ABSTRACT
We aimed to conduct a meta-analysis to evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with post-stroke depression (PSD). Six relevant electronic databases (PubMed, CENTRAL, Embase, Web of Science, CINAHL, and PsycINFO) were searched. Randomized controlled trials (RCTs) that compared rTMS with control condition for PSD were included. The mean change in depression symptom scores was defined as the primary efficacy outcome. Secondary outcomes included the remission rate of depression, stroke recovery, and cognitive function recovery. In total, 7 RCTs with 351 participants were included. At post-treatment, rTMS was significantly more effective than the control condition, with a standardized mean difference (SMD) of -1.15 (95%CI: -1.62 to -0.69; P<0.001, I2=71%) and remission with an odds ratio (OR) of 3.46 (95%CI: 1.68 to 7.12; P<0.001; I2=11%). As for stroke recovery, rTMS was also better than the control condition (SMD=-0.67, 95%CI: -1.02 to -0.32; P<0.001). However, no significant difference was found for cognitive function recovery between the two groups (SMD=4.07, 95%CI: -1.41 to 9.55; P=0.15). To explore the potential moderators for the primary outcome, a series of subgroup and sensitivity analyses were performed. The results implied that rTMS may be more effective in Asian samples than in North American samples (P=0.03). In conclusion, from the current evidence in this study, rTMS could be an effective treatment for patients with PSD. Further clinical studies with larger sample sizes and clearer subgroup definitions are needed to confirm these outcomes.
INTRODUCTION
Stroke is one of the major public health concerns in the world, because of its high morbidity, mortality, and disability rates and serious financial burden (1). As one of the major obstacles in the process of stroke recovery, post-stroke depression (PSD) has attracted more and more attention (2). Studies have shown that PSD is associated with increased physical disabilities, impaired cognitive and social function, poor quality of life, and high risk of stroke recurrence and suicidality (3). Therefore, the treatment for PSD could benefit stroke functional recovery (4).
Several treatment options are now available for PSD, including medications, psychotherapy, and physiotherapy (5 6–7). Antidepressants are widely used in various somatic diseases with depression (8), but there are many concerns focused on their safety. Due to the fact that many people who suffer from stroke are elderly or middle-aged with multiple risk factors of arteriosclerotic cardiovascular disease, antidepressants are usually cautiously prescribed for these people because of their common side effects such as blood pressure instability and QT interval prolongation (9,10). Some studies have demonstrated the efficacy of psychological therapy for PSD patients (11). However, most people worldwide, especially in low-income countries, cannot access it.
Compared to medication, physiotherapy have been demonstrated to be safer for elderly people. Among the techniques, repetitive transcranial magnetic stimulation (rTMS) is one of the most important means for PSD patients (12). rTMS uses an electromagnetic coil applied to the scalp to produce a magnetic field. It causes cortical neurons in corresponding areas and neurons in distant areas to discharge, thereby regulating the function of the local cortex and related brain networks (13,14).
In the past decades, rTMS has been widely used in the treatment of psychiatric disorders, especially for major depressive disorder (MDD) (15). A number of studies have shown that rTMS is effective and safe for MDD patients (16). The possible mechanism could be a series of physiological effects induced by the focused magnetic field on specific brain regions, increasing the level of brain-derived neurotrophic factors (BDNF) and enhancing glucose metabolism in the cortex and other specific neural networks (17). However, whether rTMS is likewise effective for PSD patients remains unknown. Some studies have demonstrated promising results, but the conclusions are limited by the small sample size (18 19–20). Therefore, a well-designed meta-analysis to pool the comprehensive clinical evidence is needed to guide the application of rTMS in PSD patients.[…]