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.