Intermittent theta-burst stimulation versus sham stimulation for suicidal ideation and psychiatric symptoms in depressive disorders: A systematic review and meta-analysis of randomized controlled trials

Suicidal ideation, depressive symptoms, anxiety, and sleep disturbance remain difficult to manage in psychiatric populations, and intermittent theta-burst stimulation (iTBS) has emerged as an accelerated, non-invasive neuromodulation strategy for these outcomes. This meta-analysis compares iTBS versus sham-iTBS across suicidal ideation, depression severity, anxiety severity, and sleep quality to guide clinical decision-making. We systematically searched relevant electronic databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Continuous outcomes were pooled as standardized mean differences (SMDs) with 95% confidence intervals using random-effects inverse-variance models in RevMan 5.4. Heterogeneity was assessed using I 2 and χ 2 statistics, and leave-one-out sensitivity analyses were performed. A p value < 0.05 was considered statistically significant. Six studies were included. iTBS significantly reduced suicidal ideation versus sham-iTBS (SMD = -0.51; 95% CI: -0.93 to -0.09; p = 0.02; I 2 = 70%; n = 181 vs. 157), and the effect remained significant with lower heterogeneity after exclusion of Qin et al. (p = 0.02; I 2 = 29%). Depression severity improved with iTBS (SMD = -1.06; 95% CI: -1.64 to -0.48; p = 0.0003; I 2 = 80%; n = 162 vs. 142), with heterogeneity decreasing to 24% after exclusion of Huang et al. Anxiety severity also improved (SMD = -0.68; 95% CI: -1.27 to -0.09; p = 0.02; I 2 = 79%; n = 139 vs. 120), and heterogeneity decreased to 38% after exclusion of Huang et al. Sleep quality did not differ significantly between groups (SMD = -0.32; 95% CI: -0.98 to 0.34; p = 0.35; I 2 = 67%; n = 75 vs. 49), based on two trials. iTBS was associated with a reduction in suicidal ideation compared with sham stimulation, but the small evidence base and between-study heterogeneity limit certainty. Secondary analyses suggested improvements in depression and anxiety severity, whereas sleep quality did not differ between groups. Larger, standardized randomized controlled trials with longer follow-up are needed to determine the magnitude and durability of any antisuicidal effect.