Näytönastekatsaukset

Repetitive transcranial magnetic stimulation (rTMS) in adult ADHD

Näytönastekatsaukset

19.5.2025

Sami Leppämäki

Level of evidence: C

Repetitive transcranial magnetic stimulation (rTMS) may not alleviate the symptoms of adult ADHD in a clinically meaningful way.

The effect of rTMS to overall ADHD symptoms is small and not significant (SMD -0.24; 95% CI -0.58; 0.1), but it alleviated inattention symptoms more than sham stimulation (-0.76; 95% CI -1.16; -0.53). However, the applicability of rTMS in Finland is poor since the only indication for rTMS approved by the authorities is the treatment of depression. The quality of evidence is low due to moderate risk of bias, imprecision and publication bias.

Table 1. Description of the included studies
Reference	Study type	Population	Intervention and comparison	Outcomes	Risk of bias [Table « Additional comments for included studies»2. Additional comments]
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	MA including randomized sham-controlled trials	RCTs of rTMS in ADHD patients, from January 1990 (inception) to January 2023 without no restrictions on country or language.	Repetitive transcranial magnetic stimulation (rTMS) compared to sham	Overall improvement in ADHD symptoms. Secondary outcomes were the association of rTMS with improvement in different ADHD symptoms.	Moderate
RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis

Table 2. Additional comments for included studies
Reference	Comments
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	The quality of eligible studies was rated according to version 2 of the Cochrane risk-of-bias tool for randomized trials. The GRADE framework was used to rate the certainty of evidence for individual outcomes of interest. The apparently higher risk of dropout in the rTMS group than the sham control group was not statistically significant (OR = 1.65, p = 0.26). Subgroup analysis on the efficacy of rTMS targeted at different brain regions demonstrated that rTMS was significantly more efficacious than sham treatment when the rPFC was targeted (SMD = -0.49, 95%CI -0.93 to -0.06, p=0.03, three studies with 87 participants) but not when the lPFC was targeted (SMD = 0.01, 95%CI -0.39 to 0. 60, p=0.67, two studies with 65 participants), which suggests that targeting the rPFC may be a more effective approach. Nevertheless, subgroup comparison between treatments targeting the rPFC and lPFC failed to achieve statistical significance (p=0.07). Four of the six included trials were conducted in Israel and the remaining two in the United States. All of the included studies enrolled adults, with five focusing exclusively on adults. The other study also recruited adolescents, the mean participant age was 18.11 years. Only self-rated assessment tools for outcome measurements, the results may not reflect improved neurocognitive ability. Since only two studies provided information on follow-up efficacy > 4 weeks after treatment, only analyzed treatment outcomes immediately after the final treatment session. MA did not report anything about adverse effects.

Results

Table 3. ADHD symptoms
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect: SMD (95% CI)
I= intervention; C=comparison; CI=confidence interval
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	5 RCTs and 158 participants	NR	NR	NR	-0.24 (-0.58; 0.1), p = 0.17
Level of evidence: low The quality of evidence is downgraded due to (imprecision and publication bias).

Table 4. Inattention
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect: SMD (95% CI)
I= intervention; C=comparison; CI=confidence interval
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	3 RCTs and 117 participants	NR	NR	NR	-0.76 (-1.16; -0.35), p = 0.0002
Level of evidence: low The quality of evidence is downgraded due to (imprecision and publication bias).

Table 5. Hyperactivity
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect: SMD (95% CI)
I= intervention; C=comparison; CI=confidence interval
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	2 RCTs and 91 participants	NR	NR	NR	0.04 (-0.41; 0.49), p=0.86
Level of evidence: low The quality of evidence is downgraded due to (imprecision and publication bias).

Table 6. Impulsivity
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect: SMD (95% CI)
I= intervention; C=comparison; CI=confidence interval
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	2 RCTs and 91 participants	NR	NR	NR	-0.43 (-1.46; 0.60), p=0.41
Level of evidence: low The quality of evidence is downgraded due to (imprecision and publication bias).

Table 7. Depression
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect: SMD (95% CI)
I= intervention; C=comparison; CI=confidence interval
«Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024»1	3 RCTs and 117 participants	NR	NR	NR	-0.02 (-0.58; 0.55), p=0.95
Level of evidence: low The quality of evidence is downgraded due to (imprecision and publication bias).

References

Chen CM, Liang SC, Sun CK, ym. A meta-analysis of randomized sham-controlled trials of repetitive transcranial magnetic stimulation for attention deficit/hyperactivity disorder. Braz J Psychiatry 2024;46():e20233428 «PMID: 38593057»PubMed