A Meta-analysis of Transcranial Magnetic Stimulation in Obsessive-Compulsive Disorder

Effects of continuous theta burst stimulation on patients with obsessive‒compulsive disorder (OCD): A systematic review and meta-analysis of randomized sham controlled trials

Despite standard pharmacological and behavioral therapies, a significant proportion of patients with obsessive‒compulsive disorder (OCD) have a suboptimal or no response. Continuous theta burst stimulation (cTBS) is a novel variant of traditional transcranial magnetic stimulation (TMS) that has shown promising results in a wide array of behavioral disorders. To integrate the evidence of its role in OCD, we conducted a systematic review and meta-analysis of pertinent randomized controlled trials (RCTs). We conducted a comprehensive literature search from inception until June 2024 on PubMed, Google Scholar, PsycINFO, Embase, and clinical trial registries. Six RCTs were identified and included in our study. Data regarding obsessive‒compulsive symptoms, depression, and anxiety were extracted and analyzed via a random effects model. We found no significant differences between the active and sham groups regarding the change in obsessive‒compulsive symptoms, neither immediately posttreatment (p = 0.98) nor at follow-up (p = 0.83). Similarly, neither group was superior in alleviating concomitant anxiety and depression. Owing to the limited number of studies and their variability in terms of brain targets and the total number of pulses administered, we cannot definitively conclude the effectiveness of cTBS in patients with OCD. However, our research highlights it as a potentially safe treatment option with no serious side effects. Future investigators should aim to optimize intervention protocols and utilize neuronavigation techniques for accurate delivery of pulses to targeted brain loci. High-powered trials with sufficient sample sizes are needed to gain deeper insight into the effects of cTBS on primary and secondary clinical manifestations of OCD.

Deep Brain Stimulation for Childhood Treatment-Resistant Obsessive-Compulsive Disorder: Mental Health Clinician Views on Candidacy Factors

INTRODUCTION

Deep brain stimulation (DBS) is approved under a humanitarian device exemption to manage treatment-resistant obsessive-compulsive disorder (TR-OCD) in adults. It is possible that DBS may be trialed or used clinically off-label in children and adolescents with TR-OCD in the future. DBS is already used to manage treatment-resistant childhood dystonia. Evidence suggests it is a safe and effective intervention for certain types of dystonia. Important questions remain unanswered about the use of DBS in children and adolescents with TR-OCD, including whether mental health clinicians would refer pediatric patients for DBS, and who would be a good candidate for DBS.

OBJECTIVES

To explore mental health clinicians' views on what clinical and psychosocial factors they would consider when determining which children with OCD would be good DBS candidates.

MATERIALS AND METHODS

In depth, semi-structured interviews were conducted with n = 25 mental health clinicians who treat pediatric patients with OCD. The interviews were transcribed, coded, and analyzed using thematic content analysis. Three questions focused on key, clinical, and psychosocial factors for assessing candidacy were analyzed to explore respondent views on candidacy factors. Our analysis details nine overarching themes expressed by clinicians, namely the patient's previous OCD treatment, OCD severity, motivation to commit to treatment, presence of comorbid conditions, family environment, education on DBS, quality of life, accessibility to treatment, and patient age and maturity.

CONCLUSIONS

Clinicians generally saw considering DBS treatment in youth as a last resort and only for very specific cases. DBS referral was predominantly viewed as acceptable for children with severe TR-OCD who have undertaken intensive, appropriate treatment without success, whose OCD has significantly reduced their quality of life, and who exhibit strong motivation to continue treatment given the right environment. Appropriate safeguards, eligibility criteria, and procedures should be discussed and identified before DBS for childhood TR-OCD becomes practice.

A transdiagnostic and translational framework for delineating the neuronal mechanisms of compulsive exercise in anorexia nervosa

OBJECTIVE

The development of novel treatments for anorexia nervosa (AN) requires a detailed understanding of the biological underpinnings of specific, commonly occurring symptoms, including compulsive exercise. There is considerable bio-behavioral overlap between AN and obsessive-compulsive disorder (OCD), therefore it is plausible that similar mechanisms underlie compulsive behavior in both populations. While the association between these conditions is widely acknowledged, defining the shared mechanisms for compulsive behavior in AN and OCD requires a novel approach.

METHODS

We present an argument that a better understanding of the neurobiological mechanisms that underpin compulsive exercise in AN can be achieved in two critical ways. First, by applying a framework of the neuronal control of OCD to exercise behavior in AN, and second, by taking better advantage of the activity-based anorexia (ABA) rodent model to directly test this framework in the context of feeding pathology.

RESULTS

A cross-disciplinary approach that spans preclinical, neuroimaging, and clinical research as well as compulsive neurocircuitry and behavior can advance our understanding of when, why, and how compulsive exercise develops in the context of AN and provide targets for novel treatment strategies.

DISCUSSION

In this article, we (i) link the expression of compulsive behavior in AN and OCD via a transition between goal-directed and habitual behavior, (ii) present disrupted cortico-striatal circuitry as a key substrate for the development of compulsive behavior in both conditions, and (iii) highlight the utility of the ABA rodent model to better understand the mechanisms of compulsive behavior relevant to AN.

PUBLIC SIGNIFICANCE

Individuals with AN who exercise compulsively are at risk of worse health outcomes and have poorer responses to standard treatments. However, when, why, and how compulsive exercise develops in AN remains inadequately understood. Identifying whether the neural circuitry underlying compulsive behavior in OCD also controls hyperactivity in the activity-based anorexia model will aid in the development of novel eating disorder treatment strategies for this high-risk population.

Public Perceptions of Neurotechnologies Used to Target Mood, Memory, and Motor Symptoms

Background

Advances in the development of neurotechnologies have the potential to revolutionize treatment of brain-based conditions. However, a critical concern revolves around the willingness of the public to embrace these technologies, especially considering the tumultuous histories of certain neurosurgical interventions. Therefore, examining public attitudes is paramount to uncovering potential barriers to adoption ensuring ethically sound innovation.

Methods

In the present study, we investigate public attitudes towards the use of four neurotechnologies (within-subjects conditions): deep brain stimulation (DBS), transcranial magnetic stimulation (TMS), pills, and MRI-guided focused ultrasound (MRgFUS) as potential treatments to a person experiencing either mood, memory, or motor symptoms (between-subjects conditions). US-based participants (N=1052; stratified to be nationally representative based on sex, race, age) were asked about their perceptions of risk, benefit, invasiveness, acceptability, perceived change to the person, and personal interest in using these neurotechnologies for symptom alleviation.

Results

Descriptive results indicate variability between technologies that the U.S. public is willing to consider if experiencing severe mood, memory, or motor symptoms. The main effect of neurotechnology revealed DBS was viewed as the most invasive and risky treatment and was perceived to lead to the greatest change to who someone is as a person. DBS was also viewed as least likely to be personally used and least acceptable for use by others. When examining the main effects of symptomatology, we found that all forms of neuromodulation were perceived as significantly more beneficial, acceptable, and likely to be used by participants for motor symptoms, followed by memory symptoms, and lastly mood symptoms. Neuromodulation (averaging across neurotechnologies) was perceived as significantly riskier, more invasive, and leading to a greater change to person for mood versus motor symptoms; however, memory and motor symptoms were perceived similarly with respect to risk, invasiveness, and change to person.

Conclusion

These results suggest that the public views neuromodulatory approaches that require surgery (i.e., DBS and MRgFUS) as riskier, more invasive, and less acceptable than those that do not. Further, findings suggest individuals may be more reluctant to alter or treat psychological symptoms with neuromodulation compared to physical symptoms.

[Treatment-resistant obsessive-compulsive disorders]

BACKGROUND

Obsessive-compulsive disorders (OCD) are mainly treated with disorder-specific cognitive behavioral therapy using exposure and response management and/or selective serotonin reuptake inhibitors; however, a significant subgroup of patients does not sufficiently benefit from this approach.

OBJECTIVE

This article provides an overview of treatment-resistant OCD.

MATERIAL AND METHODS

In this narrative review the definition, causes, diagnostic and therapeutic approaches to treatment-resistant OCD are addressed.

RESULTS

Treatment resistance can be assumed in the absence of clinically relevant improvement under therapy, in the sense of a reduction of < 25% on the Yale-Brown obsessive-compulsive scale and a score of 4 (no change) on the clinical global impression-improvement scale. The number of unsuccessful treatment attempts required to establish treatment resistance is defined differently. Causative factors include misdiagnosis, a high severity, comorbid disorders, substance use, specific symptom constellations, organic causes, environmental factors, and aggravating factors in psychotherapy and pharmacotherapy. Suggestions for diagnostic and therapeutic approaches based on the German S3 guideline on OCD are presented.

CONCLUSION

For patients with treatment resistance to first-line therapy, useful diagnostic and therapeutic recommendations are available (psychotherapeutic, psychopharmacological and neurostimulation procedures).

A closer look to neural pathways and psychopharmacology of obsessive compulsive disorder

The intricate neural pathways involved in obsessive-compulsive disorder (OCD) affect areas of our brain that control executive functioning, organization, and planning. OCD is a chronic condition that can be debilitating, afflicting millions of people worldwide. The lifetime prevalence of OCD in the US is 2.3%. OCD is predominantly characterized by obsessions consisting of intrusive and unwanted thoughts, often with impulses that are strongly associated with anxiety. Compulsions with OCD encompass repetitive behaviors or mental acts to satisfy their afflicted obsessions or impulses. While these factors can be unique to each individual, it has been widely established that the etiology of OCD is complex as it relates to neuronal pathways, psychopharmacology, and brain chemistry involved and warrants further exploration.

Past, present, and future of deep transcranial magnetic stimulation: A review in psychiatric and neurological disorders

Deep transcranial magnetic stimulation (DTMS) is a new non-invasive neuromodulation technique based on repetitive transcranial magnetic stimulation tech-nology. The new H-coil has significant advantages in the treatment and mechanism research of psychiatric and neurological disorders. This is due to its deep stimulation site and wide range of action. This paper reviews the clinical progress of DTMS in psychiatric and neurological disorders such as Parkinson's disease, Alzheimer's disease, post-stroke motor dysfunction, aphasia, and other neurological disorders, as well as anxiety, depression, and schizophrenia.