Efficacy and acceptability of noninvasive brain stimulation for treating posttraumatic stress disorder symptoms: A network meta-analysis of randomized controlled trials

Author: Ping-Tao Tseng1,2,3,4,5, Bing-Yan Zeng3,6, Hung-Yu Wang7, Bing-Syuan Zeng8, Chih-Sung Liang9,10, Yang-Chieh Brian Chen11, Brendon Stubbs12,13, Andre F Carvalho14, Andre R Brunoni15,16, Kuan-Pin Su12,17,18,19, Yu-Kang Tu20,21, Yi-Cheng Wu22, Tien-Yu Chen23,24, Dian-Jeng Li25, Pao-Yen Lin11,26, Yen-Wen Chen2, Chih-Wei Hsu11, Kuo-Chuan Hung27, Yow-Ling Shiue1,3, Cheng-Ta Li5,28,29
Affiliation:
1 Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan.
2 Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan.
3 Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan.
4 Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan.
5 Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.
6 Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan.
7 Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan.
8 Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, I-Shou University, Kaohsiung, Taiwan.
9 Department of Psychiatry, Beitou Branch, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan.
10 Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.
11 Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
12 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
13 Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK.
14 Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia.
15 Service of Interdisciplinary Neuromodulation, National Institute of Biomarkers in Psychiatry, Laboratory of Neurosciences (LIM-27), Departamento e Instituto de Psiquiatria, Faculdade de Medicina da University of Sao Paulo, Sao Paulo, Brazil.
16 Departamento de Ciências Médicas, Faculdade de Medicina da University of Sao Paulo, Sao Paulo, Brazil.
17 Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan.
18 College of Medicine, China Medical University, Taichung, Taiwan.
19 An-Nan Hospital, China Medical University, Tainan, Taiwan.
20 Institute of Health Data Analytics & Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan.
21 Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan.
22 Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan.
23 Department of Psychiatry, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan.
24 Institute of Brain Science, National Yang Ming Chiao Tung University, Taiwan.
25 Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan.
26 Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
27 Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.
28 Division of Psychiatry, School of Medicine, National Yang Ming Chiao Tung University, Taiwan.
29 Institute of Brain Science and Brain Research Center, School of Medicine, National Yang Ming Chiao Tung University, Taiwan.
Conference/Journal: Acta Psychiatr Scand
Date published: 2024 Apr 14
Other: Special Notes: doi: 10.1111/acps.13688. , Word Count: 288


Introduction:
Despite its high lifetime prevalence rate and the elevated disability caused by posttraumatic stress disorder (PTSD), treatments exhibit modest efficacy. In consideration of the abnormal connectivity between the dorsolateral prefrontal cortex (DLPFC) and amygdala in PTSD, several randomized controlled trials (RCTs) addressing the efficacy of different noninvasive brain stimulation (NIBS) modalities for PTSD management have been undertaken. However, previous RCTs have reported inconsistent results. The current network meta-analysis (NMA) aimed to compare the efficacy and acceptability of various NIBS protocols in PTSD management.

Methods:
We systematically searched ClinicalKey, Cochrane Central Register of Controlled Trials, Embase, ProQuest, PubMed, ScienceDirect, Web of Science, and ClinicalTrials.gov to identify relevant RCTs. The targeted RCTs was those comparing the efficacy of NIBS interventions, such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and transcutaneous cervical vagal nerve stimulation, in patients with PTSD. The NMA was conducted using a frequentist model. The primary outcomes were changes in the overall severity of PTSD and acceptability (to be specific, rates of dropouts for any reason).

Results:
We identified 14 RCTs that enrolled 686 participants. The NMA demonstrated that among the investigated NIBS types, high-frequency rTMS over bilateral DLPFCs was associated with the greatest reduction in overall PTSD severity. Further, in comparison with the sham controls, excitatory stimulation over the right DLPFC with/without excitatory stimulation over left DLPFC were associated with significant reductions in PTSD-related symptoms, including depression and anxiety symptoms, and overall PTSD severity.

Conclusions:
This NMA demonstrated that excitatory stimulation over the right DLPFC with or without excitatory stimulation over left DLPFC were associated with significant reductions in PTSD-related symptoms.

Trial registration:
PROSPERO CRD42023391562.

Keywords: network meta‐analysis; non‐invasive brain stimulation; post‐traumatic stress disorder; rTMS; tDCS.

PMID: 38616056 DOI: 10.1111/acps.13688

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