Ten of eighteen brain-stimulation strategies beat sham, and ECT beat the rest
Across 113 randomised trials in 6,750 adults, high-frequency left rTMS had about three times the odds of response against sham. Bitemporal ECT had nearly nine times.
Well-supported by good-quality research. how we score evidence
Caveat on this rating: The rankings are network estimates with wide intervals (bitemporal ECT 2.57 to 30.91), and 83% of trials were at low or unclear risk of bias by the authors' own count, so the ORDER of treatments is far less certain than the finding that most beat sham. The 2026 network meta-analysis of rTMS modalities in this wave reaches the same conclusion about ordering: overlapping intervals and mostly low-confidence rankings.
Nobody hands you the trials when a clinic quotes a success rate. This is the largest comparison of them.
Significant findings
In 2019 Mutz and colleagues published in the BMJ a systematic review with pairwise and network meta-analysis of every randomised trial of non-surgical brain stimulation for a major depressive episode: 113 trials, 262 treatment arms, 6,750 patients (mean age 47.9, 59% women) with major depressive disorder or bipolar depression. Ten of eighteen treatment strategies were associated with higher response than sham. The ones a clinic is likely to offer were among them: high frequency left rTMS (summary odds ratio 3.17, 95% confidence interval 2.29 to 4.37), intermittent theta burst stimulation (3.20, 1.45 to 7.08) and bilateral rTMS (4.92, 2.93 to 8.25).
The top of the table was not TMS. Bitemporal ECT (8.91, 2.57 to 30.91) and high dose right unilateral ECT (7.27, 1.90 to 27.78) had the highest odds, and in the head-to-head network estimates those two were the strategies "associated with increased response" against other active treatments, not only against sham. Every strategy was "at least as acceptable as sham therapy" on all-cause discontinuation.
The authors' own caveat is the one to carry. The quality of the evidence "was typically of low or unclear risk of bias (94 out of 113 trials, 83%) and the precision of summary estimates for treatment effect varied considerably", and the newer protocols "remain understudied" next to high frequency left rTMS and tDCS.
Worth asking
An odds ratio of three is not "three times as many people get better". It is the odds of response, and the paper reports odds. If a clinic quotes a percentage, the question is whether it comes from a sham-controlled trial or from its own patients with no comparison group.
Source
Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis — Mutz J, Vipulananthan V, Carter B, Hurlemann R, Fu CHY, Young AH (2019)
Top-tier peer-reviewed journal
Read the source: https://doi.org/10.1136/bmj.l1079
DOI: 10.1136/bmj.l1079
How this was scored
- Study design
- Meta-analysis of randomised trials
- Funding
- Funding not disclosed
- Published in
- Top-tier peer-reviewed journal
- Sample size
- 6,750
- Preregistered
- not recorded
- Conflicts disclosed
- Yes
- Independent of proponent
- not recorded
- Retracted
- No
Read the full scoring rubric, including what it can't tell you.
Published September 15, 2026.
Questions
How strong is the evidence behind this?
veisund rates this source "strong evidence". Well-supported by good-quality research. It scores 75 out of 100 on our published rubric. One caveat travels with that badge: The rankings are network estimates with wide intervals (bitemporal ECT 2.57 to 30.91), and 83% of trials were at low or unclear risk of bias by the authors' own count, so the ORDER of treatments is far less certain than the finding that most beat sham. The 2026 network meta-analysis of rTMS modalities in this wave reaches the same conclusion about ordering: overlapping intervals and mostly low-confidence rankings. The score is calculated from recorded facts about the source — study design, funding, publication venue, sample size, preregistration — not typed in by an editor.
What is the source for this?
Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis — Mutz J, Vipulananthan V, Carter B, Hurlemann R, Fu CHY, Young AH (2019). Published in: Top-tier peer-reviewed journal. DOI: 10.1136/bmj.l1079. The full source is linked on this page so you can read it yourself.
Who paid for this research, and does that matter?
Study design: Meta-analysis of randomised trials. Funding: Funding not disclosed. Independence from the proponent is not recorded. Industry sponsorship is one of the most reliably measured biases in medicine, which is why funding carries real weight in the score rather than sitting in a footnote.
Is this medical advice?
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.