Efficacy of repetitive transcranial magnetic stimulation combined with cognitive behavioral therapy for depression: a systematic review and meta-analysis

BackgroundRepetitive transcranial magnetic stimulation (rTMS) and cognitive behavioral therapy (CBT) are established treatments for depression. However, the incremental benefit of combining these approaches remains uncertain, partly because prior reviews have pooled studies with clinically heterogeneous comparator conditions. This study systematically reviewed the efficacy of rTMS combined with CBT for depression and conducted a meta-analysis restricted to trials using rTMS-based control conditions.MethodsWe systematically searched Web of Science, PubMed, Embase, EBSCOhost, China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP Database, and PsyArXiv from inception to 1 December 2025. Randomized controlled trials enrolling patients with depression and evaluating rTMS combined with CBT-spectrum interventions were eligible. Comparator conditions were stratified into rTMS controls, medication-based CBT controls, and medication controls. All eligible studies were included in the qualitative synthesis, whereas the quantitative synthesis was limited to studies comparing the combined intervention with rTMS controls. Standardized mean differences (Hedges’ g) were estimated using a random-effects model.ResultsTen randomized controlled trials involving 1,320 participants met the inclusion criteria. Qualitative synthesis suggested that the combined intervention may have advantages over both medication-based CBT controls and medication controls. Seven trials comparing the combined intervention with rTMS controls were included in the meta-analysis. The pooled analysis showed a small-to-moderate benefit of the combined intervention over rTMS control for reducing depressive symptoms (Hedges’ g = 0.38, 95% CI 0.13 to 0.63, p = 0.003), with moderate heterogeneity (I2 = 57.8%). Leave-one-out sensitivity analysis and cumulative meta-analysis indicated that the pooled estimate was stable. Egger’s test did not detect significant publication bias (p = 0.3914).ConclusionRepetitive transcranial magnetic stimulation combined with CBT appears to provide additional benefit for the treatment of depression. Meta-analytic evidence supports greater symptom improvement relative to rTMS controls, and qualitative evidence suggests possible advantages over medication-based CBT controls and medication controls. These findings provide systematic support for the clinical potential of combining neuromodulation with psychotherapy while highlighting the need for larger, higher-quality trials with standardized protocols and longer follow-up.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251267093, PROSPERO: CRD420251267093.