Effects of different transcranial magnetic stimulation modes on refractory depression in adults: a network meta-analysis

doi:10.12307/2025.966

Abstract

Abstract: OBJECTIVE: To assess the efficacy and safety of transcranial magnetic stimulation in the treatment of refractory depression and to compare the differences in efficacy between various transcranial magnetic stimulation treatment protocols in refractory depression, thereby providing a theoretical basis for the clinical selection of transcranial magnetic stimulation treatment protocols.
METHODS: A comprehensive search was conducted across multiple databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, CBM and VIP. The search terms were “transcranial magnetic stimulation, treatment-resistant depression, randomized controlled trial” in Chinese, and “depressive disorder, treatment-resistant, transcranial magnetic stimulation, randomized controlled trial” in English. The objective was to identify randomized controlled trials on the treatment of patients with refractory depression published from the establishment of the databases to September 2024. The quality of the included studies was evaluated using the Cochrane risk of bias assessment tool, version 5.1.0, and the Physiotherapy Evidence Database scale. Meta-analysis of the outcome indicators was conducted using the Review Manager 5.4 and Stata 18.0 software.
RESULTS: (1) Following a comprehensive review, 20 randomized controlled trials were included in the analysis. All of the trials were assessed to be of high or very high quality according to the Physiotherapy Evidence Database scale. (2) Meta-analysis results showed that, compared with the sham stimulation group, high-frequency repetitive transcranial magnetic stimulation could significantly reduce the scores of Hamilton Depression Rating Scale [mean difference (MD)=
-3.89, 95% confidence interval (CI): -6.14 to -1.65, P < 0.05) or the Montgomery Depression Rating Scale (MD =-3.97, 95% CI: -6.57 to -1.36, P < 0.05). (3) The probability ranking results of the network Meta-analysis showed that, in terms of the Hamilton Depression Rating Scale score, the probability ranking results were as follows: high-frequency repetitive transcranial magnetic stimulation (69.9%) > intermittent theta burst stimulation (62.8%) > bilateral theta pulse stimulation (57.5%) > low-frequency repetitive transcranial magnetic stimulation (54.9%) > bilateral sequential transcranial magnetic stimulation (49.0%) > transcranial pulsed electromagnetic field (37.0%) > sham stimulation (18.9%). And in terms of the Montgomery Depression Rating Scale score, the probability ranking results were as follows: high-frequency repetitive transcranial magnetic stimulation (93.3%) > bilateral theta pulse stimulation (50.3%) > sham stimulation (45.9%) > low-frequency repetitive transcranial magnetic stimulation (32.1%) > bilateral sequential transcranial magnetic stimulation (28.4%).
CONCLUSION: Transcranial magnetic stimulations can improve the depressive symptoms of patients with treatment-resistant depression. Among them, the high-frequency repetitive transcranial magnetic stimulation mode has the best effect on improving the depressive symptoms of patients with treatment-resistant depression, followed by the intermittent θ burst stimulation mode.

Key words: refractory depression, transcranial magnetic stimulation, high-frequency transcranial magnetic stimulation, low-frequency transcranial magnetic stimulation, bilateral sequential transcranial magnetic stimulation, intermittent theta burst stimulation, bilateral theta-pulse stimulation, transcranial pulsed electromagnetic fields, network meta-analysis

CLC Number:

Tian Jinxin, Zhao Yuxin, Hu Tong, Cui Tiantian, Ma Lihong. Effects of different transcranial magnetic stimulation modes on refractory depression in adults: a network meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2025, 29(35): 7639-7648.

Figures/Tables 10

进行不一致性检验，结果显示各组比较均为P > 0.05[33]，故使用一致性模型进行分析。网状Meta 分析共涉及到HF-rTMS、BL-rTMS、cTBS+iTBS、LF-rTMS 4种TMS模式，其中HF-rTMS、BL-rTMS、LF-rTMS刺激模式均与伪刺激进行直接比较，BL-rTMS与cTBS+iTBS、HF-rTMS与BL-rTMS之间进行直接比较[34]。对于蒙哥马利抑郁量表评分，不同TMS模式的网状关系见图7。 2.5.2 纳入研究的累积概率排序比较在汉密尔顿抑郁量表评分结局指标方面，包括19篇文献[13-17，19-32]，共1 621例患者，涉及6种TMS模式。与伪刺激组相比，HF-rTMS组降低难治性抑郁症患者汉密尔顿抑郁量表评分的效果更优，差异有显著性意义(MD=-3.84，95%CI：-5.86至-1.81)，见图8。根据估计概率值与效应量大小对不同干预方式的改善效果进行排序，结果显示HF-rTMS(69.9%) > iTBS(62.8%) > cTBS+iTBS(57.5%) > LF-rTMS(54.9%) > BL-rTMS(49.0%) > tPEMF(37.0%) > 伪刺激(18.9%)，累计概率比较见图9。在蒙哥马利抑郁量表评分结局指标方面，包括10篇文献[16-18，20，22，24，26，28，31-32]，共820例患者，涉及4种TMS模式，结果显示HF-rTMS组与伪刺激组、HF-rTMS组与BL-rTMS组比较差异有显著性意义(MD=-3.86，95%CI：-6.37至-1.36)，见图10。根据估计概率值与效应量大小对不同干预方式的改善效果进行排序，结果显示HF-rTMS(93.3%) > cTBS+ iTBS (50.3%) >伪刺激(45.9%) > LF-rTMS (32.1%) > BL-rTMS (28.4%)，累计概率比较见图11。 2.6 发表偏倚分析纳入研究的发表偏倚漏斗图，见图12。针对汉密尔顿抑郁量表评分的漏斗图，大部分圆点整体分布均匀且位于漏斗图内部，说明有较小的可能性存在发表偏倚，但有少量圆点分布在漏斗图外侧，提示纳入研究有小样本效应的可能性。针对蒙哥马利抑郁量表评分的漏斗图，纳入研究的圆点在漏斗图分布大致对称，说明存在发表偏倚的可能性较小。 2.7 不良反应分析纳入的20篇文献中，有11篇文献提及不良反应事"

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