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.