Efficacy of Transcranial Magnetic Stimulation in the Treatment of Combat-Related PTSD: A Systematic Review and Meta-analysis

Hesed Virto-Farfan^1*Fritz Fidel Váscones-Román²Valeria Rivera³Olga Karpenko⁴Elena Bochkina⁴Ekaterina Parshakova⁴Alexey Sinev⁴Gustavo E Tafet⁵Niels Pacheco-Barrios⁶

• ¹Andean University of Cusco, Cusco, Peru
• ²Universidad Peruana Cayetano Heredia Facultad de Medicina, Lima District, Peru
• ³Universidad de San Martin de Porres Facultad de Medicina Humana, La Molina, Peru
• ⁴Mental-health clinic No.1 named after N.A.Alexeev, Moscu, Russia
• ⁵Texas A&M University, College Station, United States
• ⁶Brigham and Women's Hospital, Boston, United States

Introduction Combat-related post-traumatic stress disorder (PTSD) remains highly prevalent among military personnel and veterans and is frequently chronic, disabling, and only partially responsive to first-line pharmacological and psychotherapeutic interventions. Given the central role of fronto-limbic circuit dysfunction in PTSD, transcranial magnetic stimulation (TMS) has emerged as a biologically plausible neuromodulatory strategy, yet its protocol-level efficacy in combat-exposed populations is not well established. Clarifying whether specific TMS modalities offer clinically meaningful benefit beyond sham, and whether any protocol can be prioritized, is critical for rationally integrating TMS into veteran-focused care pathways. Methods This systematic review and meta-analysis followed PRISMA 2020 and Cochrane Handbook recommendations and was prospectively registered in PROSPERO (CRD420251105555). We searched PubMed, SCOPUS, Embase, Web of Science, and EBSCO (March–June 2025) for clinical studies of adults with combat-related PTSD (DSM-IV, DSM-5, ICD-10, or ICD-11) receiving any TMS modality (rTMS, theta-burst stimulation, deep TMS, synchronized or accelerated TMS), compared with sham, standard care, or both. Primary outcomes were changes in PTSD severity measured with validated instruments (e.g., CAPS, PCL-5); secondary outcomes included depressive and anxiety symptoms, psychosocial functioning, acceptability, and safety. Random-effects meta-analyses (DerSimonian–Laird) were conducted for within-group pre–post change and between-group mean differences (TMS vs. control); heterogeneity was quantified with I². Risk of bias in randomized trials was assessed using the Cochrane RoB 2.0 tool. Results From 191 records, 7 studies (n = 963) were included in the quantitative synthesis. Five studies contributed pre–post data (including one of the randomized controlled trial that presented the pre and post data of the TMS group), showing a large, clinically meaningful pooled reduction in PTSD symptoms after TMS (pooled mean change −20.39 points; 95% CI −23.94 to −16.83; p < 0.001; I² = 88.7), with the greatest improvements observed in high-frequency (10 Hz) left DLPFC rTMS protocols delivered over 20–30 sessions. In contrast, three randomized controlled trials (n = 116) comparing active TMS with sham yielded a non-significant pooled mean difference favoring TMS (MD −3.83; 95% CI −16.32 to 8.65; p = 0.098; I² = 56.9), suggesting that a substantial portion of symptom improvement may reflect non-specific or shared therapeutic factors.