Resistant Obsessive-compulsive Disorder Research Articles

Joint anatomical, histological and imaging investigation of the midbrain target region for superolateral medial forebrain bundle (slMFB) DBS.

Deep Brain Stimulation (DBS) of the superolateral branch of the medial forebrain bundle (slMFB) is currently being researched in clinical trials and open case series as a therapeutic option for treatment resistant major depressive disorder (TR-MDD) and treatment resistant obsessive-compulsive disorder (TR-OCD). There are numerous publications describing stimulation in such proximity to the ventral tegmental area (VTA) and open questions remain concerning the stimulation target and its functional environment. As of right now, we are not aware of any publications that compare the typical electrode placements with the histologically supported tractographic depiction of the target structure. We used three cadaver midbrain samples with presumed unaltered anatomy. After fixation, staining and slicing, the histological samples were warped to the MNI (Montreal Neurological Institute) big brain environment. Utilizing a tractographic atlas, a qualitative analysis of the typical slMFB stimulation site in the lateral VTA utilizing a subset of clinically implanted DBS electrodes in n=12 patients, successfully implanted for TR-OCD was performed. A joint qualitative overlay analysis of predominantly tyrosine-hydroxylase stained histology at different resolutions in an anatomical common space was achieved. Localization of the DBS-lead bodies was found in the typical positions in front of the red nuclei in the lateral VTA. DBS lead tip region positions explained the oculomotor side effects of stimulation related to para-nigral or parabrachial pigmented sub-nuclei of the VTA, respectively. The location of active electrode contacts suggest downstream and antidromic effects on the greater VTA related medial forebrain bundle system. This is the first dedicated joint histopathological overlay analysis of DBS electrodes targeting the slMFB and lateral VTA in a common anatomical space. This analysis might serve to better understand the DBS target region for this procedure.

Efficacy and Clinical Predictors of Response to Repetitive Transcranial Magnetic Stimulation Treatment in Resistant Obsessive-compulsive Disorder

Deep transcranial magnetic stimulation has been effectively used as a therapy for refractory obsessive compulsive disorder (OCD). Number of sessions approved by FDA is 20. Here, we report the case of 59 year old female with treatment refractory obsessive compulsive disorder (OCD) whose symptoms markedly improved only after 10 sessions of deep TMS over Dorso Medial Prefrontal Cortex. Our case report shows that, even with fewer sessions than indicated, significant symptoms remission can be achieved with deeper penetration of magnetic field with marked reduction in distress of patient and significant improvement in socio-occupational domain. Her Y-BOCS score reduced by 66% at the end of 10 completed sessions.

Sex differences in clinical response to deep brain stimulation in resistant obsessive-compulsive disorder

IntroductionDeep brain stimulation (DBS) is an effective alternative to treat severe refractory obsessive-compulsive disorder (OCD), although little is known on factors predicting response. The objective of this study was to explore potential sex differences in the pattern of response to DBS in OCD patients. MethodsWe conducted a prospective observational study in 25 patients with severe resistant OCD. Response to treatment was defined as a ≥35% reduction in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. Logistic regression models were calculated to measure the likelihood of response at short and long-term follow-up by sex as measured by Y-BOCS score. Similar analyses were carried out to study changes in depressive symptomatology assessed with the Hamilton Depression Rating Scale (HDRS). Additionally, effect sizes were calculated to assess clinical significance. ResultsWe did not observe significant clinical differences between men and women prior to DBS implantation, nor in the response after one year of stimulation. At long-term follow-up, 76.9% of men could be considered responders to DBS versus only 33.3% of women. The final response odds ratio in men was 10.05 with significant confidence intervals (88.90–1.14). No other predictors of response were identified. The sex difference in Y-BOCS reduction was clinically significant, with an effect size of 3.2. The main limitation was the small sample size. ConclusionsOur results suggest that gender could influence the long-term response to DBS in OCD, a finding that needs to be confirmed in new studies given the paucity of results on predictors of response to DBS.

Agomelatine efficacy in treatment resistant obsessive-compulsive disorder: A randomized controlled trial.

Obsessive-compulsive disorder (OCD) is a prevalent and burdensome mental health condition, often resistant to conventional treatments. Agomelatine (Valdoxan), a compound acting on serotonin and melatonin systems, has shown promise in treating those with treatment-resistant OCD based on anecdotal reports and case studies. A randomized, double-blind controlled trial was conducted with 60 patients diagnosed with treatment-resistant OCD. Participants were randomized into an intervention group (receiving agomelatine 50 mg/day) and a control group (receiving placebo). OCD symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) over a 12-week period. There were no significant differences in age, gender, or baseline Y-BOCS scores between intervention and control groups. Agomelatine did not demonstrate a significant improvement in OCD symptoms compared to placebo. Adverse events were comparable between groups, and liver enzyme levels remained within the normal range. This study, while not confirming superior efficacy compared to placebo, underscores the need for continued investigation into agomelatine's potential for treating specific subgroups of OCD patients, underscoring the need for more comprehensive and well-controlled trials in the future.

The Efficacy of Combined Transcranial Magnetic Stimulation and Exposure Prevention Response on Symptoms of Resistant Obsessive Compulsive Disorder: An Intensive Day Care Program

Purpose: Obsessive-Compulsive Disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and rituals which decrease the distress. It seems that there are many treatments such as EX/RP, repetitive Transcranial Magnetic Stimulation (rTMS), medications or mindfulness for OCD, but there is no single effective treatment yet. In this study, we investigated a multi-element daily program on symptom reduction of OCD people.
 Materials and Methods: In a quasi-experimental design 13 patients were included in the study and received daily rTMS with EX/RP and biofeedback. We utilized BDI, BAI, and YBOCS tools to collect data before and after the treatment and in the subsequent one-month follow-up.
 Results: According to the BDI, BAI, and YBOCS results, the decrease in score was observed at the p<0.001 level and the changes were significant after a one-month follow-up period.
 Conclusion: The results indicated that the combination of sequenced treatments simultaneously such as rTMS and biofeedback with exposure therapy can facilitate the engagement and enhancement of self-control and distress tolerance.

Deep brain stimulation for treatment resistant obsessive compulsive disorder; an observational study with ten patients under real-life conditions.

Obsessive-compulsive disorder (OCD) affects 2-3% of the global population, causing distress in many functioning levels. Standard treatments only lead to a partial recovery, and about 10% of the patients remain treatment-resistant. Deep brain stimulation offers a treatment option for severe, therapy-refractory OCD, with a reported response of about 60%. We report a comprehensive clinical, demographic, and treatment data for patients who were treated with DBS in our institution. We offered DBS to patients with severe chronic treatment resistant OCD. Severity was defined as marked impairment in functioning and treatment resistance was defined as non-response to adequate trials of medications and psychotherapy. Between 2020 and 2022, 11 patients were implanted bilaterally in the bed nucleus of stria terminalis (BNST). Patients were evaluated with YBOCS, MADRS, GAF, CGI, and WHOQOL-BREF. We performed the ratings at baseline (before surgery), after implantation before the start of the stimulation, after reaching satisfactory stimulation parameters, and at follow-up visits 3, 6, 9, and 12 months after optimized stimulation. One patient has retracted his consent to publish the results of his treatment, thus we are reporting the results of 10 patients (5 males, 5 females, mean age: 37 years). Out of our 10 patients, 6 have shown a clear response indicated by a YBOCS-reduction between 42 and 100 percent at last follow-up. One further patient experienced a subjectively dramatic effect on OCD symptoms, but opted afterwards to stop the stimulation. The other 3 patients showed a slight, non-significant improvement of YBOCS between 8.8 and 21.9%. The overall mean YBOCS decreased from 28.3 at baseline to 13.3 (53% reduction) at the last follow-up. The improvement of the OCD symptoms was also accompanied by an improvement of depressive symptoms, global functioning, and quality of life. Our results suggest that BNST-DBS can be effective for treatment-resistant OCD patients, as indicated by a reduction in symptoms and an overall improvement in functioning. Despite the need for additional research to define the patients' selection criteria, the most appropriate anatomical target, and the most effective stimulation parameters, improved patient access for this therapy should be established.

Reboxetine Combination Therapy With Fluoxetine in Moderate to Severe Obsessive-Compulsive Disorder: A Placebo-Controlled, Double-Blind, Randomized Trial.

Reboxetine is a potent and selective norepinephrine reuptake inhibitor that was effective in combination with citalopram for resistant obsessive-compulsive disorder (OCD). This study aims to assess its effectiveness and tolerability in combination with fluoxetine in treating OCD. In this 2-center, placebo-controlled, and double-blind, randomized clinical trial, 76 patients with OCD were assigned into 2 parallel groups to receive fluoxetine (up to 80 mg/d) plus placebo (F + P) or fluoxetine (up to 80 mg/d) plus reboxetine (F + R) (10 mg twice daily) for 10 weeks. Participants were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at baseline and weeks 5 and 10. A total of 76 patients completed the trial. There was no significant difference between the 2 groups in baseline Y-BOCS scores. General linear model repeated-measures showed significant effects on time × treatment interaction on total Y-BOCS ( F = 6.33, df = 1.42, P = 0.006) and obsession subscale scores ( F = 10.39, df = 1.48, P < 0.001), and insignificance on compulsion subscale scores ( F = 1.86, df = 1.24, P = 0.173). Reboxetine combination therapy demonstrated a higher partial and complete treatment response rate ( P < 0.01) according to the Y-BOCS total scores. There was no significant difference between the 2 groups in the frequency of adverse effects. Reboxetine combination therapy with fluoxetine can effectively improve symptoms in patients with OCD in a short period of treatment. However, further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings.This trial was registered with the Iranian Registry of Clinical Trials ( www.irct.ir ; No IRCT20090117001556N129).

Electroencephalographic study of the Error Related Negativity in patients suffering from treatment-resistant obsessive-compulsive disorder

IntroductionThe physiopathology of patients with treatment-resistant obsessive-compulsive disorder (OCD) may differ from that of treatment-responsive patients. Cognitive evoked potentials may be one of the ways to detect these differences. The error-related negativity (ERN) is an electrophysiological correlate of error detection during the execution of a motor task, which is larger in patients with OCD than in typical people. According to the literature, the ERN could vary according the patients’ treatment-resistance.ObjectivesThe main goal of this study was to assess whether the ERN, which begins 20 ms before the motor response and reaches its maximum 80 ms later, was different between non-resistant and highly resistant OCD patients.MethodsForty-seven OCD patients and their age- and gender-matched controls were asked to perform a flanker task while the potentials evoked by their motor responses were recorded. For each participant, the difficulty of the task was adjusted to get an error rate of about 20%. Treatment-resistance was evaluated using Pallanti and Quercioli’s (Prog Neuropsychopharmacol Biol Psychiatry 2006; 30 400-412) resistance scales.ResultsIn all participants, response errors evoked an ERN at fronto-central electrodes [Fz, FCz, red and green lines on the figure], whereas the negativity was absent or smaller for correct responses (black and blue lines on the figure, both ps &lt; .01). As expected, the ERN of OCD patients was consistently larger and of longer duration than that of control participants (compare the green and blue lines with the red and black ones, respectively). Interestingly, the amplitude of the potentials evoked by correct responses at central and centro-parietal electrodes on the left side of the brain [C5, C3, CP5] was significantly less negative in treatment-resistant patients (all ps &lt; .05). In control participants, the ERN recorded at fronto-central electrodes were followed by a positive wave which reached its maximum between 170 and 270 ms after the response, and was larger after errors than after correct response. In OCD patients in contrast, this positive wave was absent whether the response was correct or not.Image:ConclusionsThe significant correlation observed between OCD patients’ treatment resistance and the potential evoked by correct responses on the left side of the brain suggest that this potential could be used as a marker of treatment-resistance. The absence in OCD patients of the positive wave that follows the ERN in control participants suggests that OCD patients were not fully aware of whether or not their response was correct.Disclosure of InterestNone Declared

Imagery Rescripting (ImRs) as an Adjunctive Treatment to Exposure and Response Prevention (ERP)-Resistant Obsessive-Compulsive Disorder: A Case Study

Exposure and response prevention (ERP), a specific type of Cognitive and Behaviour Therapy, is well recognised as the first-line psychological treatment in obsessive-compulsive disorder (OCD), either alone or in combination with selective serotonin reuptake inhibitor pharmacotherapy. However, given that up to half of patients suffering from OCD do not experience a clinically significant reduction in symptoms following ERP, further treatment options for treatment-resistant OCD are needed. Initial research into using ImRs as a psychological adjunct for treatment-resistant OCD has been encouraging. We provide a detailed case study of a 61-year-old male who continued, following ERP treatment, to suffer debilitating OCD symptoms of compulsive checking to prevent making mistakes. Following ERP, the individual received two sessions of ImRs as a therapy adjunct, which resulted in a further reduction of 56% in OCD symptoms. The individual reported associated improvements in mood, life satisfaction, and occupational and interpersonal relationships. This case study describes how ImRs can be incorporated into ERP treatment for OCD. Details of the ERP and ImRs treatment are provided, along with transcript excerpts to highlight the ImRs process. Further research is needed to enhance understanding of mechanisms and optimal deployment of ImRs in treatment sequencing for OCD sufferers.

Augmentation with transcranial direct current stimulation in difficult to treat obsessive-compulsive disorder: A case report

Sir, Obsessive-compulsive disorder (OCD) is associated with a lowered life quality and a greater degree of dysfunction in social and occupational functioning.[1] A significant proportion of patients with OCD, are resistant to therapy.[2] Numerous neuromodulation approaches, including deep brain stimulation (DBS), transcranial direct current stimulation (tDCS), and repetitive transcranial magnetic stimulation (TMS), have been utilized in conjunction with conventional pharmacological and psychological treatments.[3] tDCS, a noninvasive form of neurostimulation, has demonstrated a potential role as a safe and successful treatment for OCD in several trials.[2] The orbitofrontal cortex and the supplementary motor area (SMA) are the two most promising stimulation sites.[4] We present a case of a young male suffering from OCD who has a poor response to pharmacological treatment. A young male of 27 years attended the adult psychiatry outpatient department with complaints of recurrent repetitive sexual thoughts, excessive doubts, and repeated checking behavior for 3 years. The patient also had low mood, decreased interest in activities that were previously enjoyable, reduced interaction with friends and family members, disturbed sleep, disturbed sleep, and low confidence. There was no past or family history of any psychiatric or substance use. He was diagnosed with OCD, mixed obsessional thoughts and acts, and moderate depressive episodes. The patient was given an adequate trial on escitalopram (maximum 60mg/day) which was later augmented with ondansetron (8mg/day) and aripiprazole (5mg/day) but had a poor response to treatment. The patient was switched to fluvoxamine (maximum 300mg/day), clomipramine (50 mg), and buspirone (10mg), which were tried for a month, during which the patient had maintained adherence. However, the patient had only minimal response to treatment. Hence, the patient was admitted with a plan to augment the therapy with tDCS. Along with fluvoxamine 300 mg/day, clomipramine 50 mg/day, buspirone 10 mg/day, and tDCS sessions were administered (once daily for the first 10 sessions, followed by twice daily for the subsequent ten sessions). A 2-mA current was used with a ramp time of 20 s. The total duration of the session was 20 min and 40 s. Anode placement was done over SMA to target OC symptoms and cathode over the right dorsolateral prefrontal cortex (DLPFC) to target the depressive symptoms, concurrently. After 20 sessions, there was a significant reduction in YBOCS scores up to 46.4%, i.e., from an initial score of 28/40 to 15/40. Similarly, the HAM-D score changed from the initial score of 17/50 to 6/50 (64.7% reduction from the baseline severity score). The benefit was sustained for the next 4 months during the follow-up. Augmentation with tDCS can be effective for severely ill OCD patients unresponsive to drugs and behavioral therapy. Among the various types of obsessions, sexual obsessions are considered to be relatively resistant to treatment. In our case, the sexual obsessions responded well to tDCS augmentation. The patient did not report any major side effects, other than mild headaches following the initial few sessions. DBS and TMS received the most evidence, while for tDCS, evidence is less as of now.[5] However, studies in this area are few, and a well-defined protocol is lacking regarding the frequency of sessions, number of sessions, electrode placement, and the target brain areas. Hence, more RCTs in this area will help to increase the armamentarium in the treatment of resistant OCD. As a large number of patients with OCD often have comorbid depressive episodes, placement of anode over SMA and placement of cathode over the right DLPFC may be helpful in treating both conditions concurrently. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Symposium

Obsessive-compulsive disorder (OCD) is a psychiatric condition with an estimated lifetime prevalence of between 1 and 2%. OCD is considered the fourth most common mental disorder in developed countries, and according to the World Health Organization (WHO), represents the 10th leading cause of disability. Even when optimal treatment is provided, 10% of patients remain severely affected chronically. Through this symposium we want to highlight the neurobiology of treatment resistant OCD and the recent advances in treatment of the same.

Identification of biomarkers that predict response to subthalamic nucleus deep brain stimulation in resistant obsessive–compulsive disorder: protocol for an open-label follow-up study

IntroductionDeep brain stimulation (DBS) of bilateral anteromedial subthalamic nucleus (amSTN) has been found to be helpful in a subset of patients with severe, chronic and treatment-refractory obsessive–compulsive disorder (OCD). Biomarkers...

Effectiveness of repetitive transcranial magnetic stimulation (rTMS) for the treatment of obsessive-compulsive disorder (OCD): a meta-analysis

AimsOCD is a chronic and debilitating psychiatric illness. Current first-line treatments include serotonin reuptake inhibitors and cognitive behavioural therapy, but a substantial minority of patients fail to respond adequately, requiring further forms of intervention usually provided in a sequenced algorithm. Repetitive Transcranial Magnetic Stimulation (rTMS) uses magnetic pulses passed through a coil placed on the scalp to stimulate the underlying brain region. Clinical trials of r-TMS in OCD have produced conflicting results, possibly related to the variability in the site of stimulation, protocols used, and variability in the selection of patients. We perform an updated systematic review and meta-analysis of the effectiveness of rTMS for the treatment of OCD aimed to determine whether certain rTMS parameters (i.e. site, duration, protocol etc.) or patients’ characteristics (i.e age, duration of illness, illness severity, treatment resistance etc), are associated with effectiveness. Our overarching aim is to determine the place of rTMS in the sequenced OCD care-pathway.MethodThe meta-analysis is pre-registered in PROSPERO (ID: 241381). Potentially relevant studies will be retrieved using the MEDLINE, PsycINFO, and Cochrane Library databases using the parameters [‘obsessive compulsive disorder’ or ‘OCD’ or ‘obsessions’ or ‘compulsions’] AND [‘transcranial magnetic stimulation’ or ‘TMS’]. The reference lists of retained articles will also be scrutinized for additional relevant publications. Only full text English language articles will be included in the review. The methodological quality of the studies will be assessed using CONSORT criteria. A summary of the study's quality as a randomized clinical trial will be produced.ResultOur preliminary analysis shows some efficacy for r-TMS in non-treatment resistant OCD than treatment resistant OCD. Detailed results will be presented in the poster at the event. Effect measure will be either categorical (e.g. relative risk (RR) or odds ratio (OR) or continuous (mean difference or standardized mean difference - Hedge's g or Cohen's d - when taking into consideration the severity of the disorder as a dimension). These outcomes will be measured through validated instruments, in the form of both self- rated scales and observer rated scales including semi-structured interviews.ConclusionThis meta-analysis will identify the patient, illness and protocol parameters that determine clinical outcomes, as guide to optimizing the role of rTMS in the care of patients with OCD.

Disability and functional outcomes following STN, VC/VS, and combined deep brain stimulation in obsessive compulsive disorder

BackgroundOCD severity scores mostly convey information within the domain of clinical conceptualisations. To capture the full impact of any new intervention it is crucial to measure its impact on disability. For this purpose we captured prospective data on changes in disability, function and impairments with multiple tools throughout the UCL-MRC trial of Deep brain stimulation (DBS) for Obsessive Compulsive Disorder (OCD) between 2013-2017. The clinical and cognitive outcomes from the trial have already been reported in 2019. We hypothesized a concomitant improvement in perceived and observed indicators of disability with clinical improvement in OCD symptoms. This is a preliminary report of the disability outcome data from the trial.MethodSix patients with severe treatment resistant OCD were recruited for this study from the NHS England OCD Specialist Service. Eligible participants were offered lesion surgery (anterior cingulotomy) or entry to the DBS trial. OCD medication was kept constant throughout the trial. We tested the effects of DBS by comparing baseline, VC/VS, STN, both sites and CBT stages of trial on the following three assessments of function: GAF, SDS and CAOIC. An impairment focussed interview was done to quantify changes in function specific to OCD. Friedman's test was used to test for DBS effects during the double-blind crossover phases comparing baseline, amSTN and VC/VS. Post-hoc pair-wise Conover tests for significant effects were used with FDR corrections. All significant results are reported at P &lt; 0.05.ResultDBS had a significant effect across all phases for all above mentioned clinical measures. For all three measures of disability, there were significant improvements after both amSTN and VC/VS DBS. For all three measures of disability the effect of VC/VS DBS was significantly better that amSTN DBS. For all three measures of disability there was a non-significant trend (p = 0.058) for stimulation at both sites to have a better effect than stimulation of one site alone. For all three measures of disability, there were no significant difference between DBS alone and DBS and CBT.ConclusionThis study is the first to have directly compared differential effects of STN versus VC/VS DBS stimulation in OCD patients whilst testing clinical, cognitive and disability outcomes. The results of this study indicate that although both sites are equally effective in reducing OCD, stimulating VC/VS leads to a significantly greater improvement on disability scores in severe OCD.

A Comparative Study of Aripiprazole, Olanzapine, and L-Methylfolate Augmentation in Treatment Resistant Obsessive-Compulsive Disorder.

About half of the patients with Obsessive-compulsive disorder (OCD) do not respond to serotonin reuptake inhibitors (SRIs) or have a partial improvement in their symptoms. This study aimed to compare the efficiency and safety of aripiprazole, olanzapine, and L-methyl folate in patients with resistant OCD. The study consisted of an open-label prospective phase of 12-weeks to ascertain resistance to SRIs and a second 6-week open-label addition phase for non or, partial responders of the first phase. One-hundred-fifteen patients entered the 16-week open-label phase. Fifty patients (43.47%) responded to the SRIs monotherapy, two patients developed adverse effects and another three were lost to the follow up. Sixty patients (52.2%) were considered treatment-resistant and entered the 6-week open-label aripiprazole, olanzapine, or L-methyl folate addition phase; Patients showed a significant improvement over 6-week study period in olanzapine and aripiprazole group as measured by YBOCS total score (p < 0.001) while there was no change in the L-methyl folate group at the end as compared with baseline (p = 0.150). Clinical Global Impression-Severity decreased from 4.90 to 2.90 in olanzapine and aripiprazole group at the end of 6weeks while there was no change in the L-methyl folate group. The CGI-I was significant in the olanzapine and aripiprazole group (p < 0.001) while it was insignificant in the L-methyl folate group (p = 0.088). Augmentation of SRIs with olanzapine or aripiprazole could be a promising option for resistant OCD. L-methyl folate though shown to be effective in resistant depression was not effective in treatment resistant OCD.

P.783 Ten-year outcomes for deep brain stimulation in severe resistant obsessive-compulsive disorder: a prospective descriptive study

P.783 Ten-year outcomes for deep brain stimulation in severe resistant obsessive-compulsive disorder: a prospective descriptive study

Study the therapeutic role of transcranial magnetic stimulation in a sample of Egyptian patients with resistant obsessive-compulsive disorder

Background: Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric disorder that affects approximately 2-3% of the world population. The first-line treatments are selective serotonin reuptake inhibitors and cognitive behavioral therapy. Despite that, approximately 40- 60% of patients remain treatment refractive. Aim of work: Evaluating the efficacy of different frequencies of repetitive transcranial magnetic stimulation (rTMS) applied over the right dorsolateral prefrontal cortex (DLPFC) as an adjunctive treatment for resistant OCD. Patient and Methods: Thirty patients with treatment resistant OCD were randomly assigned to 2 weeks either active LF (1 Hz, n=10), HF (10 Hz, n=10) with parameters (25-minute trains, 1,500 pulses/day at 100% of the resting motor threshold RMT, 5 sessions/week) or sham (n=10) (same HF parameters with coil tilting). OCD, anxiety and depressive symptoms were assessed using: Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Hamilton Anxiety Scale (HAM-A), Beck Depression Inventory (BDI) and Clinical Global Impression-Severity scale (CGI-S) before and immediately after sessions and 3 months later. Results: A repeated-measures analysis of variance (ANOVA) revealed a non-significant reduction in Y-BOCS scores in the active groups compared with the sham group after 2 weeks and 3 months later. Similarly, there was non-significant effect of time and time×group interaction on scores of (HAM-A) (CGI-S). While there was a significant effect of time and time×group interaction on scores of (BDI) after 2 weeks with active stimulation especially LF-rTMS not after 3 months. There were no reports of serious adverse effects following the active or sham rTMS treatments. Conclusion: Neither LF nor HF rTMS over the right DLPFC appeared to be superior to sham rTMS for relieving OCD and anxiety symptoms in patients with treatment-resistant OCD. However, rTMS has a role in improving depressive symptoms, especially with LF-rTMS. Further trials with larger sample sizes should be conducted to confirm the present findings.

A prospective study of intensive in-patient treatment for obsessive-compulsive disorder

Multimodal in-patient treatment incorporating intensive cognitive-behaviour therapy (CBT) and medication management is a promising alternative for obsessive-compulsive disorder (OCD) patients who do not respond to standard out-patient treatment. We prospectively examined the short-term outcome and predictors of outcome of intensive in-patient treatment in a largely pharmacotherapy-resistant OCD sample. Fifty eight consecutive patients, admitted for treatment of OCD were evaluated at admission, at discharge and 2 months post-discharge for psychiatric diagnosis, personality disorders, obsessive beliefs, insight into obsessions and severity of obsessive-compulsive, depressive and anxiety symptoms. All patients received comprehensive treatment consisting of a combination of pharmacotherapy and intensive CBT. The mean Y-BOCS score was 29.38(±5.72) at admission, which reduced to 16.62(±7.91) at discharge and 16.75(±8.85) at follow-up. Thirty five participants (60.3%) met the prespecified criteria for response and 19 (32.8%) for remission. There was a significant reduction in Y-BOCS scores at discharge [43.67 (23.81)%] and post-discharge follow-up [2.18 (29.32)%] as compared to baseline (p<0.01). Baseline Browns Assessment of Beleifs Scale score (insight) was the only variable that statistically differentiated responders and non-responders. In-patient treatment is an effective treatment for medication resistant, severe and chronic OCD. Poor insight is a potential predictor of non-response to in-patient treatment.

Clinical utility of repeated intravenous ketamine treatment for resistant obsessive-compulsive disorder.

Glutamate modulators are used to treat OCD resistant to serotonin reuptake inhibitors (SRIs). Ketamine has shown some promise in treating OCD. Data on the use of ketamine in SRI-resistant OCD is limited, with no studies on the role of multiple ketamine infusions in this disorder. We report our experience of treating SRI- resistant OCD with multiple ketamine infusions. We reviewed the clinical charts of 14 adult inpatients with a diagnosis of SRI-resistant OCD and treated them with repeated ketamine infusions [mean (SD) = 5.4 (2.5)]. There was a significant reduction in the Yale-Brown Obsessive-Compulsive Scale (YBOCS) total score following intravenous ketamine infusions. One patient showed a dramatic response (a drop in the YBOCS to '0') and two patients showed a partial response (25-35 % reduction in the YBOCS). Eleven patients showed no clinical improvement. Ketamine may, therefore, be somewhat effective in a subset of OCD patients who are resistant to SRIs. Our findings suggest the need to examine the efficacy of ketamine in controlled studies with larger samples. It may be possible to identify predictors of response to ketamine in larger studies.

Is twice daily LF-rTMS a viable treatment option for treatment-resistant OCD? Results from an open-label feasibility study.

Several reports point to the beneficial effects of repetitive transcranial magnetic stimulation (rTMS) in the treatment of resistant obsessive-compulsive disorder (OCD). This study aimed to evaluate the safety and efficacy of rTMS targeting the dmPFC in the treatment of treatment-resistant OCD patients. Twelve patients received 20 sessions of low-frequency (LF) rTMS (1Hz, 1200 pulses) in a twice daily protocol during 10weekdays. Y-BOCS and IDS scores modestly but significantly decreased after treatment and at follow-up and HADS anxiety improved at follow-up. LF rTMS may improve OCD, anxiety, and depressive symptoms in treatment-resistant OCD and was a safe and well-tolerated treatment.