A Systematic Review of the Effects of Repetitive Transcranial Magnetic Stimulation Combined With Pharmacological Intervention on Sleep Quality and Depressive Symptoms in Patients With Depression

To systematically evaluate the intervention effect of repetitive transcranial magnetic stimulation (rTMS) combined with pharmacological interventions on sleep quality and depressive symptoms in patients with depression, identify optimal stimulation parameters, and explore potential clinical applications to facilitate individualised therapeutic strategies. Databases including Pubmed, Web of Science, Cochrane Library, Embase, CNKI, Wanfang Medical Database, and VIP database were searched up to 31 December 2024, for randomized controlled trials (RCTs) assessing rTMS combined with pharmacological intervention for sleep disorders and depressive symptoms in patients with depression. Data analysis was performed using Stata software. 17 RCTs involving 1667 patients were included. Meta-analysis revealed that rTMS significantly improved sleep quality (SMD = -0.57, 95% CI: -1.02 to -0.12, P < 0.05) and reduced depressive symptoms (SMD = -0.73, 95% CI: -1.37 to -0.10, P < 0.05). Subgroup analyses showed that the optimal parameters for improving sleep quality were high-frequency rTMS targeting the left dorsolateral prefrontal cortex, high stimulation intensity, low total pulse count (< 1200 pulses), session duration ≤ 20 min daily, for 5-8 weeks. For depressive symptoms, a daily treatment duration of 21-30 min was more effective under similar parameter conditions. rTMS effectively improves sleep quality and alleviates depressive symptoms in patients with depression, showing a dose-dependent effect with stimulation parameters. However, in patients with a prolonged disease course or greater symptom severity, particularly those with vascular and other neurological comorbidities, rTMS alone may be insufficient. Integrating additional therapeutic strategies or tailoring personalised treatment protocols may be necessary to optimise clinical outcomes. Future research should further explore the synergistic potential of rTMS combined with orexin receptor antagonists (ORAs), offering a novel, multimodal approach for managing depression with comorbid insomnia.