Effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders: a meta-analysis of sham or behaviour-controlled studies - PubMed (original) (raw)

Meta-Analysis

. 2021 Nov 9;46(6):E592-E614.

doi: 10.1503/jpn.210050. Print 2021 Nov-Dec.

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Meta-Analysis

Effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders: a meta-analysis of sham or behaviour-controlled studies

Alessandra Vergallito et al. J Psychiatry Neurosci. 2021.

Abstract

Background: The possibility of using noninvasive brain stimulation to treat mental disorders has received considerable attention recently. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are considered to be effective treatments for depressive symptoms. However, no treatment recommendation is currently available for anxiety disorders, suggesting that evidence is still limited. We conducted a systematic review of the literature and a quantitative analysis of the effectiveness of rTMS and tDCS in the treatment of anxiety disorders.

Methods: Following PRISMA guidelines, we screened 3 electronic databases up to the end of February 2020 for English-language, peer-reviewed articles that included the following: a clinical sample of patients with an anxiety disorder, the use of a noninvasive brain stimulation technique, the inclusion of a control condition, and pre/post scores on a validated questionnaire that measured symptoms of anxiety.

Results: Eleven papers met the inclusion criteria, comprising 154 participants assigned to a stimulation condition and 164 to a sham or control group. We calculated Hedge's g for scores on disorder-specific and general anxiety questionnaires before and after treatment to determine effect size, and we conducted 2 independent random-effects meta-analyses. Considering the well-known comorbidity between anxiety and depression, we ran a third meta-analysis analyzing outcomes for depression scores. Results showed a significant effect of noninvasive brain stimulation in reducing scores on disorder-specific and general anxiety questionnaires, as well as depressive symptoms, in the real stimulation compared to the control condition.

Limitations: Few studies met the inclusion criteria; more evidence is needed to strengthen conclusions about the effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders.

Conclusion: Our findings showed that noninvasive brain stimulation reduced anxiety and depression scores compared to control conditions, suggesting that it can alleviate clinical symptoms in patients with anxiety disorders.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1

Figure 1

Flow chart of study selection. rTMS = repetitive transcranial magnetic stimulation; tDCS = transcranial direct current stimulation.

Figure 2

Figure 2

Type of stimulation and target regions in included studies. Red dots indicate excitatory stimulation protocols (i.e., anodal tDCS, iTBS and high-frequency rTMS); blue dots indicate inhibitory stimulation (i.e., cathodal tDCS and low-frequency rTMS). The size of the dots correspond to the number of studies that applied an excitatory or inhibitory protocol over a specific region: 5 studies applied inhibitory stimulation protocols over the right dorsolateral prefrontal cortex, 3 studies applied excitatory stimulation protocols over the left dorsolateral prefrontal cortex, 1 study applied an excitatory stimulation protocol over the right dorsolateral prefrontal cortex, 1 study applied an inhibitory stimulation protocol over the right posterior parietal cortex, and 1 study applied an excitatory stimulation protocol over the ventromedial prefrontal cortex. Brain images were obtained from

www.nitrc.org

. iTBS = intermittent theta burst stimulation; rTMS = repetitive transcranial magnetic stimulation; tDCS = transcranial direct current stimulation.

Figure 3

Figure 3

Forest plot of the effect size of noninvasive brain stimulation on continuous specific anxiety questionnaire scores. CI = confidence interval.

Figure 4

Figure 4

Baujat plot of study distribution in terms of heterogeneity for continuous specific anxiety questionnaire scores. On visual inspection, study 8 seemed to contribute most to the statistical heterogeneity of the included studies.

Figure 5

Figure 5

Publication bias assessed by funnel plot for continuous specific anxiety questionnaire scores.

Figure 6

Figure 6

Forest plot of the effect size of noninvasive brain stimulation on continuous general anxiety questionnaire scores. CI = confidence interval.

Figure 7

Figure 7

Baujat plot of study distribution in terms of heterogeneity for continuous general anxiety questionnaire scores. On visual inspection, study 3 seemed to contribute most to the statistical heterogeneity of the included studies.

Figure 8

Figure 8

Publication bias assessed by funnel plot for continuous general anxiety questionnaire scores.

Figure 9

Figure 9

Forest plot of the effect size of noninvasive brain stimulation on continuous depression questionnaire scores. CI = confidence interval.

Figure 10

Figure 10

Baujat plot of study distribution in terms of heterogeneity for continuous depression questionnaire scores. On visual inspection, study 2 seemed to contribute most to the statistical heterogeneity of the included studies.

Figure 11

Figure 11

Publication bias assessed by funnel plot for continuous depression questionnaire scores.

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