Wang Junjie, Zhou Yingqun, Gan Hong, Pang Jiaoyan, Li Hui, Wang Jijun, Li Chunbo
Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Shanghai Arch Psychiatry. 2017 Apr 25;29(2):61-76. doi: 10.11919/j.issn.1002-0829.217024.
Negative symptoms are one of the most difficult areas in the treatment of schizophrenia because antipsychotics are often less effective towards them. Repetitive transcranial magnetic stimulation (rTMS) is a new technique for cerebral cortex stimulation and is believed to be a safe and promising method for the treatment of mental disorders. As the clinical research and new treatment models have increased in recent years, the efficacy towards negative symptoms and safety evaluation of rTMS treatment should also be updated.
To explore the efficacy and safety of rTMS in the treatment of negative symptoms for patients with schizophrenia.
We searched for relevant controlled clinical trials from the following databases: PubMed, EMBASE, the Cochrane Library, EBSCO, Web of Science, China National Knowledge Infrastructure (CNKI), VIP, Wanfang Data, SINOMED, and Airiti Library. The retrieval time went up to January 2, 2017. The research literature was screened according to the predefined inclusion and exclusion criteria. After data extraction, statistical analysis was conducted by using RevMan 5.3 and Stata 14. Quality evaluation was done on the included research articles. The Cochrane risk of bias assessment tool was adopted for assessing risk of bias. The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system recommendation grading method was used as the reference standard.
A total of 3500 articles were retrieved. In the end, there were 29 articles included in the metaanalysis with a total sample size of 1440. After the meta-analysis, it was found that the use of antipsychotic treatment combined with rTMS could improve the negative symptoms of patients (SMD=-0.40, 95% CI= -0.62-0.18). Based on the bias of the efficacy evaluation assessed by the Cochrane risk of bias assessment tool, there were 6 studies rated as having "high risk of bias" and the rest were rated as "unable to determine". According to the assessment, development and evaluation criteria of the GRADE classification, the evidence quality for the efficacy evaluation index was "moderate". The acceptability of rTMS treatment was better (RR= 0.75, 95% CI= 0.491.15, based on the 1492 samples from the 28 studies), however, the patients who received the rTMS treatment had a higher rate of mild adverse effects (RR= 2.20, 95% CI= 1.53~ 3.18, based on the 1296 samples from the 23 studies).
The use of the antipsychotic treatment incorporated with rTMS treatment can slightly improve the negative symptoms of patients with schizophrenia and has better acceptability and fewer adverse effects. Nevertheless, there is publication bias in this study and the heterogeneity of the study is relatively high. Therefore, we need to be cautious when interpreting the results.
阴性症状是精神分裂症治疗中最棘手的领域之一，因为抗精神病药物对其往往疗效欠佳。重复经颅磁刺激（rTMS）是一种刺激大脑皮层的新技术，被认为是治疗精神障碍的一种安全且有前景的方法。近年来，随着临床研究和新治疗模式的增加，rTMS治疗对阴性症状的疗效及安全性评估也应更新。
探讨rTMS治疗精神分裂症患者阴性症状的疗效及安全性。
我们从以下数据库检索相关对照临床试验：PubMed、EMBASE、Cochrane图书馆、EBSCO、科学引文索引、中国知网（CNKI）、维普资讯、万方数据、中国生物医学文献数据库和华艺数位图书馆。检索时间截至2017年1月2日。根据预先设定的纳入和排除标准筛选研究文献。数据提取后，使用RevMan 5.3和Stata 14进行统计分析。对纳入的研究文章进行质量评估。采用Cochrane偏倚风险评估工具评估偏倚风险。以推荐分级的评估、制定与评价（GRADE）系统推荐分级方法作为参考标准。
共检索到3500篇文章。最终，有29篇文章纳入荟萃分析，总样本量为1440。荟萃分析后发现，抗精神病药物治疗联合rTMS可改善患者的阴性症状（标准化均数差=-0.40，95%置信区间=-0.62-0.18）。根据Cochrane偏倚风险评估工具评估的疗效评估偏倚，有6项研究被评为“高偏倚风险”，其余被评为“无法确定”。根据GRADE分类的评估、制定与评价标准，疗效评估指标的证据质量为“中等”。rTMS治疗的可接受性较好（基于28项研究的1492个样本，相对危险度=0.75，95%置信区间=0.491.15），然而，接受rTMS治疗的患者轻度不良反应发生率较高（基于23项研究的1296个样本，相对危险度=2.20，95%置信区间=1.5~3.18）。
抗精神病药物治疗联合rTMS治疗可轻微改善精神分裂症患者的阴性症状，具有较好的可接受性且不良反应较少。然而，本研究存在发表偏倚，研究的异质性相对较高。因此，在解释结果时我们需要谨慎。
