J Wang, Y Zhou, H Gan, J Pang, H Li, J Wang and C Li,
Shanghai archives of psychiatry, Apr 25 2017
Negative symptoms are one of the most difficult areas in the treatment of schizophrenia because antipsychotics are often less effective towards them. Repetitive transcranial magnetic stimulation (rTMS) is a new technique for cerebral cortex stimulation and is believed to be a safe and promising method for the treatment of mental disorders. As the clinical research and new treatment models have increased in recent years, the efficacy towards negative symptoms and safety evaluation of rTMS treatment should also be updated.To explore the efficacy and safety of rTMS in the treatment of negative symptoms for patients with schizophrenia.We searched for relevant controlled clinical trials from the following databases: PubMed, EMBASE, the Cochrane Library, EBSCO, Web of Science, China National Knowledge Infrastructure (CNKI), VIP, Wanfang Data, SINOMED, and Airiti Library. The retrieval time went up to January 2, 2017. The research literature was screened according to the predefined inclusion and exclusion criteria. After data extraction, statistical analysis was conducted by using RevMan 5.3 and Stata 14. Quality evaluation was done on the included research articles. The Cochrane risk of bias assessment tool was adopted for assessing risk of bias. The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system recommendation grading method was used as the reference standard.A total of 3500 articles were retrieved. In the end, there were 29 articles included in the metaanalysis with a total sample size of 1440. After the meta-analysis, it was found that the use of antipsychotic treatment combined with rTMS could improve the negative symptoms of patients (SMD=-0.40, 95% CI= -0.62~-0.18). Based on the bias of the efficacy evaluation assessed by the Cochrane risk of bias assessment tool, there were 6 studies rated as having "high risk of bias" and the rest were rated as "unable to determine". According to the assessment, development and evaluation criteria of the GRADE classification, the evidence quality for the efficacy evaluation index was "moderate". The acceptability of rTMS treatment was better (RR= 0.75, 95% CI= 0.49~1.15, based on the 1492 samples from the 28 studies), however, the patients who received the rTMS treatment had a higher rate of mild adverse effects (RR= 2.20, 95% CI= 1.53~ 3.18, based on the 1296 samples from the 23 studies).The use of the antipsychotic treatment incorporated with rTMS treatment can slightly improve the negative symptoms of patients with schizophrenia and has better acceptability and fewer adverse effects. Nevertheless, there is publication bias in this study and the heterogeneity of the study is relatively high. Therefore, we need to be cautious when interpreting the results.阴性症状是精神分裂症治疗的难点之一，抗精 神病药物对其疗效较差。重复经颅磁刺激（repetitive transcranial magnetic stimulation, rTMS）是一项新型脑 皮质刺激技术，被认为是一项安全而有前景的精神障 碍治疗方法，近年来临床研究及新的治疗模式增多， rTMS 治疗阴性症状的疗效和安全性评价需要更新。.探索rTMS 治疗对精神分裂症患者阴性症状的 有效性及安全性。.我们从以下数据库搜索了相关的临床对照试验： PubMed、EMBASE、the Cochrane Library、EBSCO、Web of science、中国知网、维普、万方、中国生物医学文 摘数据库、台湾学术文献数据库等数据库，检索时间 截止于2017 年1 月2 日。按照预先定好的纳入和排 除标准筛选研究文献，提取数据后应用RevMan 5.3 和 Stata 14.0 对数据进行统计分析。对纳入研究进行质量 评价，采用Cochrane 风险评估偏倚工具评估各种偏 倚的风险性。结合GRADE (Grades of Recommendation, Assessment, Development, and Evaluation, GRADE) 系统 推荐分级方法为参照标准，进行主要结局指标证据水 平的分级。.总共检索到3500 篇文献，最终29 篇文献纳入 meta 分析，合计样本量1440 例。进行meta 分析后发现， 抗精神病药物治疗合并使用rTMS 可改善患者的阴性症 状（SMD=-0.40，95%CI=-0.62~-0.18）。根据Cochrane 风险评估偏倚工具对疗效的评估的偏倚进行评估，其 中6 篇研究评价为“ 高偏倚风险”，其它为“ 无法判断”。 根据GRADE 分级的评估、制定和评价标准，该疗效评 估指标的证据质量是“ 中等”。rTMS 治疗的可接受性 较好（RR=0.75，95%CI=0.49~1.15，基于28 项研究的 1492 例样本），但接受rTMS 治疗的患者出现轻微不 良反应的比率更高（RR=2.20，95%CI=1.53~3.18，基于 23 项研究的1296 例样本）。.抗精神病药物治疗合并使用rTMS 治疗可以一 定程度改善精神分裂症患者的阴性症状，可接受性较 好，不良反应较轻。但是本研究存在发表性偏倚，且 研究的异质性较高，所以对结果进行解释时需要慎重。.