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.

中文翻译：

---

经颅磁刺激治疗重度抑郁症的疗效和安全性：对已发表的随机对照试验荟萃分析的总体回顾和再分析

目标

我们重新分析了已发表的荟萃分析中的数据，这些荟萃分析测试了经颅磁刺激 (TMS) 对成人重度抑郁症 (MDD) 的影响。我们应用最新的元分析技术来处理异质性，包括随机效应 Hartung-Knapp-Sidik-Jonkman 方法和估计的 95% 预测区间。已发表的荟萃分析中的异质性实践被评估为次要目标。

研究设计和设置

我们通过荟萃分析对系统评价进行了系统搜索，其中包括评估 TMS 对 MDD 的疗效、耐受性和副作用的随机对照试验。我们使用评估评价的测量工具 (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 项系统评价并重新分析了 15 项荟萃分析。所有荟萃分析的作者都将结果解释为表明 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% 的预测区间包括无效值和在相反影响方向上捕获的值。我们还在一些荟萃分析中检测到小型研究效应的存在，25 篇系统评价中有 24 篇获得了 AMSTAR 2 评级为极低。

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对结果进行了解释，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评价存在高偏倚风险，并且在一些荟萃分析中存在小型研究效应。由于这些原因，我们认为 TMS 治疗 MDD 可能不如当前证据表明的那样有效，并且在某些人群中的耐受性可能较低。