Relationships between obsessive-compulsive disorder, depression and functioning before and after exposure and response prevention therapy

Safety and efficacy of targeting the supplementary motor area with double-cone deep transcranial magnetic stimulation vs figure-eight coil in treatment of obsessive-compulsive disorder with comorbid major depressive disorder

BACKGROUND AND OBJECTIVE

The Supplementary Motor Area (SMA), a relatively large brain structure predominantly located along the interhemispheric fissure, is an established target for repetitive Transcranial Magnetic Stimulation (rTMS) treatment of Obsessive-Compulsive Disorder (OCD). We investigated the feasibility, safety, and efficacy of targeting SMA using a double-cone "deep" TMS coil compared to conventional figure-eight coil for treatment of OCD with comorbid Major Depressive Disorder (MDD).

METHODS

Sixty-two patients with treatment-resistant OCD and comorbid MDD participated in the study. All patients received high-frequency rTMS over the left dorsolateral prefrontal cortex (DLPFC) with a figure-eight coil (MagVenture B70), followed by 1 Hz rTMS over the bilateral SMA using either the B70 (N = 25) or double-cone deep coil (MagVenture DB80) (n = 23) for 36 treatment sessions. Weekly clinical assessments were conducted.

RESULTS

Subjects overall had significant reductions in OCD and depressive symptom severity at the primary endpoint. Subjects stimulated at SMA with the double-cone deep coil had statistically significantly lesser reductions in overall OCD and depression symptom severity compared to the figure-eight group. The intensity of stimulation at SMA was significantly greater with the double-cone deep than figure-eight coil and e-field modeling showed that it affected broader regions beyond SMA (off-target stimulation). There was no significant difference in reported tolerability between groups.

CONCLUSIONS

SMA stimulation using either a double-cone deep or conventional figure-of-eight coil was safe and was associated with a significant reduction in comorbid OCD and depression symptoms, but the higher intensities of stimulation with the double-cone deep coil used in this study were significantly less clinically beneficial than figure-eight coil stimulation.

Multifaceted, Brief Intensive Home-Based Exposure Treatment in Patients with Obsessive-Compulsive Disorder Who are Nonresponsive to Regular Cognitive Behavior Therapy: An Uncontrolled Pilot Study

OBJECTIVE

To test a multifaceted treatment program for patients with obsessive-compulsive disorder (OCD) who did not respond to regular cognitive behavior therapy (CBT). The treatment addresses several factors that may play a role in maintaining OCD.

METHODS

We designed a treatment consisting of a 6-day intensive, individual exposure in vivo with response prevention (ERP) format, with 24 therapist-assisted treatment hours at the patient's home and 12 self-controlled ERP hours, including behavioral activation and family interventions. Next, we investigated the effect (obsessive-compulsive symptoms, comorbidity, functioning, quality of life, OCD-related interaction patterns) and feasibility (dropout, treatment satisfaction, and organization) of this program using pre-post-tests, pre-follow-up tests, and qualitative data from patients, family members, and therapists.

RESULTS

In a sample of 22 participants, obsessive-compulsive symptoms (Y-BOCS pre: 28.7, post: 15.9; Wilcoxon S-R tests P<0.01) improved significantly, as did most other effect measures. Results were largely, but not completely, preserved at 3-month follow-up. There was only 1 dropout. Patients, family members, and therapists were satisfied with the treatment. Implementation of the treatment did not pose difficulties.

CONCLUSIONS

In nonresponders with OCD, a multifaceted, brief, intensive home-based ERP program targeting factors maintaining OCD is promising and feasible. Extra care is needed to maintain improvement.

Ketamine Infusion in a Resistant Obsessive-Compulsive Disorder Patient in Bangladesh with Severe Suicidal Ideation: A Case Report

Treatment of resistant obsessive-compulsive disorder (OCD) typically results in insufficient symptom alleviation, and even long-term medication often fails to have the intended effect. Ketamine is a potent non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Studies have shown that low-dose ketamine infusion results in a considerable reduction in obsessive-compulsive symptoms and a rapid resolution of suicidal ideation. This is a case report on the effect of intravenous ketamine infusion on a patient with resistant OCD and severe suicidal ideation. Intravenous (IV) ketamine was given once a week over consecutive three weeks with necessary precautions. Psychometric tools such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Clinical Global Impressions Scale (CGI-S), the Beck Scale for Suicidal Ideations (BSSI), and Depression Anxiety and Stress Scale 21 (DASS-21) were applied before and after infusions. Obsessive-compulsive symptoms and suicidal severity started to decrease rapidly after the first infusion. However, after a transient improvement, these symptoms again began to increase after a stressful incident on the second day of the first infusion. All the symptoms measured by validated rating scales showed continued improvement after the following two infusions. The improvement was sustained until discharge (one week after the last infusion) and subsequent follow-up in the sixth and 12th weeks. The role of ketamine in reducing suicidal thoughts and behavior is already established. Very few studies emphasized its effectiveness in improving severe/resistant obsessive-compulsive symptoms. This pioneering work may offer scope for similar research in the relevant field.

A protocol for a randomized controlled trial of exposure and response prevention for veterans with obsessive compulsive disorder

BACKGROUND

Obsessive compulsive disorder (OCD) is effectively treated with exposure and response prevention (ERP), yet very few veterans receive ERP for OCD within the Veterans Health Administration (VHA). Veterans are a clinically complex population, and no prior research has evaluated the effectiveness of ERP in veterans with OCD or comorbid OCD and posttraumatic stress disorder (PTSD). Given the limited accessibility of ERP-trained providers within VHA, assessment of video telehealth (VTH) delivery of ERP is warranted.

METHODS

A sample of 160 veterans with OCD (80 diagnosed with comorbid PTSD) will be randomly assigned to receive up to 16 sessions of ERP or a stress management training control delivered via VTH. Assessments will occur at baseline, posttreatment, and 6-month follow-up. The primary outcome will evaluate the impact of ERP on participants' functioning, and secondary outcomes will include quality of life and OCD symptoms. At posttreatment, qualitative interviews with veterans, clinicians, and administrators will explore barriers and facilitators to treatment delivery, and the implementation potential of ERP.

CONCLUSIONS

Results will provide direction for the treatment of OCD and comorbid PTSD in veterans, as well as guidance for future implementation efforts for ERP within VHA.

CLINICALTRIALS

gov Identifier:NCT05240924.

Depressive symptoms during deep transcranial magnetic stimulation or sham treatment for obsessive-compulsive disorder

BACKGROUND

Evidence suggests that depressive symptoms tend to improve concurrently with obsessive-compulsive disorder (OCD) symptoms during cognitive behavioral therapy (CBT), despite depression not being the primary target of intervention. Studies examining the temporal or mediational relationships of OCD and depressive symptoms have indicated a bidirectional relationship, as prior levels of OCD symptoms influenced subsequent levels of depression, and vice versa. Deep transcranial magnetic stimulation (dTMS) has recently emerged as a treatment option for OCD. Whether dTMS affects depression symptoms similarly to CBT remains to be examined.

METHODS

The current study employed a random intercept cross-lagged panel model (RI-CLPM) to examine the relationship of OCD and depression symptoms in 94 treatment refractory patients, undergoing dTMS or sham treatment.

RESULTS

Both OCD and depression symptoms improved significantly. However, a stable, cross-lagged relationship between the variables was not supported. Changes in one symptom domain could not be used to predict the other.

LIMITATIONS

The present study was conducted in a treatment refractory population, meaning the present findings may not generalize to treatment naïve patients or those with less severe OCD symptoms. It is unclear whether the study was sufficiently powered to detect the effects of interest, and this concern also meant that examining the dTMS and sham groups independently was not feasible.

CONCLUSIONS

When treating OCD with dTMS, depression symptoms appear likely to diminish but should be monitored throughout, and additional interventions applied if needed.

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

BACKGROUND

Obsessive-compulsive disorder (OCD) is a debilitating illness with substantial morbidity. Although pharmacological and behavioral evidence-based treatments have shown efficacy, many patients remain unresponsive to this first-line care. Repetitive transcranial magnetic stimulation (rTMS) has shown significant promise for patients with treatment-refractory affective disorders. Therefore, we conducted a meta-analysis of randomized controlled trials to examine the therapeutic benefit of rTMS in patients with OCD and explore moderators of its treatment effects.

METHODS

PubMed (1997-Dec 31, 2022) and PsycINFO were searched for randomized sham-controlled trials of rTMS to treat OCD using the following terms: "obsessive-compulsive disorder," "transcranial magnetic stimulation," and "randomized controlled trial." Clinical characteristics and effect sizes were extracted from 25 randomized controlled trials (860 participants). A random effects model calculated the effect sizes for treatment efficacy and treatment response using the clinician-rated Yale-Brown Obsessive Compulsive Scale.

RESULTS

Across randomized controlled trials, rTMS exhibited a moderate therapeutic effect (g = 0.65) on OCD symptom severity and a 3-fold increased likelihood of treatment response (relative risk = 3.15) compared with sham conditions. Greater improvement in comorbid depression severity corresponded with greater treatment effects of rTMS on OCD symptom severity. In addition, longer rTMS sessions and fewer overall sessions predicted greater clinical improvement.

CONCLUSIONS

rTMS is moderately effective for reducing OCD symptom severity. It holds potential to serve as a therapeutic intervention, particularly for patients with OCD who have failed standard treatments and those with comorbid depression. Further research is needed to optimize rTMS protocols and evaluate the long-term efficacy of rTMS for OCD.

Considerations for the treatment of obsessive-compulsive disorder in patients who have comorbid major depression

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder that affects a significant number of individuals worldwide. Major depressive disorder (MDD) is among the most common comorbidities reported in people with OCD. The emergence of MDD in individuals with OCD can be attributed to the increased severity of OCD symptoms and their profound impact on daily functioning. Depressive symptoms can also modify the course of OCD.

AREAS COVERED

In this review, the authors explore potential shared neurobiological mechanisms that may underlie both OCD and MDD, such as disturbed sleep patterns, immunological dysregulations, and neuroendocrine changes. Furthermore, they address the challenges clinicians face when managing comorbid OCD and MDD. The authors also discuss a range of treatment options for OCD associated with MDD, including augmentation strategies for serotonin reuptake inhibitors (e.g. aripiprazole), psychotherapy (especially CBT/EPR), transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and deep brain stimulation (DBS).

EXPERT OPINION

Although there is no 'rule of thumb' or universally acceptable strategy in the treatment of OCD comorbid with MDD, many clinicians, including the authors, tend to adopt a unique transdiagnostic approach to the treatment of OCD and related disorders, focusing on strategies known to be effective across diagnoses. Nevertheless, the existing 'cisdiagnostic approaches' still retain importance, i.e. specific therapeutic strategies tailored for more severe forms of individual disorders.

Efficacy of Personalized-Computerized Inhibitory Training program (PCIT) combined with exposure and response prevention on treatment outcomes in patients with contamination obsessive-compulsive disorder

BACKGROUND

Cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) is the most effective and first-line treatment for obsessive-compulsive disorder (OCD). However, a significant number of people leave it or do not respond to it effectively. The present study aimed to examine the efficacy of personalized-computerized inhibitory training (P-CIT) program combined with ERP on treatment outcomes in patients with contamination OCD.

MATERIALS AND METHODS

The present research method was based on an experimental design with pre-test, post-test, and the two intervention and control groups. Thirty patients with contamination OCD were randomly assigned to the two groups of intervention and control based on the inclusion and exclusion criteria. The measures used in this study were Yale-Brown Scale, Stroop task, World Health Organization's Quality of Life Questionnaire, Structured Clinical Interview for DSM-5, and Depression Anxiety and Stress Scales -21.

RESULTS

The results showed a significant reduction in severity of symptoms (F = 0.75, P < 001) and severity of anxiety (F = 0.75, P < 001) for the intervention group. Furthermore, task control (F = 12.44, P < 001), mental health (F = 28.32, P < 001), physical health (F = 2.48, P < 001), and overall quality of life (F = 0.19, P = 001) improved in the intervention group after the intervention.

CONCLUSION

When P-CIT is exerted along with ERP, it may enhance inhibition of compulsions and increase the efficacy of ERP through improved task control, thereby resulting in reduced symptom severity and improved treatment outcomes in patients with contamination OCD.

The relationship between symptoms of obsessive compulsive disorder and depression during therapy: A random intercept cross-lagged panel model

BACKGROUND AND OBJECTIVES

We know little about how symptoms of obsessive-compulsive disorder and depression interact during psychological therapy. Although some previous research suggests that reductions in the severity of depression are driven by reductions in OCD, support for this conclusion is limited due to the exclusion of individuals with severe depression and limitations of the statistical approaches used.

METHODS

This study re-examined the interaction between symptoms of OCD and depression during therapy in a sample of 137 adults with a primary diagnosis of OCD and a full range of depression severity. All participants received a 12 to 16-week specialist residential treatment. Participants completed the Florida Obsessive Compulsive Inventory and Patient Health Questionnaire for depression weekly. The relationship between severity of OCD and depression was examined using a random intercept cross-lagged panel model.

RESULTS

Both cross-lagged paths were significant, with prior levels of OCD influencing subsequent levels of depression, and prior levels of depression influencing subsequent levels of OCD.

LIMITATIONS

The present study was conducted in a residential setting, meaning the findings may not generalise to outpatient settings characterised by less severe OCD and depression.

CONCLUSIONS

Contrary to previous findings, which suggest that the influence of OCD on depression is far greater than the reverse, our findings suggest that OCD and depression influence each other equally. As improvements in mood can help to improve symptoms of OCD, it appears important to target depression concurrently during treatment for OCD. This would be a new treatment target for improvement outcomes in OCD.

Examining depression symptoms within OCD: the role of experiential avoidance

BACKGROUND

Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD.

AIMS

This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD.

METHOD

The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability.

RESULTS

At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT.

CONCLUSIONS

This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.

Is my patient too sad to approach their fear? Depression severity and imaginal exposure outcomes for patients with OCD

BACKGROUND AND OBJECTIVES

There is conflicting research on how comorbid depression impacts the treatment of obsessive compulsive disorder (OCD) with exposure with response prevention. To better understand this relationship, the current study tests theoretical claims that greater depression limits motivation to engage in exposures, restricts habituation, and interferes with adaptive learning.

METHODS

Fifty-one individuals with OCD completed a diagnostic interview and self-report questionnaires assessing depression symptom severity and then participated in a standardized imaginal exposure protocol, in which they repeatedly approached an idiosyncratic fear deemed "moderately anxiety-provoking."

RESULTS

Contrary to expectations, linear regression models indicated that depression symptom severity was not independently associated with motivation, subjective or objective within-session habituation or adaptive learning outcomes. However, the perceived likelihood of the best-case scenario occurring as a result of the exposure moderated the relationship between depression severity and motivation to engage in the exposure exercise.

LIMITATIONS

Use of a one-session exposure protocol precludes conclusions regarding how depression is associated with outcomes in a full ERP treatment.

CONCLUSIONS

Depression symptom severity was not independently associated with motivation, habituation, or adaptive learning. The observed non-significant effects suggest that degree of depression, on its own, is not a meaningful indicator of how patients with OCD will fare an exposure intervention.

Predictors of Intensive Treatment in Patients With Obsessive-Compulsive Disorder

Background: Few studies have investigated which patients with obsessive-compulsive disorder (OCD) do not recover through regular cognitive behavior therapy or pharmacotherapy and subsequently end up in intensive treatment like day treatment or inpatient treatment. Knowing the predictors of intensive treatment in these patients is significant because it could prevent intensive treatment. This study has identified predictors of intensive treatment in patients with OCD. Methods: Using 6-year longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA), potential predictors of intensive treatment were assessed in patients with OCD (n = 419). Intensive treatment was assessed using the Treatment Inventory Costs in Patients with Psychiatric Disorders (TIC-P). Examined potential predictors were: sociodemographics, and clinical and psychosocial characteristics. Logistic Generalized Estimating Equations was used to estimate to what extent the various characteristics (at baseline, 2- and 4-year assessment) predicted intensive treatment in the following 2 years, averaged over the three assessment periods. Results: Being single, more severe comorbid depression, use of psychotropic medication, and a low quality of life predicted intensive treatment in the following 2 years. Conclusions: Therapists should be aware that patients with OCD who are single, who have more severe comorbid depression, who use psychotropic medication, and who have a low quality of life or a drop in quality of life are at risk for intensive treatment. Intensive treatment might be prevented by focusing regular treatment not only on OCD symptoms but also on comorbid depression and on quality of life. Intensive treatment might be improved by providing extra support in treatment or by adjusting treatment to impairments due to comorbid depressive symptoms or a low quality of life.

Mediating Role of Rumination and Negative Affect in the Effect of Mind-Wandering on Symptoms in Patients With Obsessive-Compulsive Disorder

To explore the relationship between negative affect, mind-wandering, rumination and obsessive-compulsive symptoms, 100 patients with obsessive-compulsive disorder and 100 healthy controls were assessed using the Obsessive-Compulsive Inventory, the Beck Anxiety Inventory, the Beck Depression Inventory, the Mind Wandering Scale and the Ruminative Response Scale. The results show that (i) patients diagnosed with obsessive-compulsive disorder displayed higher obsessive-compulsive symptoms, negative affect, mind-wandering and rumination compared with healthy controls; (ii) negative affect, mind-wandering and rumination were positively correlated with the severity of obsessive-compulsive symptoms; (iii) mind-wandering predicted the severity of obsessive-compulsive symptoms (both directly and indirectly); (iv) rumination and negative affect mediated the relationship between mind-wandering and obsessive-compulsive symptoms. The results preliminarily reveal the relationship between mind-wandering and psychopathological obsessive-compulsive symptoms, providing a reference for exploring novel psychological treatments for obsessive-compulsive disorder.

Effects and side effects of a transdiagnostic bias modification intervention in a mixed sample with obsessive-compulsive and/or depressive symptoms-a randomized controlled trial

Obsessive-compulsive disorder (OCD) and major depression disorder (MDD) are underdiagnosed and undertreated mental disorders. Prior studies have verified the efficacy of the self-help manual My Metacognitive Training (myMCT) for patients with primary OCD. As depression and OCD share a number of (meta)cognitive biases and dysfunctional coping strategies, we examined the efficacy of myMCT in a mixed patient sample with OCD and/or depression. A total of 80 Italian-speaking individuals with symptoms of OCD and/or depression were randomized to either myMCT or to a waitlist control group (both groups had access to care as usual during the intervention). Post-assessment was carried out 6 weeks after inclusion. Scores on the Beck Depression Inventory-II scale (BDI-II) served as the primary outcome. Adverse effects were assessed with a newly devised self-report scale. Participants in the myMCT condition showed significant symptom improvement on the BDI-II scale at a medium to large effect size compared to the control group (using intention-to-treat and per protocol analyses). The intention-to-treat analyses yielded significant positive effects on the PHQ-9 scores and psychological as well as environmental well-being in favor of myMCT; for the OCI-R total score, group differences bordered significance in favor of the myMCT. The most prevalent adverse effects were feeling pressured by the suggested exercises or feeling bad due to not performing the exercises correctly. Our results indicate that the myMCT manual represents an effective program for patients with OCD as well as those with depressive symptoms in an Italian-speaking population. Adverse events due to unguided self-help deserve more attention in the future.

The effects of depression on the treatment of OCD in a residential sample

Studies investigating the impact of depressive symptoms on obsessive-compulsive disorder (OCD) treatment have yielded mixed findings. The purpose of the study is to extend previous research, which primarily used outpatient samples, to determine whether depression affects OCD treatment outcome among patients receiving intensive residential treatment. OCD patients receiving residential treatment based primarily on exposure and response prevention (ERP) provided data regarding symptoms of depression and OCD at admission and discharge. Patients reported large and significant reductions in OCD symptoms over the course of treatment. Change in OCD symptoms was not significantly affected by depressive symptoms, including patients with severe depressive symptoms. Change in depressive symptoms over the course of treatment was, however, robustly related to change in OCD symptoms, especially among patients who began treatment with severe symptoms of depression. These findings suggest that cognitive-behavior therapy delivered in a residential treatment setting drastically reduces OCD symptoms regardless of depressive symptoms.

Metacognitive Training for Obsessive-Compulsive Disorder: a study protocol for a randomized controlled trial

BACKGROUND

A high number of patients with obsessive-compulsive disorder (OCD) do not receive cognitive-behavioral therapy with exposure and response prevention, which is the most effective treatment for OCD. Therefore, Metacognitive Training for OCD (MCT-OCD) was developed, which is a structured group therapy aiming at the modification of dysfunctional (meta-)cognitive biases, beliefs and coping styles. It can be administered by less trained personnel, thus may reach a higher number of patients. An uncontrolled pilot study (MCT-OCD pilot version) provided first evidence that the training is highly accepted by patients; OC symptoms decreased with a high effect size (η2partial = 0.50). The aim of the present study is to address the shortcomings of the pilot study (e.g., no control group) and to assess the efficacy of the revised version of the MCT-OCD in the framework of a randomized controlled trial.

METHODS

Eighty patients with OCD will be recruited. After a blinded assessment at baseline (-t1), patients will be randomly assigned either to the intervention group (MCT-OCD; n = 40) or to a care as usual control group (n = 40). The MCT-OCD aims to enhance patients' metacognitive competence in eight modules by addressing dysfunctional (meta-)cognitive biases and beliefs associated with OCD (e.g., intolerance of uncertainty). After 8 weeks, patients will be invited to a post assessment (t1), and then they will receive a follow-up online questionnaire 3 months following t1 (t2). The primary outcome is the Y-BOCS total score, and the secondary outcomes include the HDRS, OCI-R, OBQ-44, MCQ-30, WHOQOL-BREF, BDI-II, and subjective appraisal ratings of the MCT-OCD. We expect that OC symptoms will decrease more in the intervention group compared with the care as usual control group from -t1 to t1 and that treatment gains will be maintained until t2.

DISCUSSION

The planned study is the first to investigate the MCT-OCD, a promising new treatment, in a randomized controlled trial. The MCT-OCD may help to overcome existing treatment barriers for patients with OCD.

TRIAL REGISTRATION

German Registry for Clinical Studies ( DRKS00013539 ), 22.02.2018.