Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)? A Meta-Analysis of the Efficacy of rTMS in Psychiatric Disorders

Objective: Repetitive transcranial magnetic stimulation (rTMS) is a safe treatment method with few side effects. However, efficacy for various psychiatric disorders is currently not clear.

Data sources: A literature search was performed from 1966 through October 2008 using PubMed, Ovid Medline, Embase Psychiatry, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and PsycINFO. The following search terms were used: transcranial magnetic stimulation, TMS, repetitive TMS, psychiatry, mental disorder, psychiatric disorder, anxiety disorder, attention-deficit hyperactivity disorder, bipolar disorder, catatonia, mania, depression, obsessive-compulsive disorder, psychosis, posttraumatic stress disorder, schizophrenia, Tourette’s syndrome, bulimia nervosa, and addiction.

Study selection: Data were obtained from randomized, sham-controlled studies of rTMS treatment for depression (34 studies), auditory verbal hallucinations (AVH, 7 studies), negative symptoms in schizophrenia (7 studies), and obsessive-compulsive disorder (OCD, 3 studies). Studies of rTMS versus electroconvulsive treatment (ECT, 6 studies) for depression were meta-analyzed.

Data extraction: Standardized mean effect sizes of rTMS versus sham were computed based on pretreatment-posttreatment comparisons.

Data synthesis: The mean weighted effect size of rTMS versus sham for depression was 0.55 (P’ ‰<‘ ‰.001). Monotherapy with rTMS was more effective than rTMS as adjunctive to antidepressant medication. ECT was superior to rTMS in the treatment of depression (mean weighted effect size −0.47, P’ ‰=’ ‰.004). In the treatment of AVH, rTMS was superior to sham treatment, with a mean weighted effect size of 0.54 (P’ ‰<‘ ‰.001). The mean weighted effect size for rTMS versus sham in the treatment of negative symptoms in schizophrenia was 0.39 (P’ ‰=’ ‰.11) and for OCD, 0.15 (P’ ‰=’ ‰.52). Side effects were mild, yet more prevalent with high-frequency rTMS at frontal locations.

Conclusions: It is time to provide rTMS as a clinical treatment method for depression, for auditory verbal hallucinations, and possibly for negative symptoms. We do not recommend rTMS for the treatment of OCD.

J Clin Psychiatry 2010;71(7):873-884

Submitted: November 13, 2008; accepted February 2, 2009.

Online ahead of print: March 9, 2010 (doi:10.4088/JCP.08m04872gre).

Corresponding author: Christina W. Slotema, MD, Lijnbaan 4, 2512 VA, The Hague, the Netherlands ([email protected]).