Efficacy, safety and moderating factors of repetitive transcranial magnetic stimulation in post-traumatic stress disorder: A systematic review and meta-analysis.

Repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential intervention for post-traumatic stress disorder (PTSD), although the available evidence remains limited and heterogeneous. This study aimed to systematically review and meta-analyze the efficacy, safety, and potential moderators of rTMS for PTSD, focusing exclusively on randomized controlled trials. A systematic search of multiple databases was conducted from inception to February 2025 and updated to April 2026 to identify studies comparing rTMS with sham stimulation, pharmacological treatment, or alternative rTMS protocols (high versus low frequency stimulation). Random-effects meta-analyses were performed, along with subgroup and meta-regression analyses to explore potential moderators. Sixteen randomized controlled trials comprising 786 participants were included in the primary meta-analysis comparing rTMS with sham for self-reported PTSD symptoms. rTMS showed a statistically significant large effect in reducing symptoms relative to sham, although between-study heterogeneity was substantial and prediction intervals were wide. Findings based on interview-reported outcomes did not reach statistical significance. Follow-up analyses provided sparse and uncertain evidence of effects beyond the treatment period. Secondary analyses found limited evidence for improvements in comorbid symptoms of anxiety and depression, with significant effects restricted to specific comparisons or follow-up time points. Adverse events were generally mild, and serious adverse events were rare, with no clear evidence that they were attributable to rTMS. Given the substantial heterogeneity, limited follow-up evidence, and low or very low certainty of the evidence, these findings should be interpreted cautiously and do not allow firm conclusions regarding the efficacy, durability, or safety of rTMS for PTSD.