Oostra E, Jazdzyk P, Vis V, Dalhuisen I, Hoogendoorn A W, Planting C H M, van Eijndhoven P F, van der Werf Y D, van den Heuvel O A, van Exel E
Amsterdam UMC, Dept. Psychiatry, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
Amsterdam UMC, Dept Anatomy & Neuroscience, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
Acta Psychiatr Scand. 2025 Apr;151(4):485-505. doi: 10.1111/acps.13768. Epub 2024 Nov 21.
Repetitive transcranial magnetic stimulation (rTMS) is effective for treatment-resistant depression (TRD). Optimal rTMS parameters remain unclear, especially whether number of sessions or amount of pulses contribute more to treatment outcome. We hypothesize that treatment outcome depends on the number of sessions rather than on the amount of pulses.
We searched databases for randomized clinical trials (RCTs) on high-frequent (HF) or low-frequent (LF)-rTMS targeting the left or right DLPFC for TRD. Treatment efficacy was measured using standardized mean difference (SMD), calculated from pre- and post-treatment depression scores. Meta-regressions were used to explore linear associations between SMD and rTMS pulses, pulses/session and sessions for HF and LF-rTMS, separately for active and sham-rTMS. If these variables showed no linear association with SMD, we divided the data into quartiles and explored subgroup SMDs.
Eighty-seven RCTs were included: 67 studied HF-rTMS, eleven studied LF-rTMS, and nine studied both. No linear association was found between SMD and amount of pulses or pulses/session for HF and LF-rTMS. Subgroup analyses showed the largest SMDs for 1200-1500 HF-pulses/session and 360-450 LF-pulses/session. The number of sessions was significantly associated with SMD for active HF (β = 0.09, p < 0.05) and LF-rTMS (β = 0.06, p < 0.01). Thirty was the maximal number of sessions, in the included RCTs.
More rTMS sessions, but not more pulses, were associated with improved treatment outcome, in both HF and LF-rTMS. Our findings suggest that 1200-1500 HF-pulses/session and 360-450 LF-pulses/session are already sufficient, and that a treatment course should consist of least 30 sessions for higher chance of response.
重复经颅磁刺激（rTMS）对难治性抑郁症（TRD）有效。最佳rTMS参数仍不明确，尤其是治疗疗程数或脉冲量对治疗效果的影响更大。我们假设治疗效果取决于治疗疗程数而非脉冲量。
我们检索数据库，查找针对TRD采用高频（HF）或低频（LF）-rTMS刺激左侧或右侧背外侧前额叶皮质（DLPFC）的随机临床试验（RCT）。使用标准化均数差（SMD）来衡量治疗效果，该指标根据治疗前后的抑郁评分计算得出。采用Meta回归分别探讨HF和LF-rTMS的SMD与rTMS脉冲量、每次脉冲量及治疗疗程数之间的线性关系，同时区分真实治疗组和假刺激组。如果这些变量与SMD无线性关系，我们将数据分为四分位数并探讨亚组的SMD。
共纳入87项RCT：67项研究HF-rTMS，11项研究LF-rTMS，9项同时研究了两者。未发现HF和LF-rTMS的SMD与脉冲量或每次脉冲量之间存在线性关系。亚组分析显示，每次疗程1200 - 1500次HF脉冲和360 - 450次LF脉冲时SMD最大。治疗疗程数与真实治疗组的HF（β = 0.09，p < 0.05）和LF-rTMS（β = 0.06，p < 0.01）的SMD显著相关。在纳入的RCT中，治疗疗程数最多为30次。
在HF和LF-rTMS中，更多的rTMS治疗疗程而非更多的脉冲量与更好的治疗效果相关。我们的研究结果表明，每次疗程1200 - 1500次HF脉冲和360 - 450次LF脉冲已足够，并且一个治疗疗程至少应包括30次，以提高反应几率。
