Theta burst most likely the best rTMS form, in a network where three of 141 trials were low risk of bias
A 2026 network meta-analysis put theta burst first among rTMS forms, then said the effects were modest, the intervals overlapped, and most rankings were low or very low confidence.
Well-supported by good-quality research. how we score evidence
Caveat on this rating: The strongest thing this paper says is about its own evidence base: 138 of 141 trials at high risk of bias or with concerns. Any ranking built on that is provisional, which the authors state. The 2019 BMJ network in this wave, with a different trial set, likewise found overlapping intervals among the TMS forms.
Significant findings
Zhang and colleagues searched eight databases, in English and Chinese, to 8 October 2025 for randomised trials comparing rTMS forms in adults with unipolar major depression: low and high frequency, left and right, bilateral, deep TMS, theta burst and accelerated protocols. Theta burst stimulation "had the highest probability of being the most effective rTMS modality for depression". In the treatment-resistant subgroup it had the highest probability of response (SUCRA 87.5%) and remission (79.2%), significantly better than sham. In the non-resistant subgroup accelerated TMS ranked first for response (SUCRA 83.0%) and low frequency right rTMS first for remission (SUCRA 81.5%, odds ratio 7.16). No active form differed from sham on acceptability in any subgroup.
Then the authors say the rest. "The risk-of-bias assessment categorized 87 studies as high risk, 51 as having some concerns, and only three as low risk." Confidence in the comparisons was "largely rated as low or very low", with one exception, bilateral versus sham for remission, at moderate. Their closing sentence: theta burst had the highest probability of being best, "but the confidence intervals overlapped across multiple comparisons, and the effect sizes were modest. High-quality head-to-head trials are needed to confirm these probabilistic rankings."
Worth asking
A probabilistic ranking is a bet, not a result. If a clinic says its protocol is "the most effective", the honest version is "the one most likely to be, in a network where the intervals overlap". Which protocol is on offer, and what does the clinic's own sham-controlled data show?
Source
Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder: A Systematic Review and Network Meta-Analysis — Zhang Y, Meng J, Liu X, Tang H, Zhong D, Li Y (2026)
Reputable peer-reviewed journal
Read the source: https://doi.org/10.1111/jebm.70155
DOI: 10.1111/jebm.70155
How this was scored
- Study design
- Meta-analysis of randomised trials
- Funding
- Funding not disclosed
- Published in
- Reputable peer-reviewed journal
- Sample size
- 10,587
- Preregistered
- not recorded
- Conflicts disclosed
- not recorded
- 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 70 out of 100 on our published rubric. One caveat travels with that badge: The strongest thing this paper says is about its own evidence base: 138 of 141 trials at high risk of bias or with concerns. Any ranking built on that is provisional, which the authors state. The 2019 BMJ network in this wave, with a different trial set, likewise found overlapping intervals among the TMS forms. 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?
Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder: A Systematic Review and Network Meta-Analysis — Zhang Y, Meng J, Liu X, Tang H, Zhong D, Li Y (2026). Published in: Reputable peer-reviewed journal. DOI: 10.1111/jebm.70155. 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.