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
Abstract
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.
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Most clinical rTMS treatments for MDD occur daily and are applied using scalp-based targeting of DLPFC; these standard treatments are only modestly effective, even in the general MDD population.
“Most clinical rTMS treatments for MDD occur daily (one rTMS session per day) and are applied using scalp-based targeting of DLPFC. These standard treatments are only modestly effective, even in the general MDD population (17, 24–31).”
tDCS may enhance acute attention and working memory in people with depression.
“This finding suggests that tDCS may enhance acute attention and working memory in people with depression, in line with the acute attention-enhancing effects found following equivalent stimulation in individuals post-stroke.31”
From Transcranial direct current stimulation for depression: 3-week, randomised, sham-controlled trial (2012) · cites this paper as [31]
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Self-citationMajor depressive disorder: new clinical, neurobiological, and treatment perspectives
Kupfer, D. J., Frank, E., & Phillips, M. L. (2012) · The Lancet · doi:10.1016/s0140-6736(11)60602-8 · Cited by 894 · see citing works
Malhi, G. S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P. B., Fritz, K., Hopwood, M., Lyndon, B., Mulder, R., Murray, G., et al. (2015) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867415617657 · Cited by 842 · see citing works
“…the use of rTMS in depression have been conducted in patients who have failed to respond to one or more antidepressant medication strategies. rTMS treatment appears to be effective whether it is applied as a monotherapy or in conjunction with antidepressant medication (Slotema et al., 2010).”
BackgroundInfluentialDefault mode network mechanisms of transcranial magnetic stimulation in depression
Liston, C., Chen, A. C., Zebley, B. D., Drysdale, A. T., Gordon, R., Leuchter, B., Voss, H. U., Casey, B. J., Etkin, A., & Dubin, M. J. (2014) · Biological Psychiatry · doi:10.1016/j.biopsych.2014.01.023 · Cited by 763 · see citing works
McClintock, S. M., Reti, I. M., Carpenter, L. L., McDonald, W. M., Dubin, M., Taylor, S. F., Cook, I. A., O’Reardon, J., Husain, M. M., Wall, C., et al. (2018) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.16cs10905 · Cited by 693 · see citing works
Perera, T., George, M. S., Grammer, G., Janicak, P. G., Pascual-Leone, A., & Wirecki, T. S. (2016) · Brain Stimulation · doi:10.1016/j.brs.2016.03.010 · Cited by 674 · see citing works
Malhi, G. S., Bell, E., Bassett, D., Boyce, P., Bryant, R., Hazell, P., Hopwood, M., Lyndon, B., Mulder, R., Porter, R., et al. (2021) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867420979353 · Cited by 614 · see citing works
Berlim, M. T., van den Eynde, F., Tovar-Perdomo, S., & Daskalakis, Z. J. (2014) · Psychological Medicine · doi:10.1017/s0033291713000512 · Cited by 620 · see citing works
Brunelin, J., Mondino, M., Gassab, L., Haesebaert, F., Gaha, L., Suaud-Chagny, M.-F., Saoud, M., Mechri, A., & Poulet, E. (2012) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2012.11071091 · Cited by 520 · see citing works
Transcranial direct current stimulation for depression: 3-week, randomised, sham-controlled trial
Loo, C. K., Alonzo, A., Martin, D., Mitchell, P. B., Galvez, V., & Sachdev, P. (2012) · British Journal of Psychiatry · doi:10.1192/bjp.bp.111.097634 · Cited by 455 · see citing works
Levkovitz, Y., Isserles, M., Padberg, F., Lisanby, S. H., Bystritsky, A., Xia, G., Tendler, A., Daskalakis, Z. J., Winston, J. L., Dannon, P., et al. (2015) · World Psychiatry · doi:10.1002/wps.20199 · Cited by 442 · see citing works
Transcranial magnetic brain stimulation: Therapeutic promises and scientific gaps
Wassermann, E. M., & Zimmermann, T. (2012) · Pharmacology & Therapeutics · doi:10.1016/j.pharmthera.2011.09.003 · Cited by 243 · see citing works
Meron, D., Hedger, N., Garner, M., & Baldwin, D. S. (2015) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2015.07.012 · Cited by 220 · see citing works
Fitzgerald, P. B., Hoy, K. E., Anderson, R. J., & Daskalakis, Z. J. (2016) · Depression and Anxiety · doi:10.1002/da.22503 · Cited by 204 · see citing works
Ren, J., Li, H., Palaniyappan, L., Liu, H., Wang, J., Li, C., & Rossini, P. M. (2014) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2014.02.004 · Cited by 199 · see citing works
Bailey, N. W., Hoy, K. E., Rogasch, N. C., Thomson, R. H., McQueen, S., Elliot, D., Sullivan, C. M., Fulcher, B. D., Daskalakis, Z. J., & Fitzgerald, P. B. (2018) · Brain Stimulation · doi:10.1016/j.brs.2017.10.015 · Cited by 162 · see citing works
Kaster, T. S., Daskalakis, Z. J., Noda, Y., Knyahnytska, Y., Downar, J., Rajji, T. K., Levkovitz, Y., Zangen, A., Butters, M. A., Mulsant, B. H., et al. (2018) · Neuropsychopharmacology · doi:10.1038/s41386-018-0121-x · Cited by 174 · see citing works
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., et al. (2011) · Biological Psychiatry · doi:10.1016/j.biopsych.2010.09.051 · Cited by 137 · see citing works
Blumberger, D. M., Mulsant, B. H., Fitzgerald, P. B., Rajji, T. K., Ravindran, A. V., Young, L. T., Levinson, A. J., & Daskalakis, Z. J. (2012) · The World Journal of Biological Psychiatry · doi:10.3109/15622975.2011.579163 · Cited by 118 · see citing works
Dell’Osso, B., Camuri, G., Castellano, F., Vecchi, V., Benedetti, M., Bortolussi, S., & Altamura, A. C. (2011) · Clinical Practice & Epidemiology in Mental Health · doi:10.2174/1745017901107010167 · Cited by 105 · see citing works
Somatic therapies for treatment-resistant depression: ECT, TMS, VNS, DBS
Cusin, C., & Dougherty, D. D. (2012) · Biology of Mood & Anxiety Disorders · doi:10.1186/2045-5380-2-14 · Cited by 98 · see citing works
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Raymaekers, S., Luyten, L., Bervoets, C., Gabriëls, L., & Nuttin, B. (2017) · Translational Psychiatry · doi:10.1038/tp.2017.66 · Cited by 82 · see citing works
Meerwijk, E. L., Ford, J. M., & Weiss, S. J. (2015) · Biological Psychology · doi:10.1016/j.biopsycho.2015.01.003 · Cited by 84 · see citing works
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Chen, J.-J., Liu, Z., Zhu, D., Li, Q., Zhang, H., Huang, H., Wei, Y., Mu, J., Yang, D., & Xie, P. (2014) · Psychiatry Research · doi:10.1016/j.psychres.2014.05.010 · Cited by 71 · see citing works
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Neuromodulation in Obsessive-Compulsive Disorder
Bais, M., Figee, M., & Denys, D. (2014) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2014.06.003 · Cited by 53 · see citing works
Homan, P., Neumeister, A., Nugent, A. C., Charney, D. S., Drevets, W. C., & Hasler, G. (2015) · Translational Psychiatry · doi:10.1038/tp.2015.25 · Cited by 46 · see citing works
Slotema, C. W., Blom, J. D., Niemantsverdriet, M. B. A., Deen, M., & Sommer, I. E. C. (2018) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2018.00084 · Cited by 46 · see citing works
Self-citationBrini, S., Brudasca, N. I., Hodkinson, A., Kaluzinska, K., Wach, A., Storman, D., Prokop-Dorner, A., Jemioło, P., & Bala, M. M. (2023) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102236 · Cited by 44 · see citing works
Concurrent TMS to the primary motor cortex augments slow motor learning
Narayana, S., Zhang, W., Rogers, W., Strickland, C., Franklin, C., Lancaster, J. L., & Fox, P. T. (2014) · NeuroImage · doi:10.1016/j.neuroimage.2013.07.024 · Cited by 41 · see citing works
Repetitive transcranial magnetic stimulation for the treatment of postpartum depression
Cox, E. Q., Killenberg, S., Frische, R., McClure, R., Hill, M., Jenson, J., Pearson, B., & Meltzer-Brody, S. E. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.11.069 · Cited by 33 · see citing works
Neuromodulation of Attentional Control in Major Depression: A Pilot DeepTMS Study
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Multivariate Patterns of Posterior Cortical Activity Differentiate Forms of Emotional Distancing
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Advances in the management of treatment-resistant anxiety disorders
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Adding Low-Field Magnetic Stimulation to Noninvasive Electromagnetic Neuromodulatory Therapies
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Changes in mindfulness following repetitive transcranial magnetic stimulation for mood disorders.
Leong, K., Chan, P., Grabovac, A., Wilkins-Ho, M., & Perri, M. (2013) · The Canadian Journal of Psychiatry · doi:10.1177/070674371305801206 · Cited by 11 · see citing works
Oberman, L. M., Penafiel, A. I., Dieterich, R., Phan, C. T., Chou, Y.-Y., Pham, D. L., Adamson, M. M., Hines, C. E., Rezaee, Z., Deng, Z.-D., et al. (2025) · Frontiers in Neurology · doi:10.3389/fneur.2025.1605157
- Authors
- Slotema, C. W., Blom, J. D., Hoek, H. W., & Sommer, I. E. C.
- Affiliations
- Parnassia Groep (NL)
- Columbia University (US)
- Utrecht University (NL)
- Corresponding author
- Slotema, Christina W.
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2010-03-09
- Volume
- 71
- Issue
- 07
- Pages
- 873-884
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2149866856
- Cited by
- 584
- References
- 89
- Citations by year
- 2026: 12 · 2025: 20 · 2024: 19 · 2023: 15 · 2022: 21 · 2021: 24 · 2020: 29 · 2019: 52 · 2018: 46 · 2017: 33 · 2016: 38 · 2015: 36 · 2014: 64 · 2013: 65 · 2012: 57
- FWCI
- 33.54
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Topics
- Life Sciences › Neuroscience › Neurology › Transcranial Magnetic Stimulation Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Keywords
- repetitive transcranial magnetic stimulation, depression, auditory verbal hallucinations, obsessive-compulsive disorder, electroconvulsive therapy, treatment efficacy, adverse effects, mental illness, adjunctive antidepressant therapy, high-frequency rTMS, Tourette syndrome, bipolar disorder, post-traumatic stress disorder, bulimia nervosa
- MeSH terms
- Mental Disorders, Combined Modality Therapy, Depressive Disorder, Electroconvulsive Therapy, Hallucinations, Humans, Obsessive-Compulsive Disorder, Psychiatric Status Rating Scales, Schizophrenia, Schizophrenic Psychology, Randomized Controlled Trials as Topic, Treatment Outcome, Transcranial Magnetic Stimulation
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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