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Can Low-Frequency Repetitive Transcranial Magnetic Stimulation Really Relieve Medication-Resistant Auditory Verbal Hallucinations? Negative Results from a Large Randomized Controlled Trial
Abstract
Background Several studies have applied low-frequency repetitive transcranial magnetic stimulation (rTMS) directed at the left temporoparietal area (TP) for the treatment of auditory verbal hallucinations (AVH), but findings on efficacy are inconsistent. Furthermore, recent functional magnetic resonance imaging (fMRI) studies indicate that the left TP is not a general focus of activation during the experience of AVH. The aims of this study are twofold: to investigate the effects of rTMS on AVH in a double blind, randomized, sham-controlled study; and to investigate whether the efficacy can be improved when rTMS is guided by individual fMRI scans of hallucinatory activation.Methods Sixty-two patients with medication-resistant AVH were randomized over three conditions: rTMS targeted at the area of maximal hallucinatory activation calculated from individual fMRI scans during AVH, rTMS directed at the left TP, and sham treatment. Repetitive TMS was applied during 15 sessions of 20 min each, at 1 Hz and 90% of the individual motor threshold. The severity of AVH and other psychotic symptoms were monitored during treatment and 3-month follow-up, with the Auditory Hallucination Rating Scale, the Positive and Negative Syndrome Scale, and the Psychotic Symptom Rating Scales.Results The effects of fMRI-guided rTMS and left TP rTMS on the severity of AVH were comparable to those of sham treatment. No differences in severity of general psychotic symptoms were found among the three treatment conditions.Conclusions Low-frequency rTMS administered to the left TP or to the site of maximal hallucinatory activation is not more effective for medication-resistant AVH than sham treatment.
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“Notably, a relatively large randomized controlled trial (N = 62) failed to find any significant advantage of active rTMS over sham stimulation”
From Auditory verbal hallucinations as atypical inner speech monitoring, and the potential of neurostimulation as a treatment option (2013) · cites this paper as Slotema et al., 2011
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“Of the three studies discussed here that have achieved adequate power, one finds no effect of neurostimulation (Slotema et al., 2011), and the other two originate from the same institution (Hoffman et al., 2005, 2013).”
From Auditory verbal hallucinations as atypical inner speech monitoring, and the potential of neurostimulation as a treatment option (2013) · cites this paper as Slotema et al., 2011
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“In addition, low-frequency stimulation of left temporoparietal sites is also common, and is comparatively effective against auditory hallucinations (Lai et al., 2010; Slotema et al., 2011, 2014; Yue et al., 2013).”
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“In spite of these promising findings, it is clear that rTMS does not work equally well for all patients; a recent large scale study failed to find a beneficial effect of rTMS on the severity and frequency of AH (Slotema et al., 2011).”
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Repetitive Transcranial Magnetic Stimulation for Auditory Verbal Hallucinations in Schizophrenia
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“Although some studies have been negative (Slotema et al., 2011), several meta-analyses (Aleman et al., 2007; Freitas et al., 2009; Slotema et al., 2010; Tranulis et al., 2008) have concluded that rTMS is more effective than a sham control in treating auditory-verbal hallucinations in schizophrenia.”
Understanding the biophysical effects of transcranial magnetic stimulation on brain tissue
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“In particular, the study by (Slotema et al., 2011) with a relatively large sample reported no significant difference when comparing active to sham rTMS.”
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“Our findings also correlate with a doubleblind, randomized, sham-controlled study of 62 patients completed in March 2011 [20], which concluded that low-frequency rTMS administered to the left temporoparietal cortex (shown to be the site of maximal hallucinatory activation) is not more effective for medicationresistant…”
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“In an open-label trial using fMRI whilst patients reported AVHs, rTMS sessions were performed over the individual locations of activation peaks (Sommer et al., 2007).”
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High frequency rTMS; a more effective treatment for auditory verbal hallucinations?
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“However, administering 1 Hz rTMS to this target had no effect on positive symptoms compared to a structurally defined anatomical target or sham treatment [74].”
Tiefe Hirnstimulation bei der Schizophrenie
Kuhn, J., Bodatsch, M., Sturm, V., Lenartz, D., Klosterkötter, J., Uhlhaas, P. J., Winter, C., & Gruendler, T. O. J. (2011) · Fortschritte der Neurologie · Psychiatrie · doi:10.1055/s-0031-1281733 · Cited by 23
“in the largest randomized controlled trial no superiority of TMS compared to placebo has been found (Aleman, Sommer & Kahn, 2007; Slotema et al., 2010; Slotema et al., 2011).”
BackgroundPredicting response to rTMS for auditory hallucinations: Younger patients and females do better
Koops, S., Slotema, C. W., Kos, C., Bais, L., Aleman, A., Blom, J. D., & Sommer, I. E. (2017) · Schizophrenia Research · doi:10.1016/j.schres.2017.08.060 · Cited by 22
“We analyzed data from 123 patients who received rTMS, from fi ve previously published randomized controlled trials (RCTs) of which patient-level data was available (Bais et al., 2014; De Weijer et al., 2014; Koops et al., 2016; Slotema et al., 2011; Van Lutterveld et al., 2012).”
Wagner, E. M., Honer, W. G., Sommer, I. E., Koops, S., Blumberger, D. M., Daskalakis, Z. J., Lange, J. J. D.-D., Bais, L., Knegtering, H., Aleman, A., et al. (2020) · The World Journal of Biological Psychiatry · doi:10.1080/15622975.2020.1733080 · Cited by 23
“Our results did not show a significant superior effect of active rTMS compared to sham for AH (stimulation of TPC) and NS studies (stimulation of DLPFC) when applied to augment an unsuccessful treatment with clozapine when response rates or symptomatic changes were analysed.”
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Reproducibility of brain activation during auditory verbal hallucinations
Diederen, K. M. J., Charbonnier, L., Neggers, S. F. W., van Lutterveld, R., Daalman, K., Slotema, C. W., Kahn, R. S., & Sommer, I. E. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.01.025 · Cited by 19
“Patients were selected for participation from a larger group of patients with chronic hallucinations (Slotema et al., 2011) if they met the following criteria: (1) the presence of two subsequent AVH scans in which (2) intermittent AVH were experienced (i.e., AVH alternated with non-AVH state), (3)…”
Xie, Y.-J., Guan, M.-Z., He, Y., Wang, Z.-H., Ma, Z.-J., Fang, P., & Wang, H.-N. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1071769 · Cited by 20
Hearing Safety of Long-Term Treatment with Theta Burst Stimulation
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Auditory verbal hallucinations: imaging, analysis, and intervention
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“The largest study so far (n = 62) found no difference between verum and placebo TMS on the severity of AVH [21].”
The effect of rTMS on auditory hallucinations: clues from an EEG-rTMS study.
van Lutterveld, R., Koops, S., Schutter, D., Geertsema, E., Stam, C., Kahn, R., & Sommer, I. (2012) · Schizophrenia Research · doi:10.1016/j.schres.2012.01.010 · Cited by 17
Xie, Y., Guan, M., Zhang, T., Ma, C., Wang, L., Lin, X., Li, C., Wang, Z., Ma, Z., Wang, H., et al. (2024) · Translational Psychiatry · doi:10.1038/s41398-024-03106-4 · Cited by 18
“Studies have highlighted its potential, particularly when administered at low-frequency (typically 1 Hz), to alleviate AVH symptoms [11 – 13], despite some reports of negative fi ndings [14].”
BackgroundSlotema, C. W., Blom, J. D., de Weijer, A. D., Hoek, H. W., & Sommer, I. E. (2011) · Brain stimulation · doi:10.1016/j.brs.2011.10.005 · Cited by 17
Targeting VMPFC‐amygdala circuit with TMS in substance use disorder: A mechanistic framework
Soleimani, G., Conelea, C. A., Kuplicki, R., Opitz, A., Lim, K. O., Paulus, M. P., & Ekhtiari, H. (2025) · Addiction Biology · doi:10.1111/adb.70011 · Cited by 18
Neuroimaging Effects of 1 Hz Right Temporoparietal rTMS on Normal Auditory Processing
Tracy, D. K., de Abreu, M. D. S., Orlov, N. D., Mao, L., Lage, C., & Shergill, S. S. (2014) · Journal of Clinical Neurophysiology · doi:10.1097/wnp.0000000000000098 · Cited by 16
“The largest (n 1⁄4 62) randomized control trial to date (Slotema et al., 2011), which compared left temporoparietal “treatment as normal” and guided TMS focused on the region of maximal cortical activity when hallucinating–as measured through pre-rTMS functional magnetic resonance imaging (fMRI)–failed to show any sup…”
BackgroundMethodInfluentialBaliga, S. P., & Mehta, U. M. (2021) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2021.662976 · Cited by 16
Schönfeldt-Lecuona, C., Cárdenas-Morales, L., Moreno-Aguirre, A., Dorn, K., Langguth, B., Brühl, A. B., Kammer, T., & Herwig, U. (2012) · Brain Topography · doi:10.1007/s10548-012-0218-1 · Cited by 15
“This finding suggesting a focal ‘‘hyperexcitability’’ as a pathophysiological correlate of AH prompted a series of studies in which 1 Hz rTMS was successfully used to reduce the severity of hallucinations (Hoffman et al. 1999a, 2005; Hoffman and Cavus 2002; Fitzgerald et al. 2005; Brunelin et al. 2006; Rosa et al. 200…”
BackgroundInfluentialTwice daily low frequency rTMS for treatment-resistant auditory hallucinations
Brunelin, J., Galvão, F., & Mondino, M. (2022) · International Journal of Clinical and Health Psychology · doi:10.1016/j.ijchp.2022.100344 · Cited by 13
“, 2009), 2 delivered 15 sessions (Hoffman et al., 2013; Slotema et al., 2011) and 2 delivered 20 sessions (Blumberger et al.”
BackgroundKronick, J., Sabesan, P., Burhan, A. M., & Palaniyappan, L. K. (2021) · Schizophrenia Research · doi:10.1016/j.schres.2021.06.009 · Cited by 13
Zhang, J., Tusuzian, E., Morfini, F., Bauer, C. C. C., Stone, L., Awad, A., Shinn, A. K., Niznikiewicz, M. A., & Whitfield, S. (2025) · Depression and Anxiety · doi:10.1155/da/2848929 · Cited by 13
“Recent neuromodulatory methods such as transcranial magnetic stimulation or electroconvulsive therapy may not be well tolerated and may be limited in effectiveness [8, 9].”
AUDITORY HALLUCINATIONS ELICIT SIMILAR BRAIN ACTIVATION IN PSYCHOTIC AND NON-PSYCHOTIC INDIVIDUALS
Sommer, I. E. (2012) · Schizophrenia Research · doi:10.1016/s0920-9964(12)70250-5 · Cited by 10
Ning, Y., Zheng, S., Feng, S., Zhang, B., & Jia, H. (2021) · Frontiers in Neurology · doi:10.3389/fneur.2021.766736 · Cited by 10
Xie, Y., Li, C., Guan, M., Zhang, T., Ma, C., Wang, Z., Ma, Z., Wang, H., & Fang, P. (2024) · Human Brain Mapping · doi:10.1002/hbm.26614 · Cited by 8
“…inner speech perception and AVH (Bohlken et al., 2017; Nathou et al., 2015), low-frequency rTMS has demonstrated significant reduction in AVH symptoms among s patients with schizophrenia (Poulet et al., 2005; Vercammen et al., 2009), although some findings are inconclusive (Slotema et al., 2011).”
ResultAbbs, B., Achalia, R. M., Adelufosi, A. O., Aktener, A. Y., Beveridge, N. J., Bhakta, S. G., Blackman, R. K., Bora, E., Byun, M. S., Cabanis, M., et al. (2012) · Schizophrenia Research · doi:10.1016/j.schres.2012.07.024 · Cited by 8
“He reported open label RCT assessing Relapse with Risperidone LAI vs. Oral Quetiapine.”
MethodInfluentialCao, Z.-C., Xiao, X.-Z., Zhao, Y., Jiang, Y.-H., Xie, C., Martinot, M. P., Artiges, E., Li, Z., Daskalakis, Z., Yang, Y., et al. (2022) · bioRxiv · doi:10.3389/fnins.2022.1079078 · Cited by 10
“Though techniques like neuronavigation have increased the accuracy in locating these ROIs, improvement in treatment efficacy is relatively limited (Slotema et al., 2011).”
BackgroundKim, M., Lee, T. H., Hwang, W. J., Lee, T. Y., & Kwon, J. S. (2018) · Clinical EEG and Neuroscience · doi:10.1177/1550059418815228 · Cited by 8
Li, H., Wang, Y., Jiang, J., Li, W., & Li, C. (2016) · Europe PMC (PubMed Central) · doi:10.11919/j.issn.1002-0829.216121 · Cited by 7
“In most patients, AH can be alleviated using antipsychotics, however, 25 to 30% of patients have persistent auditory hallucinations which are not responsive to antipsychotics.([2,4-5]) Transcranial direct current stimulation (tDCS) is a non-invasion brain stimulation which has been suggested as a safe and promising tr…”
BackgroundMarras, A., & Pallanti, S. (2013) · Case Reports in Psychiatry · doi:10.1155/2013/930304 · Cited by 10
Blanco-Lopez, M. J., Cudeiro-Blanco, J., Iglesias, G., Gago, A., & Cudeiro, J. (2016) · Schizophrenia Research · doi:10.1016/j.schres.2016.02.024 · Cited by 7
“However there remains some controversy and other authors have found that rTMS is no more effective than sham treatment (Slotema et al., 2011).”
BackgroundrTMS deserves a fair chance as a novel treatment for depression
Aleman, A., Slotema, C. W., & Sommer, I. E. (2014) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.12277 · Cited by 7
Carr, R., Cannon, A., Finelli, V., Bukala, B. R., Cimen, Y., Filipova, P., Cummings, C., Pillinger, T., Howes, O. D., & McCutcheon, R. A. (2025) · Molecular Psychiatry · doi:10.1038/s41380-025-03255-y · Cited by 6
Deep Brain Stimulation in Schizophrenia
Kuhn, J., Bodatsch, M., Sturm, V., Lenartz, D., Klosterkötter, J., Uhlhaas, P. J., Winter, C., & Gruendler, T. O. J. (2014) · Activitas Nervosa Superior · doi:10.1007/bf03379611 · Cited by 6
“Meta-analyses revealed at best a moderate effect-size of TMS in the treatment of auditory hallucinations, and in the largest randomized controlled trial no superiority of TMS compared to placebo has been found (Aleman, Sommer & Kahn, 2007; Slotema et al., 2010; Slotema et al., 2011).”
BackgroundMethodSchulz, T., Berger, C., Krecklow, B., Kurth, J., Schwarzenboeck, S. M., Foley, P. B., Thome, J., Krause, B. J., & Hoeppner, J. (2014) · Journal of Neural Transmission · doi:10.1007/s00702-013-1151-5 · Cited by 6
“…found by Hoffman et al. (2013): 17.5 ± 19.3 weeks; Slotema et al. (2012) found in a meta-analysis, however, that benefit was negligible by 4 weeks], as has the degree of placebo response elicited by the procedure (Vercammen et al. 2009; MontagneLarmurier et al. 2011; Slotema et al. 2011, 2012).”
InfluentialPerspectives in Brain Imaging and Computer-Assisted Technologies for the Treatment of Hallucinations
Foucher, J. (2012) · Springer eBooks · doi:10.1007/978-1-4614-4121-2_27 · Cited by 6
Time varying dynamics of hallucinations in clinical and non-clinical voice-hearers
Marschall, T. M., Koops, S., Brederoo, S., Cabral, J., Ćurĉić‐Blake, B., & Sommer, I. E. (2023) · NeuroImage Clinical · doi:10.1016/j.nicl.2023.103351 · Cited by 4
“Clinical voice-hearers were selected from another study by our group described in Slotema et al. (2011).”
Illuminating posterior targets for transcranial magnetic stimulation beyond the prefrontal cortex
McCalley, D. M., Sanderson, L. L., Dowdle, L. T., Padula, C. B., Siddiqi, S., Ellard, K. K., & Taylor, J. J. (2025) · Nature Mental Health · doi:10.1038/s44220-025-00433-3 · Cited by 4
Briend, F., Nathou, C., Delcroix, N., Dollfus, S., & Etard, O. (2020) · Schizophrenia Research · doi:10.1016/j.schres.2020.09.001 · Cited by 5
Zhong, S., Hu, Y., Fu, Y., Cao, L., & Zhang, B. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-038557 · Cited by 4
Metadata
- Authors
- Slotema, C. W., Blom, J. D., de Weijer, A. D., Diederen, K. M., Goekoop, R., Looijestijn, J., Daalman, K., Rijkaart, A.-M., Kahn, R. S., Hoek, H. W., & Sommer, I. E. C.
- Affiliations
- Parnassia Groep (NL)
- University Medical Center Utrecht (NL)
- University Medical Center Groningen (NL)
- Corresponding author
- Slotema, Christina W.
- ORCID
- Venue
- Biological Psychiatry
- Publisher
- Elsevier BV
- Published
- 2011-03
- Volume
- 69
- Issue
- 5
- Pages
- 450-456
- ISSN
- 0006-3223 (ISSN-L)
- OpenAlex
- W2098660547
- Cited by
- 137
- References
- 42
- Citations by year
- 2026: 5 · 2025: 9 · 2024: 4 · 2023: 4 · 2022: 3 · 2021: 6 · 2020: 7 · 2019: 3 · 2018: 5 · 2017: 9 · 2016: 11 · 2015: 8 · 2014: 13 · 2013: 15 · 2012: 22
- FWCI
- 9.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Biological Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Funders
- NWO ZonMW (Dutch Scientific Research Foundation-Dutch National Institute of Health Research
- Stichting tot Steun (Dutch Support Foundation
- Topics
- Life Sciences › Neuroscience › Neurology › Transcranial Magnetic Stimulation Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Life Sciences › Neuroscience › Cognitive Neuroscience › Hallucinations in medical conditions
- Keywords
- auditory verbal hallucinations, low-frequency repetitive transcranial magnetic stimulation, left temporoparietal cortex, sham-controlled treatment, treatment efficacy, psychotic symptoms
- MeSH terms
- Adult, Brain, Data Interpretation, Statistical, Double-Blind Method, Drug Resistance, Female, Hallucinations, Humans, Magnetic Resonance Imaging, Male, Psychiatric Status Rating Scales, Psychotic Disorders, Schizophrenia, Schizophrenic Psychology, Antipsychotic Agents, Treatment Outcome, Transcranial Magnetic Stimulation
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