title: Transcranial magnetic stimulation for posttraumatic stress disorder: an updated systematic review and meta-analysis.
abstract: BACKGROUND
  Transcranial magnetic stimulation (TMS) is a promising non-pharmacological intervention for posttraumatic stress disorder (PTSD). However, randomized controlled trials (RCTs) and meta-analyses have reported mixed results.
  
  
  OBJECTIVE
  To review articles that assess the efficacy of TMS in PTSD treatment.
  
  
  METHODS
  A systematic review using MEDLINE and other databases to identify studies from the first RCT available up to September 2015. The primary outcome was based on PTSD scores (continuous variable). The main outcome was Hedges' g. We used a random-effects model using the statistical packages for meta-analysis available in Stata 13 for Mac OSX. Heterogeneity was evaluated with I2 (> 35% for heterogeneity) and the χ2 test (p < 0.10 for heterogeneity). Publication bias was evaluated using a funnel plot. Meta-regression was performed using the random-effects model.
  
  
  RESULTS
  Five RCTs (n = 118) were included. Active TMS was significantly superior to sham TMS for PTSD symptoms (Hedges' g = 0.74; 95% confidence interval = 0.06-1.42). Heterogeneity was significant in our analysis (I2 = 71.4% and p = 0.01 for the χ2 test). The funnel plot shows that studies were evenly distributed, with just one study located marginally at the edge of the funnel and one study located out of the funnel. We found that exclusion of either study did not have a significant impact on the results. Meta-regression found no particular influence of any variable on the results.
  
  
  CONCLUSIONS
  Active TMS was superior to sham stimulation for amelioration of PTSD symptoms. Further RCTs with larger sample sizes are fundamental to clarify the precise impact of TMS in PTSD.
authors.affiliation: Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil.
authors.forename: Alisson Paulino
authors.initials: AP
authors.lastname: Trevizol
authors.affiliation: Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil.
authors.forename: Mirna Duarte
authors.initials: MD
authors.lastname: Barros
authors.affiliation: Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil.
authors.forename: Paula Oliveira
authors.initials: PO
authors.lastname: Silva
authors.affiliation: Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, Ontario, Canada.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Osuch
authors.affiliation: Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil.
authors.forename: Quirino
authors.initials: Q
authors.lastname: Cordeiro
authors.affiliation: Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil.
authors.forename: Pedro
authors.initials: P
authors.lastname: Shiozawa
mesh_terms: D006801:Humans; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy*; D050781:Transcranial Magnetic Stimulation