# Integrated Repetitive Transcranial Magnetic Stimulation and Acceptance and Commitment Therapy for Veterans with Chronic Pain and Depression

> **NIH VA I21** · VA SAN DIEGO HEALTHCARE SYSTEM · 2024 · —

## Abstract

Comorbid depression is highly prevalent in Veterans with chronic pain and contributes to greater pain
severity, functional impairment, and suicide risk relative to those with chronic pain alone. Despite the well-
known association between chronic pain and depression, current treatments fall short of producing meaningful
improvements in function and quality of life in this population. In this application, we propose to address this
problem by a novel intervention that combines repetitive Transcranial Magnetic Stimulation (rTMS) and
Acceptance and Commitment Therapy (ACT).
 ACT is an evidence-based psychosocial intervention that improves function in Veterans with chronic
pain. However, similar to the broader literature, comorbid depression significantly limits the efficacy of ACT,
which may be directly related to dysfunctional brain circuits that maintain depression. rTMS is a non-invasive
brain stimulation intervention that is FDA-cleared for the treatment of depression. The most commonly targeted
stimulation area is the left dorsolateral prefrontal cortex (DLFPC), a prefrontal brain region involved in cognitive
control and emotion regulation. rTMS over the left DLPFC has also been used to reduce pain intensity in
patients with chronic pain, as the DLPFC is implicated in the affective processing of painful stimuli. Importantly,
while rTMS has been shown to reduce depression severity and pain intensity, it does not directly address
function. Thus, the proposed research will integrate rTMS and ACT with the goal of maximizing functional
improvement in Veterans with chronic pain and depression.
 The purpose of this application is to examine the feasibility of a future randomized efficacy trial. A total
of 24 Veterans with chronic pain and depression will be randomized into DLPFC-rTMS + ACT or sham-rTMS +
ACT conditions. Multiple metrics of feasibility will be assessed, including general interest in the study,
willingness to participate, enrollment, retention, drop-out, number of adverse events, and participant blindness
to condition, as well as ratings of credibility, expectation, and treatment satisfaction. We will also estimate the
preliminary impact of DLPFC-rTMS + ACT and sham-rTMS + ACT on function as measured by reductions in
pain interference (primary clinical outcome). The intent of preliminary analyses is to obtain an additional
indicator for a future large-scale trial, not to verify group differences. Further, we will include two cognitive
control tasks, the Emotion Distractor and Attention-to-Breath tasks, with concurrent EEG recording as a
potential objective indicator of treatment response. The study team has previously demonstrated the
association between depression severity and DLPFC activity on these tasks. In the proposed study, we will
explore the associations between treatment-related change in DLPFC activity and treatment outcomes.
 Veterans with chronic pain and depression do not have access to effective treatments. To address thi...

## Key facts

- **NIH application ID:** 10754571
- **Project number:** 5I21RX004090-02
- **Recipient organization:** VA SAN DIEGO HEALTHCARE SYSTEM
- **Principal Investigator:** Matthew S Herbert
- **Activity code:** I21 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2022-11-01 → 2025-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10754571

## Citation

> US National Institutes of Health, RePORTER application 10754571, Integrated Repetitive Transcranial Magnetic Stimulation and Acceptance and Commitment Therapy for Veterans with Chronic Pain and Depression (5I21RX004090-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10754571. Licensed CC0.

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