Repetitive deep TMS in alcohol dependent patients halts progression of white matter changes in early abstinence

Aim Alcohol use disorder (AUD) is the most prevalent form of addiction, with a great burden on society and limited treatment options. A recent clinical trial reported significant clinical benefits of deep transcranial magnetic stimulations (Deep TMS) targeting midline frontocortical areas. However, the underlying biological substrate remained elusive. Here, we report the effect of Deep TMS on the microstructure of white matter. Methods A total of 37 (14 females) AUD treatment‐seeking patients were randomized to sham or active Deep TMS. Twenty (six females) age‐matched healthy controls were included. White matter integrity was evaluated by fractional anisotropy (FA). Secondary measures included brain functional connectivity and self‐reports of craving and drinking units in the 3 months of follow‐up period. Results White matter integrity was compromised in patients with AUD relative to healthy controls, as reflected by the widespread reduction in FA. This alteration progressed during early abstinence (3 weeks) in the absence of Deep TMS. However, stimulation of midline frontocortical areas arrested the progression of FA changes in association with decreased craving and relapse scores. Reconstruction of axonal tracts from white‐matter regions showing preserved FA values identified cortical regions in the posterior cingulate and dorsomedial prefrontal cortices where functional connectivity was persistently modulated. These effects were absent in the sham‐stimulated group. Conclusions By integrating brain structure and function to characterize the alcohol‐dependent brain, this study provides mechanistic insights into the TMS effect, pointing to myelin plasticity as a possible mediator.