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. 2025 Jun 13:16:1491487.
doi: 10.3389/fpsyt.2025.1491487. eCollection 2025.

Accelerated neurostimulation protocols for auditory hallucinations: a systematic review and meta-analysis

Tremearne Hotz  1 , Natalia Kosyakova  1 , Manu Sharma  1
Affiliations

Accelerated neurostimulation protocols for auditory hallucinations: a systematic review and meta-analysis

Tremearne Hotz et al. Front Psychiatry. .

Abstract

Objective: To explore the efficacy and characteristics of accelerated (more than once daily) protocols of repetitive transcranial magnetic stimulation (rTMS) and transcranial Electrical Stimulation (tES) in treating auditory hallucinations (AH) and other psychotic symptoms.

Methods: "We searched Pubmed" using relevant MeSH terms and keywords to identify relevant literature. Standard mean difference (SMD) and 95% confidence interval (CI) values were used to evaluate the effects of rTMS and tES.

Results: Eighteen studies were included, eight which used rTMS and ten which used tES. AHs and positive psychotic symptoms (PPS) improved in all studies from before to after treatment (SMD = 0.64, 95%CI = 0.77 to 0.51). Superiority was seen in the groups using fMRI guidance and using cTBS. Thirteen studies used a sham group as a control, which collectively showed statistically significant improvement in AHs with a moderate effect size (SMD = 0.34, 95%CI - 0.50 to 0.18). However, these studies included a high level of heterogeneity as measured by Cochran's Q and I2. Meta-analysis performed showed no consistent improvement of negative symptoms and did not differ significantly between the treatment and sham groups.

Conclusion: There appears to be a therapeutic effect for accelerated neurostimulation protocols for AHs on par with non-accelerated approaches. These protocols take up less overall time and often provide less overall stimulus. This result needs to be confirmed by large-scale randomized controlled trials before this finding can be recommended in clinical practice.

Systematic review registration: https://osf.io/69azy/, identifier 10.17605/OSF.IO/69AZY.

Keywords: accelerated; auditory hallucinations (AH); psychosis; theta burst stimulation (TBS); transcranial magnetic stimulation (TMS).

PubMed Disclaimer

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
PRISMA flow diagram of study selection.
Figure 2
Figure 2
Cochrane risk of bias assessment summary.
Figure 3
Figure 3
Cochrane risk of bias assessment.
Figure 4
Figure 4
Weighted pooled effect size between AHs before and after treatment with TMS or tES. Dashed line - overall mean improvement. Grey bubbles - effect size of studies. White bubbles - average effect sizes.
Figure 5
Figure 5
Weighted pooled effect size of improvement of AHS between sham and treatment groups after TMS or tES treatment. Dashed line - overall mean improvement. Grey bubbles - effect size of studies. White bubbles - average effect sizes.
Figure 6
Figure 6
Weight pooled effect size between subjects before and after treatment with rTMS or tES for positive psychotic symptoms as measured by PANSS-P. Dashed line - overall mean improvement. Grey bubbles - effect size of studies. White bubbles - average effect sizes.
Figure 7
Figure 7
Weighted pooled effect size between subjects before and after treatment with rTMS or tES for negative psychotic symptoms as measured by PANSS-N. Dashed line - overall mean improvement. Grey bubbles - effect size of studies. White bubbles - average effect sizes.
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