Efficacy and safety of accelerated transcranial magnetic stimulation on suicidality in depressive disorders: A systematic review and meta-analysis

BACKGROUND: Accelerated transcranial magnetic stimulation (aTMS), which delivers multiple stimulation sessions per day over a condensed treatment period, has been proposed as a rapid intervention for suicidality in depressive disorders, but the quality and certainty of supporting evidence remain unclear. This systematic review and meta-analysis assessed the efficacy, safety, and feasibility of aTMS in reducing suicidality. METHODS: PubMed, Embase, Scopus, and Web of Science were searched through April 30, 2025, for randomized controlled trials (RCTs) and open-label studies on aTMS (≥2 sessions/day) in individuals aged >12 years with depressive disorders and suicidality. The primary outcome was change in suicidal ideation severity, assessed using validated clinician-rated or self-reported suicidality scales. Secondary outcomes included suicidality at follow-up, response rates, depressive symptoms, adverse effects, and dropout rates. Risk of bias was assessed using RoB 2 and ROBINS-I, and certainty of evidence was rated via GRADE. Meta-analyses used a random-effects model. RESULTS: Thirteen studies (7 RCTs, 6 open-label; N = 625) met inclusion criteria; six RCTs (N = 310) were included in the meta-analysis. aTMS showed no significant advantage over sham or standard TMS for suicidality post-treatment (SMD = 0.17; 95% CI -0.62, 0.95), at follow-up (SMD = 0.76; -0.14, 1.65), or for depressive symptoms (SMD = 1.05; -0.28, 2.39). Suicidality response (OR = 1.55) showed a non-significant trend favoring aTMS. Adverse effects were generally mild but more frequent with aTMS (OR = 1.95); dropout rates were similar (OR = 1.47). DISCUSSION: Current evidence does not support accelerated TMS as superior to sham or standard TMS for reducing suicidality; however, its feasibility appears acceptable. Open-label studies suggest potential benefits of personalized, fMRI-guided targeting approaches. Interpretation of these findings is limited by substantial heterogeneity in stimulation protocols and comparator conditions across included trials. PROSPERO registration: CRD42024623555.