

Memory problems.

Struggling to deal with change.

Loss of simple joys and pleasure in life.

Inability to make decisions.

Furthermore, PTSD often occurs or causes parallel mental health issues such as:

Depression and anxiety disorders.

Suicidal ideation and/or self-harm.

Dissociative disorders.

Substance abuse.

Similar to other psychiatric conditions such as Major Depressive Disorder, the mainstay of treatment for PTSD involves medications and specific types of therapy.  Therapy typically involves common approaches such as CBT (cognitive behavioral therapy) or more targeted therapy such as EMDR (eye movement desensitization and reprocessing), CPT (cognitive processing therapy), or exposure therapy. As is the case with Major Depression, however, PTSD treatment can often be resistant to these approaches. A recent meta-analysis showed that less than half of patients receiving trauma focused therapy achieved a meaningful response to treatment, some two-thirds of patients failed to achieve remission, and one-third dropped out of treatment. And the effect size for medications was even less than for therapy.²

TMS offers a unique approach and compelling results in the treatment of PTSD.  Numerous studies have shown TMS to be an effective treatment option for PTSD when medications and therapy have not worked. Different protocols have been utilized in an attempt to treat the core symptoms of PTSD, but most, similar to depression treatment, also target an area of the brain called the dorsolateral prefrontal cortex. This area on the surface of the brain is involved in regulating deeper brain structures and can affect key areas of the brain that are involved in PTSD symptoms such as the amygdala and hippocampus. 

What do the studies show? 

Research has been going on for quite some time with TMS treatment for PTSD. A meta-analysis from 2014 summarized that TMS treatment for PTSD was effective and that the effect size was similar to TMS treatment for Major Depression.³ Studies reviewed included RCTs (randomized controlled studies) - the gold standard for research - and utilized validated rating scales for PTSD such as the PCL-5 (PTSD checklist) and the CAPS-5 (clinician administered PTSD scale). Some of the studies utilized as few as 10 treatments in two weeks and were found to be beneficial, but more sessions and more pulses per session tended to show greater improvement in symptoms.

More recent meta-analyses reviewing TMS treatment for PTSD have found similar and even more robust findings.⁴⁵⁶ RCTs have consistently shown at least one-third of patients with improvement on PTSD rating scales and others have been closer to one-half of patients experiencing significant response. Longer term response data is more limited, but points to at least 2-3 months of sustained response following treatment and a more recent paper has found benefit with TMS up to 1 year post treatment.⁷

In 2021, the VA implemented a nationwide study to evaluate clinical outcomes in veterans being treated with TMS.⁸ While the primary inclusion criteria for this study was Major Depression, around 68% of the patients in this study also suffered from comorbid PTSD, and both Major Depression and PTSD responses were measured. Of the 340 veterans with comorbid PTSD, 65.3% showed response and 46.1% no longer met threshold criteria after receiving an adequate dose of TMS.

Read more: TMS success rate →

Another study, which examined TMS as a monotherapy for PTSD and compared a 1 Hz protocol to a 10 Hz protocol, also found clinically significant improvements in PTSD symptoms after 30 TMS treatments.⁹ This study utilized multiple rating scales to evaluate response and remission results, and they found that around 29-46% of patients experienced response and 21-33% experienced remission (depending on rating scale). In addition to these findings, they also saw that both the 1 Hz and 10 Hz groups showed similar improvements in both PTSD and depressive symptoms, and these improvements were sustained at a 3 month follow up. 

As listed above, a number of studies have shown very good results with TMS. It is not currently FDA approved for the treatment of PTSD, but often utilized off-label as PTSD can frequently be treatment resistant. As noted, other psychiatric conditions also commonly co-occur with PTSD. Major Depression occurs in some half of all PTSD sufferers. In light of this, additional treatment protocols that target PTSD more specifically can often be added into TMS being utilized to treat Major Depression at the same time. Interestingly with TMS for PTSD, a right-sided treatment target (as opposed to left-sided used in Major Depression) often provides benefit. An inhibitory vs excitatory protocol can also be tried based on response to treatment and based on specific symptoms of PTSD that are present.

Currently, repetitive Transcranial Magnetic Stimulation-rTMS, can be considered for patients with PTSD who have not responded to or tolerated standard treatments such as:

- SSRI antidepressants or other medications.

- Talk Therapy.

It also can be a good add-on treatment option for those already receiving TMS for Major Depression. Inspire TMS Denver does not charge additional fees for add-on treatments. And our out-of-pocket rates for those seeking care outside insurance coverage are competitive. Read more: TMS therapy cost  →

TMS has an excellent track record for treatment-resistant disorders such as PTSD.

TMS therapy remains a relatively new therapy only receiving FDA approval for Treatment Resistant Major Depression in 2008. However, thousands of publications and studies have taken place over the last decade-plus since then, exploring it’s benefit for other conditions such as PTSD.

As with TMS therapy for Major Depression, TMS therapy for PTSD follows a similar course - 5 sessions per week for 6 weeks with a 3-week taper following. Individual treatment plans may vary, however. Similarly, response times vary with TMS.  Some patients experience relief from symptoms in just one to two weeks, while others take four to six weeks and may require modifications to treatment parameters and/or additional treatment sessions. More questions about TMS Therapy for PTSD or other content on this page? Please contact us here to see about a free phone consultation.

If you have struggled with depression in the past, the heightened vulnerability of pregnancy and the postpartum period can increase the likelihood for depression. For some, however, the postpartum period can be their first experience with clinical depression. 

Baby blues tend to disperse after a few days as hormones rebalance and familiarity with your new baby grows and settles. Postpartum depression symptoms continue longer, however, and intensify. Postpartum depression is not drastically different from a Major Depressive Episode outside the unique factors occurring and time frame of the postpartum period. Displaying a combination of the following symptoms for more than a few days urges the need for medical consultation.

Uncontrollable crying for lengthy periods with no apparent reason.

Recurring severe mood swings.

Irrational anxiety and worry that impedes daily life or the ability to care for the baby.

Verbalizing guilt, shame, and hopelessness.

Disclosing and radiating profound sadness and despair.

Significant lack of concentration; regularly losing and forgetting things.

Inability or avoidance of tasks and decisions

Withdrawal from partner and others

Strong reluctance to be alone with the baby - often due to fear of something bad happening to the newborn.

Apathy towards the baby, significant others, activities, and hobbies.

Lack of sleep, changes in appetite, and excessive fatigue.

Suicidal or homicidal thoughts.

Delusional, paranoid, or other psychotic thinking or hallucinations.

Postpartum depression tests are available online and if symptoms above are experienced, mental health services should be sought right away. Resources such as the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or their web chat at suicidepreventionlifeline.org/chat are available if thoughts of suicide or psychotic symptoms occur. Additional crisis services are available through the state of CO or a mental health crisis walk-in center, or the ER in an urgent crisis. But how can we treat postpartum depression before reaching this point? 

A number of studies have pointed to TMS therapy as being a particularly effective treatment for postpartum depression.²³⁴⁵ These studies are relatively smaller in scale compared to the larger studies that have looked at response to TMS treatment in Treatment Resistant Major Depressive disorder, but are quite promising. Several involved lack of any medication use and the remission rates were 70-90%. The long-term response was similarly quite strong. And similar to larger studies using TMS for treatment resistant depression, the therapy was safe and well-tolerated. TMS provides an alternative to traditional treatment and the short treatment sessions (now even faster with theta-burst stimulation - read here for more about Theta Burst stimulation) can support new mothers getting back to a sense of mental wellbeing and enjoying motherhood.

The team at Inspire TMS Denver offers individual consultations to explore if and how TMS could support your postpartum depression. TMS therapy offers a non-invasive and non-systemic treatment avoiding medication side effects and providing a safe treatment for mom and baby during a challenging time. If traditional treatments are not working or not an option, TMS presents a great choice for relief from depression and anxiety in the postpartum time frame.  Should you elect to pursue TMS therapy for postpartum depression and associated symptoms, rest assured that Inspire TMS Denver will tailor treatment protocols to your individual symptoms and situation. More questions about TMS therapy for Postpartum depression or other information on this page? Please contact us here to see about a free consultation.

During one study from 2014, after 10 days of rTMS treatment, study participants saw an improvement in total sleep time, sleep efficiency, sleep onset latency, total wake time, and wake time after sleep onset.²

Another larger study from 2013, found that rTMS improved both Slow Wave Sleep and REM sleep in comparison with CBT and hypnotic medications such as Ambien. They reported that TMS had the lowest relapse rate for insomnia and was a better long term treatment option for insomnia than CBT or medications.³

TMS is most commonly known to treat Major Depressive Disorder (FDA Approved) and Generalized Anxiety Disorder (off label, but gaining traction), and while treating these disorders, a secondary effect of improved sleep and relief from insomnia is often seen. In one study, right sided rTMS treatment, typically used to treat anxiety, showed the most improvement in sleep quality with an increase in average time of sleep, decreased number of times eyes opened during sleep, and improved sympathetic activity in sleep.⁴

Read more: How TMS therapy works →

In another, Huang et al. 2018 described right sided stimulation for generalized anxiety and insomnia using a low-frequency protocol for 10 days, showing improvement in the Hamilton Rating Scale for Anxiety as well as the Pittsburgh Sleep Quality Index in 36 patients.

Another study by Li et al. 2013 studied 30 patients with major depressive disorder and 30 patients with major depressive disorder associated with insomnia receiving TMS.  Both groups improved with respect to depression and the latter as well to insomnia.⁵

Another study in 2017, found TMS to the right dorsolateral prefrontal cortex improved insomnia in 20 out of 25 patients.⁶

Read more: TMS therapy for depression →

Several other studies targeting anxiety with the use of TMS likewise showed improvement in sleep parameters.⁷⁸ Other studies have similarly shown improvements in sleep parameters and quality of sleep with left sided treatment in the context of depression treatment. Measuring cortisol and melatonin levels, another case study revealed excitatory left sided treatment, which is typically used to treat depression symptoms, as effective in decreasing cortisol levels, the stress hormone, and increasing melatonin levels two days after treatment, thus resulting in improved sleep and relief from insomnia.⁹

Read more: TMS therapy for anxiety →

In a recent meta-analysis looking at multiple studies using TMS for various indications, TMS was superior to sham treatment in improving sleep efficiency, total sleep time, sleep onset latency, wake up after sleep onset, and number of awakenings.¹⁰

Sleep disruption is a by-product of Restless Leg Syndrome preventing undisturbed sleep. Several studies have shown improvement in RLS and sleep with the use of TMS.¹¹¹²  Improvements occurred in total sleep hours, quality of sleep, and reduction in leg movements. And benefits were sustained for at least 2 months on repeat check-in.

Sleep improvement has been demonstrated in several studies evaluating insomnia associated with chronic back pain, Parkinson’s Disease, and in the context of Substance Use Disorder treatment.¹³¹⁴¹⁵¹⁶

Read more: TMS vs medication →

As with other areas of neuropsychiatric research, the full use of Transcranial Magnetic Stimulation continues to be explored and insomnia symptoms have occurred in many studies. Positive developments spur further research and studies leading to improved and enhanced solutions for the myriad of neuropsychiatric conditions. As a non-invasive, and potentially fast acting treatment, how much more sleep can you afford to lose?

The team at Inspire TMS Denver can offer individual consultations to explore if and how TMS could support you with depression, anxiety, and insomnia. Although TMS treatment specifically for insomnia remains off-label and not covered by insurance, we offer competitive sliding scale self-payment options and insomnia often coexists in Major Depressive Disorder - which is FDA approved and insurance covered. Every contraindication will be robustly examined and if treatment is supported, the team will compose a bespoke, personalized treatment schedule catering to you and your condition. Schedule a free consultation or call us today. →