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Sousa MM, Costa AD, Almeida C, Soriano-Mas C, Silva Moreira P, Morgado P. Symptom provocation in obsessive-compulsive disorder: Validation of the Braga Obsessive Compulsive image set (BOCIS). J Psychiatr Res 2024; 175:144-152. [PMID: 38733929 DOI: 10.1016/j.jpsychires.2024.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/15/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024]
Abstract
Symptom provocation paradigms are paramount to understand a heterogeneous disorder as obsessive-compulsive disorder (OCD). The main aim of our work was to develop and validate an open-access set of OCD-related images comprising three main subtypes: washing, checking, and symmetry. Twenty-six OCD patients and 25 controls provided valence and arousal ratings for a set of OCD-related, aversive, and neutral images. Linear mixed model analyses were used to estimate the main effects of group, image category, and group-image category interaction in image ratings. All main effects were found to be significant for both arousal and valence ratings, except for the group in arousal ratings. Path analysis confirmed our hypothesis that the OCI-R subscales influenced the subjective ratings of the corresponding image categories, particularly among patients. Independent samples t-tests were performed for each OCD picture to compose the set. Arousal demonstrated a greater capacity to distinguish controls and patients, thus sustaining our choice of using these ratings for the final Braga Obsessive-Compulsive Image Set (BOCIS). Our study demonstrated that the stimuli of the BOCIS reliably portray OCD-like triggers for washing, checking and symmetry subtypes. Its open-access availability will facilitate significant progress in both clinical and research settings.
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Affiliation(s)
- Mafalda Machado Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS-3Bs PT Government Associate Laboratory, Braga, Guimarães, Portugal; Clinical Academic Center-Braga (2CA), Braga, Portugal.
| | - Ana Daniela Costa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS-3Bs PT Government Associate Laboratory, Braga, Guimarães, Portugal; Clinical Academic Center-Braga (2CA), Braga, Portugal
| | | | - Carles Soriano-Mas
- Department of Social Psychology and Quantitative Psychology, Institude of Neurosciences, Universitat de Barcelona, Spain; Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain
| | - Pedro Silva Moreira
- Psychology Research Centre, School of Psychology, University of Minho, Braga, Portugal
| | - Pedro Morgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS-3Bs PT Government Associate Laboratory, Braga, Guimarães, Portugal; Clinical Academic Center-Braga (2CA), Braga, Portugal
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Ching THW, Amoroso L, Bohner C, D’Amico E, Eilbott J, Entezar T, Fitzpatrick M, Fram G, Grazioplene R, Hokanson J, Jankovsky A, Kichuk SA, Martins B, Patel P, Schaer H, Shnayder S, Witherow C, Pittenger C, Kelmendi B. Safety, feasibility, tolerability, and clinical effects of repeated psilocybin dosing combined with non-directive support in the treatment of obsessive-compulsive disorder: protocol for a randomized, waitlist-controlled trial with blinded ratings. Front Psychiatry 2024; 14:1278823. [PMID: 38264632 PMCID: PMC10803438 DOI: 10.3389/fpsyt.2023.1278823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/26/2023] [Indexed: 01/25/2024] Open
Abstract
Background To date, few randomized controlled trials of psilocybin with non-directive support exist for obsessive-compulsive disorder (OCD). Results and participant feedback from an interim analysis of an ongoing single-dose trial (NCT03356483) converged on the possibility of administering a higher fixed dose and/or more doses of psilocybin in future trials for presumably greater benefits. Objectives This trial aims to evaluate the safety, feasibility, tolerability, and clinical effects of two doses of psilocybin paired with non-directive support in the treatment of OCD. This trial also seeks to examine whether two doses of psilocybin lead to greater OCD symptom reduction than a single dose, and to elucidate psychological mechanisms underlying the effects of psilocybin on OCD. Design A randomized (1:1), waitlist-controlled design with blinded ratings will be used to examine the effects of two doses of oral psilocybin paired with non-directive support vs. waitlist control on OCD symptoms. An adaptive dose selection strategy will be implemented (i.e., first dose: 25 mg; second dose: 25 or 30 mg). Methods and analysis This single-site trial will enroll 30 adult participants with treatment-refractory OCD. Aside from safety, feasibility, and tolerability metrics, primary outcomes include OCD symptoms assessed on the Yale-Brown Obsessive-Compulsive Scale - Second Edition (Y-BOCS-II). A blinded independent rater will assess primary outcomes at baseline and the primary endpoint at the end of the second dosing week. Participants will be followed up to 12 months post-second dosing. Participants randomized to waitlist will be rescreened after 7 weeks post-randomization, and begin their delayed treatment phase thereafter if still eligible. Ethics Written informed consent will be obtained from participants. The institutional review board has approved this trial (protocol v. 1.7; HIC #2000032623). Discussion This study seeks to advance our ability to treat refractory OCD, and catalyze future research seeking to optimize the process of psilocybin treatment for OCD through understanding relevant psychological mechanisms.Clinical trial registration: ClinicalTrials.gov, identifier NCT05370911.
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Affiliation(s)
- Terence H. W. Ching
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Lucia Amoroso
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Calvin Bohner
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Elizabeth D’Amico
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Jeffrey Eilbott
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Tara Entezar
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Madison Fitzpatrick
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Geena Fram
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Rachael Grazioplene
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Jamila Hokanson
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Anastasia Jankovsky
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Stephen A. Kichuk
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Bradford Martins
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Prerana Patel
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Henry Schaer
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Sarah Shnayder
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Chelsea Witherow
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Christopher Pittenger
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
- Department of Psychology, Yale University, New Haven, CT, United States
- Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT, United States
- Child Study Center, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin Kelmendi
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
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Smárason O, Boedeker PJ, Guzick AG, Tendler A, Sheth SA, Goodman WK, Storch EA. Depressive symptoms during deep transcranial magnetic stimulation or sham treatment for obsessive-compulsive disorder. J Affect Disord 2024; 344:466-472. [PMID: 37852581 DOI: 10.1016/j.jad.2023.10.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/22/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
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.
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Affiliation(s)
- Orri Smárason
- Faculty of Psychology, University of Iceland, Reykjavik, Iceland; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.
| | - Peter J Boedeker
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Andrew G Guzick
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Aron Tendler
- BrainsWay Ltd., 19 Hartum St., Jerusalem 9777518, Israel
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Zrenner B, Zrenner C, Balderston N, Blumberger DM, Kloiber S, Laposa JM, Tadayonnejad R, Trevizol AP, Zai G, Feusner JD. Toward personalized circuit-based closed-loop brain-interventions in psychiatry: using symptom provocation to extract EEG-markers of brain circuit activity. Front Neural Circuits 2023; 17:1208930. [PMID: 37671039 PMCID: PMC10475600 DOI: 10.3389/fncir.2023.1208930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/31/2023] [Indexed: 09/07/2023] Open
Abstract
Symptom provocation is a well-established component of psychiatric research and therapy. It is hypothesized that specific activation of those brain circuits involved in the symptomatic expression of a brain pathology makes the relevant neural substrate accessible as a target for therapeutic interventions. For example, in the treatment of obsessive-compulsive disorder (OCD), symptom provocation is an important part of psychotherapy and is also performed prior to therapeutic brain stimulation with transcranial magnetic stimulation (TMS). Here, we discuss the potential of symptom provocation to isolate neurophysiological biomarkers reflecting the fluctuating activity of relevant brain networks with the goal of subsequently using these markers as targets to guide therapy. We put forward a general experimental framework based on the rapid switching between psychiatric symptom states. This enable neurophysiological measures to be derived from EEG and/or TMS-evoked EEG measures of brain activity during both states. By subtracting the data recorded during the baseline state from that recorded during the provoked state, the resulting contrast would ideally isolate the specific neural circuits differentially activated during the expression of symptoms. A similar approach enables the design of effective classifiers of brain activity from EEG data in Brain-Computer Interfaces (BCI). To obtain reliable contrast data, psychiatric state switching needs to be achieved multiple times during a continuous recording so that slow changes of brain activity affect both conditions equally. This is achieved easily for conditions that can be controlled intentionally, such as motor imagery, attention, or memory retention. With regard to psychiatric symptoms, an increase can often be provoked effectively relatively easily, however, it can be difficult to reliably and rapidly return to a baseline state. Here, we review different approaches to return from a provoked state to a baseline state and how these may be applied to different symptoms occurring in different psychiatric disorders.
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Affiliation(s)
- Brigitte Zrenner
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
- University Psychiatry Hospital, University of Tübingen, Tübingen, Germany
| | - Christoph Zrenner
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute for Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- University Neurology Hospital, University of Tübingen, Tübingen, Germany
| | - Nicholas Balderston
- Center for Neuromodulation in Depression and Stress (CNDS), Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel M. Blumberger
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Stefan Kloiber
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Judith M. Laposa
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Reza Tadayonnejad
- TMS Clinical and Research Service, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
- Division of the Humanities and Social Sciences, California Institute of Technology, Pasadena, CA, United States
| | - Alisson Paulino Trevizol
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Gwyneth Zai
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jamie D. Feusner
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
- Division of the Humanities and Social Sciences, California Institute of Technology, Pasadena, CA, United States
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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Cotovio G, Ventura F, Rodrigues da Silva D, Pereira P, Oliveira-Maia AJ. Regulatory Clearance and Approval of Therapeutic Protocols of Transcranial Magnetic Stimulation for Psychiatric Disorders. Brain Sci 2023; 13:1029. [PMID: 37508962 PMCID: PMC10377201 DOI: 10.3390/brainsci13071029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Non-invasive brain stimulation techniques (NIBS) have been widely used in both clinical and research contexts in neuropsychiatry. They are safe and well-tolerated, making NIBS an interesting option for application in different settings. Transcranial magnetic stimulation (TMS) is one of these strategies. It uses electromagnetic pulses for focal modulate ion of neuronal activity in brain cortical regions. When pulses are applied repeatedly (repetitive transcranial magnetic stimulation-rTMS), they are thought to induce long-lasting neuroplastic effects, proposed to be a therapeutic mechanism for rTMS, with efficacy and safety initially demonstrated for treatment-resistant depression (TRD). Since then, many rTMS treatment protocols emerged for other difficult to treat psychiatric conditions. Moreover, multiple clinical studies, including large multi-center trials and several meta-analyses, have confirmed its clinical efficacy in different neuropsychiatric disorders, resulting in evidence-based guidelines and recommendations. Currently, rTMS is cleared by multiple regulatory agencies for the treatment of TRD, depression with comorbid anxiety disorders, obsessive compulsive disorder, and substance use disorders, such as smoking cessation. Importantly, current research supports the potential future use of rTMS for other psychiatric syndromes, including the negative symptoms of schizophrenia and post-traumatic stress disorder. More precise knowledge of formal indications for rTMS therapeutic use in psychiatry is critical to enhance clinical decision making in this area.
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Affiliation(s)
- Gonçalo Cotovio
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (G.C.)
- NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- Departamento de Psiquiatria e Saúde Mental, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal
| | - Fabiana Ventura
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (G.C.)
- Departamento de Psiquiatria e Saúde Mental, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
| | - Daniel Rodrigues da Silva
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (G.C.)
| | - Patrícia Pereira
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (G.C.)
- Portuguese Red Cross Health School, 1300-125 Lisbon, Portugal
| | - Albino J. Oliveira-Maia
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (G.C.)
- NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
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Jannati A, Oberman LM, Rotenberg A, Pascual-Leone A. Assessing the mechanisms of brain plasticity by transcranial magnetic stimulation. Neuropsychopharmacology 2023; 48:191-208. [PMID: 36198876 PMCID: PMC9700722 DOI: 10.1038/s41386-022-01453-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/10/2022]
Abstract
Transcranial magnetic stimulation (TMS) is a non-invasive technique for focal brain stimulation based on electromagnetic induction where a fluctuating magnetic field induces a small intracranial electric current in the brain. For more than 35 years, TMS has shown promise in the diagnosis and treatment of neurological and psychiatric disorders in adults. In this review, we provide a brief introduction to the TMS technique with a focus on repetitive TMS (rTMS) protocols, particularly theta-burst stimulation (TBS), and relevant rTMS-derived metrics of brain plasticity. We then discuss the TMS-EEG technique, the use of neuronavigation in TMS, the neural substrate of TBS measures of plasticity, the inter- and intraindividual variability of those measures, effects of age and genetic factors on TBS aftereffects, and then summarize alterations of TMS-TBS measures of plasticity in major neurological and psychiatric disorders including autism spectrum disorder, schizophrenia, depression, traumatic brain injury, Alzheimer's disease, and diabetes. Finally, we discuss the translational studies of TMS-TBS measures of plasticity and their therapeutic implications.
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Affiliation(s)
- Ali Jannati
- Neuromodulation Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
- F. M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Lindsay M Oberman
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Alexander Rotenberg
- Neuromodulation Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- F. M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alvaro Pascual-Leone
- Department of Neurology, Harvard Medical School, Boston, MA, USA.
- Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Wolk Center for Memory Health, Hebrew SeniorLife, Boston, MA, USA.
- Guttmann Brain Health Institute, Institut Guttmann, Barcelona, Spain.
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Tzirini M, Roth Y, Harmelech T, Zibman S, Pell GS, Kimiskidis VK, Tendler A, Zangen A, Samaras T. Detailed measurements and simulations of electric field distribution of two TMS coils cleared for obsessive compulsive disorder in the brain and in specific regions associated with OCD. PLoS One 2022; 17:e0263145. [PMID: 36040972 PMCID: PMC9426893 DOI: 10.1371/journal.pone.0263145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
The FDA cleared deep transcranial magnetic stimulation (Deep TMS) with the H7 coil for obsessive-compulsive disorder (OCD) treatment, following a double-blinded placebo-controlled multicenter trial. Two years later the FDA cleared TMS with the D-B80 coil on the basis of substantial equivalence. In order to investigate the induced electric field characteristics of the two coils, these were placed at the treatment position for OCD over the prefrontal cortex of a head phantom, and the field distribution was measured. Additionally, numerical simulations were performed in eight Population Head Model repository models with two sets of conductivity values and three Virtual Population anatomical head models and their homogeneous versions. The H7 was found to induce significantly higher maximal electric fields (p<0.0001, t = 11.08) and to stimulate two to five times larger volumes in the brain (p<0.0001, t = 6.71). The rate of decay of electric field with distance is significantly slower for the H7 coil (p < 0.0001, Wilcoxon matched-pairs test). The field at the scalp is 306% of the field at a 3 cm depth with the D-B80, and 155% with the H7 coil. The H7 induces significantly higher intensities in broader volumes within the brain and in specific brain regions known to be implicated in OCD (dorsal anterior cingulate cortex (dACC), dorsolateral prefrontal cortex (dlPFC), inferior frontal gyrus (IFG), orbitofrontal cortex (OFC) and pre-supplementary motor area (pre-SMA)) compared to the D-B80. Significant field ≥ 80 V/m is induced by the H7 (D-B80) in 15% (1%) of the dACC, 78% (29%) of the pre-SMA, 50% (20%) of the dlPFC, 30% (12%) of the OFC and 15% (1%) of the IFG. Considering the substantial differences between the two coils, the clinical efficacy in OCD should be tested and verified separately for each coil.
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Affiliation(s)
- Marietta Tzirini
- School of Physics, Faculty of Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- THESS, Thessaloniki Software Solution S.A., Thessaloniki, Greece
- * E-mail:
| | - Yiftach Roth
- Department of Life Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- BrainsWay Ltd., Jerusalem, Israel
| | | | | | - Gaby S. Pell
- Department of Life Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- BrainsWay Ltd., Jerusalem, Israel
| | - Vasilios K. Kimiskidis
- 1st Department of Neurology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aron Tendler
- Department of Life Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- BrainsWay Ltd., Jerusalem, Israel
- Advanced Mental Health Care Inc., United States of America
| | - Abraham Zangen
- Department of Life Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Theodoros Samaras
- School of Physics, Faculty of Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Physics, University of Malta, Msida, Malta
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Lechner WV, Philip NS, Kahler CW, Houben K, Tirrell E, Carpenter LL. Combined Working Memory Training and Transcranial Magnetic Stimulation Demonstrates Low Feasibility and Potentially Worse Outcomes on Delay to Smoking and Cognitive Tasks: A Randomized 2 × 2 Factorial Design Pilot and Feasibility Study. Nicotine Tob Res 2022; 24:1871-1880. [PMID: 35907262 PMCID: PMC9653077 DOI: 10.1093/ntr/ntac183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Repetitive Transcranial Magnetic Stimulation (rTMS) has shown promising results in treating several Substance Use Disorders including Tobacco Use Disorder. However, questions remain regarding how to optimize treatment outcomes. Enhancement of working memory by rTMS is a potential therapeutic mechanism. The current pilot study examined whether rTMS plus a cognitive training program could enhance the effects of rTMS on smoking behaviors using a controlled, factorial design. AIMS AND METHODS We hypothesized that cognitive training plus stimulation would improve control over smoking behaviors, resulting in enhanced cognitive performance and increased latency to smoke on a delay to smoking analog task. Using a 2 × 2 factorial design, nicotine dependent smokers (n = 43) were randomized to receive 10 sessions of active (10 Hz) or sham rTMS delivered to the left dorsolateral prefrontal cortex, plus active or sham working memory training (WMT) prior to and following stimulation. RESULTS Contrary to hypotheses, we observed a significant interaction effect, indicating that combining the two active interventions (rTMS+WMT) resulted in worse performance on the smoking analog task (B = -33.0, 95% CI = -64.39, -1.61, p < .05), compared to delivering either intervention alone. Additionally, although active rTMS (compared to sham rTMS) improved letter-sequencing performance (B = 1.23, 95% CI = 0.08-2.38, p < .05), and active WMT (compared to sham WMT) improved back-digit task performance (B = 1.53, 95% CI = 0.02-3.05, p < .05), combining interventions worsened the effect of each on a back-digit task (B = -3.01, 95% CI = -5.96, -0.052, p < .05). CONCLUSIONS These preliminary findings indicate potential iatrogenic effects of combining rTMS and this working memory training intervention and underscore the need for rigorous evaluation of substance specific conceptual frameworks when selecting future combination interventions. IMPLICATIONS Counter to hypothesis, this study found no additional benefit of adding a working memory training program to a rTMS protocol in a sample of daily smokers. The combination condition (active rTMS + active training) resulted in worse performance on a delay to smoking analog task and a measure of working memory performance compared to delivering either intervention alone. These preliminary findings inform strategies for optimizing rTMS in smokers and highlight the need for future studies to consider several key components of candidate combination interventions, including effects on regulation of substance use. CLINICAL TRIAL REGISTRATION (IF ANY) The trial was registered at ClinicalTrials.gov (NCT03337113).
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Affiliation(s)
- William V Lechner
- Corresponding Author: William V. Lechner, PhD, Department of Psychological Sciences, Kent State University, 600 Hilltop Dr., Kent, OH 44242, USA. Telephone: (330) 672-3786; E-mail:
| | - Noah S Philip
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Butler Hospital TMS Clinic and Neuromodulation Research Facility, Providence, RI, USA,VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
| | - Christopher W Kahler
- Center for Alcohol and Addiction Studies and the Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Katrijn Houben
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Eric Tirrell
- Butler Hospital TMS Clinic and Neuromodulation Research Facility, Providence, RI, USA
| | - Linda L Carpenter
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Butler Hospital TMS Clinic and Neuromodulation Research Facility, Providence, RI, USA
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9
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Maia A, Almeida S, Cotovio G, Rodrigues da Silva D, Viana FF, Grácio J, Oliveira-Maia AJ. Symptom provocation for treatment of obsessive-compulsive disorder using transcranial magnetic stimulation: A step-by-step guide for professional training. Front Psychiatry 2022; 13:924370. [PMID: 35990054 PMCID: PMC9382110 DOI: 10.3389/fpsyt.2022.924370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation technique that was cleared by the Food and Drug Administration (FDA) for the treatment of Obsessive-Compulsive Disorder (OCD) in 2018. The approved protocol includes individualized symptom provocation before each stimulation session, to elicit a moderate level of obsessional distress. Although symptom provocation can be a delicate, demanding, and uncomfortable procedure, structured training methods for those who are going to apply it are not available. Here, we describe a model for training in symptom provocation for TMS technicians, developed at the Champalimaud Clinical Centre in Lisbon, Portugal. Our programme includes two-sessions dedicated to clinical communication and symptom provocation techniques from a theoretical and practical perspective. Additionally, supervision meetings are conducted during treatment of patients, allowing regular case discussion and redefinition of symptom provocation hierarchy, as needed. In addition to having a strong practical component, our training program is short and pragmatic, allowing for easy implementation and fluid transition to clinical practice. By sharing our experience, we hope to contribute to systematize training procedures required for symptom provocation in the context of TMS, and to qualitatively describe a methodology that can be used for implementation of TMS programmes for the treatment of OCD.
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Affiliation(s)
- Ana Maia
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal.,Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Sílvia Almeida
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal.,Graduate Programme in Clinical and Health Psychology, Faculdade de Psicologia da Universidade de Lisboa, Lisbon, Portugal
| | - Gonçalo Cotovio
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal.,Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Francisco Faro Viana
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Jaime Grácio
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal.,NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Albino J Oliveira-Maia
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal.,NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, Portugal
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10
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Zangen A, Moshe H, Martinez D, Barnea‐Ygael N, Vapnik T, Bystritsky A, Duffy W, Toder D, Casuto L, Grosz ML, Nunes EV, Ward H, Tendler A, Feifel D, Morales O, Roth Y, Iosifescu D, Winston J, Wirecki T, Stein A, Deutsch F, Li X, George MS. Repetitive transcranial magnetic stimulation for smoking cessation: a pivotal multicenter double-blind randomized controlled trial. World Psychiatry 2021; 20:397-404. [PMID: 34505368 PMCID: PMC8429333 DOI: 10.1002/wps.20905] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation method increasingly used to treat psychiatric disorders, primarily depression. Initial studies suggest that rTMS may help to treat addictions, but evaluation in multicenter randomized controlled trials (RCTs) is needed. We conducted a multicenter double-blind RCT in 262 chronic smokers meeting DSM-5 criteria for tobacco use disorder, who had made at least one prior failed attempt to quit, with 68% having made at least three failed attempts. They received three weeks of daily bilat-eral active or sham rTMS to the lateral prefrontal and insular cortices, followed by once weekly rTMS for three weeks. Each rTMS session was administered following a cue-induced craving procedure, and participants were monitored for a total of six weeks. Those in abstinence were monitored for additional 12 weeks. The primary outcome measure was the four-week continuous quit rate (CQR) until Week 18 in the intent-to-treat efficacy set, as determined by daily smoking diaries and verified by urine cotinine measures. The trial was registered at ClinicalTrials.gov (NCT02126124). In the intent-to-treat analysis set (N=234), the CQR until Week 18 was 19.4% following active and 8.7% following sham rTMS (X2 =5.655, p=0.017). Among completers (N=169), the CQR until Week 18 was 28.0% and 11.7%, respectively (X2 =7.219, p=0.007). The reduction in cigarette consumption and craving was significantly greater in the active than the sham group as early as two weeks into treatment. This study establishes a safe treatment protocol that promotes smoking cessation by stimulating relevant brain circuits. It represents the first large multicenter RCT of brain stimulation in addiction medicine, and has led to the first clearance by the US Food and Drug Administration for rTMS as an aid in smok-ing cessation for adults.
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Affiliation(s)
- Abraham Zangen
- Department of Life Sciences and Zlotowski Centre for NeuroscienceBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Hagar Moshe
- Department of Life Sciences and Zlotowski Centre for NeuroscienceBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Diana Martinez
- Department of PsychiatryColumbia University Irving Medical CenterNew YorkNYUSA
| | - Noam Barnea‐Ygael
- Department of Life Sciences and Zlotowski Centre for NeuroscienceBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Tanya Vapnik
- Pacific Institute of Medical ResearchLos AngelesCAUSA
| | | | | | - Doron Toder
- Department of Life Sciences and Zlotowski Centre for NeuroscienceBen‐Gurion University of the NegevBeer‐ShevaIsrael,Beer‐Sheva Mental Health Center, Ministry of HealthBeer‐ShevaIsrael
| | - Leah Casuto
- Lindner Center of HOPE, and University of Cincinnati Department of Psychiatry and Behavioral MedicineCincinnatiOHUSA
| | - Moran Lipkinsky Grosz
- Tel Aviv University Medical School, Tel Aviv and Be’er Yaacov Mental Health CenterBe'er YaacovIsrael
| | - Edward V. Nunes
- Department of PsychiatryColumbia University Irving Medical CenterNew YorkNYUSA
| | - Herbert Ward
- Department of PsychiatryUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Aron Tendler
- Advanced Mental Health Care Inc.Royal Palm BeachFLUSA
| | | | | | - Yiftach Roth
- Department of Life Sciences and Zlotowski Centre for NeuroscienceBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Dan V. Iosifescu
- New York University School of Medicine and Nathan Kline InstituteNew YorkNYUSA
| | | | | | - Ahava Stein
- A. Stein ‐ Regulatory Affairs Consulting Ltd.Kfar SabaIsrael
| | | | - Xingbao Li
- Brain Stimulation DivisionPsychiatry, Medical University of South CarolinaCharlestonSCUSA
| | - Mark S. George
- Brain Stimulation DivisionPsychiatry, Medical University of South CarolinaCharlestonSCUSA,Ralph H. Johnson VA Medical CenterCharlestonSCUSA
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11
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Oberman LM, Hynd M, Nielson DM, Towbin KE, Lisanby SH, Stringaris A. Repetitive Transcranial Magnetic Stimulation for Adolescent Major Depressive Disorder: A Focus on Neurodevelopment. Front Psychiatry 2021; 12:642847. [PMID: 33927653 PMCID: PMC8076574 DOI: 10.3389/fpsyt.2021.642847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Adolescent depression is a potentially lethal condition and a leading cause of disability for this age group. There is an urgent need for novel efficacious treatments since half of adolescents with depression fail to respond to current therapies and up to 70% of those who respond will relapse within 5 years. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising treatment for major depressive disorder (MDD) in adults who do not respond to pharmacological or behavioral interventions. In contrast, rTMS has not demonstrated the same degree of efficacy in adolescent MDD. We argue that this is due, in part, to conceptual and methodological shortcomings in the existing literature. In our review, we first provide a neurodevelopmentally focused overview of adolescent depression. We then summarize the rTMS literature in adult and adolescent MDD focusing on both the putative mechanisms of action and neurodevelopmental factors that may influence efficacy in adolescents. We then identify limitations in the existing adolescent MDD rTMS literature and propose specific parameters and approaches that may be used to optimize efficacy in this uniquely vulnerable age group. Specifically, we suggest ways in which future studies reduce clinical and neural heterogeneity, optimize neuronavigation by drawing from functional brain imaging, apply current knowledge of rTMS parameters and neurodevelopment, and employ an experimental therapeutics platform to identify neural targets and biomarkers for response. We conclude that rTMS is worthy of further investigation. Furthermore, we suggest that following these recommendations in future studies will offer a more rigorous test of rTMS as an effective treatment for adolescent depression.
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12
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Tendler A, Roth Y, Harmelech T. Deep repetitive TMS with the H7 coil is sufficient to treat comorbid MDD and OCD. Brain Stimul 2021; 14:658-661. [PMID: 33831605 DOI: 10.1016/j.brs.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/26/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Aron Tendler
- BrainsWay Ltd, USA; Advanced Mental Health Care Inc, USA; Department of Biology, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Yiftach Roth
- BrainsWay Ltd, Israel; Department of Life Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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13
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Storch EA, Tendler A, Schneider SC, Guzick AG, La Buissonniere-Ariza V, Goodman WK. Moderators and predictors of response to deep transcranial magnetic stimulation for obsessive-compulsive disorder. J Psychiatr Res 2021; 136:508-514. [PMID: 33218749 DOI: 10.1016/j.jpsychires.2020.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/25/2020] [Accepted: 10/16/2020] [Indexed: 02/08/2023]
Abstract
Deep transcranial magnetic stimulation (dTMS) has emerged as a treatment option for adults with obsessive-compulsive disorder (OCD) who continue to exhibit impairing symptoms following an adequate response to first line interventions. Currently, little is known about the predictors or moderators of dTMS outcome for OCD. This paper examined if several theoretically relevant variables may predict and moderate treatment effects including OCD symptom severity, functional impairment, co-occurring depressive symptoms, age, gender, age of OCD onset, and family history of OCD. As part of a previously reported study, 100 patients received 29 dTMS or sham stimulation treatments over 6 weeks. dTMS was administered using a Magstim Rapid2 TMS (The Magstim Co. Ltd., Whitland, Carmarthenshire, United Kingdom) stimulator equipped with a H shaped coil design, which was specifically designed to stimulate the dorsal mPFC-ACC bilaterally. Findings suggest older participants and those with lower OCD severity and disability respond faster to both dTMS and sham stimulation. dTMS of the dorsal mPFC/ACC appeared to have larger benefits for individuals with greater OCD severity, whereas the difference between treatment arms was minimal in those with lower severity. Implications of these findings for treatment of OCD are discussed.
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Affiliation(s)
- Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, USA.
| | | | - Sophie C Schneider
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, USA; BrainsWay Inc, USA
| | - Andrew G Guzick
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, USA; BrainsWay Inc, USA
| | | | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, USA; BrainsWay Inc, USA
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14
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Roth Y, Barnea-Ygael N, Carmi L, Storch EA, Tendler A, Zangen A. Deep transcranial magnetic stimulation for obsessive-compulsive disorder is efficacious even in patients who failed multiple medications and CBT. Psychiatry Res 2020; 290:113179. [PMID: 32540588 DOI: 10.1016/j.psychres.2020.113179] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
OCD is a chronic and disabling disease with a lifetime prevalence of 2%-3%. About 40-60% of these patients do not adequately respond to pharmacotherapy and CBT. Deep transcranial magnetic stimulation (dTMS) was shown to be safe and effective as a treatment alternative for OCD and recently received regulatory approvals. Yet it is unclear whether patients who failed numerous medications and/or CBT can still benefit from dTMS. Here, we analyzed recent data from a double-blind multicenter dTMS study and found efficacy of this novel treatment even in OCD patient cohorts who previously failed to respond to multiple medications and CBT.
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Affiliation(s)
- Yiftach Roth
- The Department of Life Sciences and the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noam Barnea-Ygael
- The Department of Life Sciences and the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Lior Carmi
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eric A Storch
- Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, TX, USA
| | - Aron Tendler
- Advanced Mental Health Care, Inc., Palm Beach, FL, USA
| | - Abraham Zangen
- The Department of Life Sciences and the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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15
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McCathern AG, Mathai DS, Cho RY, Goodman WK, Storch EA. Deep transcranial magnetic stimulation for obsessive compulsive disorder. Expert Rev Neurother 2020; 20:1029-1036. [PMID: 32684005 DOI: 10.1080/14737175.2020.1798232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Obsessive-compulsive disorder (OCD) is a common psychiatric disorder that can be chronic and debilitating if not properly treated. Current first-line treatments for OCD include cognitive-behavioral therapy with exposure and response prevention and serotonin uptake inhibitor medications; however, these therapies are not effective for all individuals. AREAS COVERED Deep transcranial magnetic stimulation (dTMS) has been hypothesized to be an effective alternative for individuals with treatment-resistant OCD. dTMS has thought to be favorable due to its low side effect profile and its minimally invasive nature. EXPERT OPINION This review evaluates the current research on effectiveness of dTMS therapy for individuals with treatment-resistant OCD. This review also investigates shortcomings in current dTMS research and the hypothesized future of dTMS therapy.
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Affiliation(s)
- Alexis G McCathern
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX, USA
| | - David S Mathai
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX, USA
| | - Raymond Y Cho
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX, USA
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