经颅磁刺激治疗重性抑郁障碍的疗效和安全性：系统评价和已发表随机对照试验荟萃分析的再分析。
Efficacy and safety of transcranial magnetic stimulation for treating major depressive disorder: An umbrella review and re-analysis of published meta-analyses of randomised controlled trials.
机构信息
Division of Health Services Research and Management School of Health Sciences, City, University of London, London, United Kingdom.
Division of Health Services Research and Management School of Health Sciences, City, University of London, London, United Kingdom.
出版信息
Clin Psychol Rev. 2023 Mar;100:102236. doi: 10.1016/j.cpr.2022.102236. Epub 2022 Dec 8.
OBJECTIVES
We re-analysed data from published meta-analyses testing the effects of Transcranial Magnetic Stimulation (TMS) on Major Depressive Disorder (MDD) in adults. We applied up-to-date meta-analytic techniques for handling heterogeneity including the random-effects Hartung-Knapp-Sidik-Jonkman method and estimated 95% prediction intervals. Heterogeneity practices in published meta-analyses were assessed as a secondary aim.
STUDY DESIGN AND SETTING
We performed systematic searches of systematic reviews with meta-analyses that included randomised controlled trials assessing the efficacy, tolerability, and side effects of TMS on MDD. We performed risk of bias assessment using A MeaSurement Tool to Assess Reviews (AMSTAR) 2 and re-analysed meta-analyses involving 10 or more primary studies.
RESULTS
We included 29 systematic reviews and re-analysed 15 meta-analyses. Authors of all meta-analyses interpreted findings to suggest TMS is safe and effective for MDD. Our re-analysis showed that in 14 out of 15 meta-analyses, the 95% prediction intervals included the null and captured values in the opposite effect direction. We also detected presence of small-study effects in some meta-analyses and 24 out of 25 systematic reviews received an AMSTAR 2 rating classed as critically low.
CONCLUSION
Authors of all included meta-analyses interpreted findings to suggest TMS is safe and effective for MDD despite lack of comprehensive investigation of heterogeneity. Our re-analysis revealed the direction and magnitude of treatment effects vary widely across different settings. We also found high risk of bias in the majority of included systematic reviews and presence of small-study effects in some meta-analyses. Because of these reasons, we argue TMS for MDD may not be as effective and potentially less tolerated in some populations than current evidence suggests.
目的
我们重新分析了已发表的荟萃分析数据，这些分析旨在测试经颅磁刺激（TMS）对成人重度抑郁症（MDD）的疗效。我们应用了最新的荟萃分析技术来处理异质性，包括随机效应的 Hartung-Knapp-Sidik-Jonkman 方法，并估计了 95%预测区间。作为次要目标，我们评估了发表的荟萃分析中的异质性处理实践。
研究设计和设置
我们对包括随机对照试验的系统综述进行了系统搜索，这些试验评估了 TMS 治疗 MDD 的疗效、耐受性和副作用。我们使用 A MeaSurement Tool to Assess Reviews（AMSTAR 2）进行了偏倚风险评估，并重新分析了涉及 10 项或更多主要研究的荟萃分析。
结果
我们纳入了 29 项系统综述，并重新分析了 15 项荟萃分析。所有荟萃分析的作者都解释了研究结果，表明 TMS 对 MDD 是安全有效的。我们的重新分析表明，在 15 项荟萃分析中的 14 项中，95%预测区间包括零值，并捕捉到了相反效应方向的数值。我们还在一些荟萃分析中检测到了小样本研究效应，在 25 项系统综述中有 24 项获得了被归类为极低的 AMSTAR 2 评分。
结论
尽管缺乏对异质性的全面调查，但所有纳入的荟萃分析的作者都解释了研究结果，表明 TMS 对 MDD 是安全有效的。我们的重新分析表明，不同环境下治疗效果的方向和幅度差异很大。我们还发现，大多数纳入的系统综述存在偏倚风险，并且一些荟萃分析中存在小样本研究效应。由于这些原因，我们认为 TMS 治疗 MDD 在某些人群中的效果可能不如当前证据表明的那样有效，且潜在的耐受性可能较差。
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