Meta-analysis of the Efficacy and Safety of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression.

Background: Repetitive transcranial magnetic stimulation (rTMS) is a new type of physiotherapy technology that has been widely used in the research of depression. Although many clinical trials have found that compared to the placebo interventions, rTMS has a significant effect on the improvement of depressive symptoms, the outcomes remain inconsistent due to differences in rTMS treatment frequency, parameter settings, and site for stimulation.

Aims: This study systematically evaluated the safety and efficacy of rTMS combined with antidepressants for the treatment of depression in Chinese and English randomized, double-blind and sham controlled trials and explored the possible related factors affecting the efficacy and safety.

Methods: We used keywords "depression" and "transcranial magnetic Stimulaton" as filters to search for the Clinical Randomized Controlled Trials (RCTs) of rTMS treatments for depression both in Chinese electronic databases: Wan fang, Wellpresi, and China Knowledge Network and in English electronic databases: PubMed, Web of Science, Embase, PsycINFO, Cochrane Library (total 8 databases) up to January 5, 2017; assessed the quality of the included studies with Cochrane risk of bias assessment tool; and according to the trial groups performed statistical analysis of the efficacy and safety presented in the included studies with RevMan5.3 software.

Results: A total of 9798 articles were retrieved, and finally, 29 studies were included in this study, with a total sample size of 1659, in which the sample size of the study groups was 838, and the control group sample size was 821. After Meta-analysis, we found that treatment combined rTMS with antidepressants improves depressive symptoms in patients with depression (SDM=-0.84, 95%CI=-1.19 ~ -0.48). Based on the Cochrane risk bias Assessment tool, an assessment of the bias of the included studies was conducted, one of which was assessed as having a "high risk of bias" and others as "impossible to judge". None of the included studies reported significant adverse events, and Meta-analysis showed no statistically significant differences in dropout rate between the two groups (RR=1.27, 95%CI: 0.75~ 2.12, Z=0.89, p =0.37).

Conclusion: treatment that combined rTMS with antidepressant medication for depressive symptoms has a certain therapeutic advantage versus the placebo controls, demonstrated slight side effects, and attained good acceptability, but the differences between trials remained relatively large. Clinical trials with large sample sizes are required for further exploration of the possible related factors affecting the efficacy.