Table 2.
Summary of studies using rTMS for the treatment of OCD
| Author (year) | Country of origin | Study design | No. of participants | Targeted brain region | Targeted symptom | Measurement | Duration of treatment | Coil/ rTMS parameters/stimulation method | Outcome/significant improvements | Assessment and follow-up | Conclusion | Side effects |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Sachdev et al. (2007) | Australia | Double-blind, randomized, sham controlled followed by open-label phase | 18 adults | Left DLPFC | Obsessive symptoms | YBOCS MADRS BDI STAI-I |
TWO weeks | Focal 8-shaped 70 mm coil, with 30 trains of 5 s each, at 10 Hz and 110% MT, with 25-s inter-train intervals (1,500 stimuli per session) | This study did not support the efficacy of high frequency Left DLPFC rTMS given over two weeks In OCD, as there was no improvement in obsession scores |
Weekly throughout the study and after one and six months of the last treatment | Two weeks of rTMS over the left DLPFC is ineffective for treatment-resistant OCD | Transient headache, localized scalp pain |
| Kang et al. (2009) | Republic of Korea | A double-blind sham-controlled investigation | 21 patients | Right DLPFC | Effect of rTMS on cognitive functions Anxiety symptoms Obsessive compulsive symptoms |
YBOCS MADRS |
10 days | Focal 8-shaped 70 mm coil, with daily sessions for the first 2 weeks At 1 Hz and (100% and 110%) RMT, at 10 min (1,200 stimuli/d) |
The study did not show any clinically meaningful efficacy of sequentially applied low-frequency rTMS over a right DLPFC and SMA of patients with OCD | At baseline, after one and two weeks of stimulation and two weeks after the final session | The study did not show any clinically meaningful efficacy of sequentially applied low-frequency rTMS over a right DLPFC and SMA of patients with OCD | Transient headache, localized scalp pain |
| Mantovani et al. (2010) | USA | This trial consisted of two phases, namely, 4-wk double blind and 4-wk open-label | 21 Patients with 8 women | Coil was positioned over pre-SMA | Increases in right hemisphere MT and normalization of baseline hemispheric asymmetry of cortical excitability | HAMD 24, YBOCS CGI-S, BDI-II HAMA-14 |
4-wk double blind and 4-wk open-label | A vacuum cooled 70-mm figure-of-eight coil. Stimulation of 1-Hz, 20-min train at 100% MT, once a day, 5 d/wk., for 4 wk. (in Phase 1) to 8 wk. (in Phase 2 | There was an average of 25% reduction in the YBOCS compared to a 12% reduction in those receiving sham. For the 4 wk. and for the 8 wks. 28.2 + −5.8 to 14.5+ −3.6 | Every two weeks and self-rating forms filled at the end of every week | There was an average of 25% reduction in the YBOCS compared to a 12% reduction in those receiving sham. For the 4 wks. and for the 8 wks. 28.2 + −5.8 to 14.5 + −3.6 | nil |
| Sachdev et al. (2001) | Australia | Single-blind, randomized, non sham controlled | 12 patients | Right DLPFC And L DLPFC |
To compare the efficacy of both RDLPFC and LDLPFC | YBOCS, MADRS, BDI, STAI-I |
Two weeks | Active RDLPFC10 sessions, RDLPFC, 10 Hz, 110% MT, 15 min, 30 trains, 5 s on, 25 s off, fi g-8 coil Active LDLPFC idem, LDLPFC |
Global reduction in YBOCS score _ 40% from baseline to wk. 2 and wk. 6 | At baseline, two weeks, six weeks | Significant improvement in relieving OC symptoms, reducing clinical severity or improving treatment response; for both LDLPFC and LDLPFC | Nil |
| Gomes et al. (2012) | Brazil | Randomized double-blind trial | 22 right-handed outpatients (women: 13; men: 9), age 18 to 60 years | Coil positioned over pre-SMA | To assess the efficacy of low-frequency rTMS to the SMA in treatment-resistant OCD and further examine the duration of a significant clinical effect | HAMD YBOCS | Two weeks | Focal 8-shaped,70-mm coil with 1-Hz, 20-min trains (1,200 pulses/day) at 100% MT. once per day, five days per week, for two weeks | No significant reduction in Y-BOCS for baseline but at 2 wks, there was a significant reduction for the active group. No significant difference between groups for anxiety and depression symptoms | baseline, after rTMS treatment and 14 weeks after the end of rTMS treatment | No significant reduction in Y-BOCS for baseline but at 2 wks, there was a significant reduction for the active group. No significant difference between groups for anxiety and depression symptoms | Mild headache, scalp discomfort, cervical pain |
| Ma et al. (2014) | China | Double blind sham-controlled study | 46 patients completed after 2 treatments9 inpatients and 37 outpatients. Aged between 18 and 60 | Bilateral DLPFC | Obsessive, depressive and anxiety symptoms in OCD patients | HAMD YBOCS HRSD, CGI | Two weeks | A 9 cm circular coil. 80% MT. Daily for 5 sessions a wk. for 2 wks. with 20 min. each min included 4 s of active stimulation and 56 s of rest | The result showed that there were changes in scores of YBOCS, HRSD and HAMA over time following both α-TMS and sham treatments | Baseline, after the 5th and 10th sessions of treatment and 1 wk. after completing the entire treatment | αEEG-guided TMS may be an effective treatment for OCD and related anxiety | Mild headache |
| Nauczyciel et al. (2014) | France | A randomized, double-blind, crossover design | 19 patients | Right orbitofrontal cortex (OFC) | Reduction in clinical symptoms, as measured on the Y-BOCS | YBOCS MADRS CGI |
Two per day for one week | DB-80 butterfly double-cone coil with 120% MT, 1 Hz, 1,200 pulses per session over the right OFC. 10 sessions, two per day over one week | At day 7, a significant decrease in Y-BOCS scores, was observed compared with baseline, at day 35, no difference was observed in this decrease from the Y-BOCS baseline between active and sham stimulations | Assessments were performed before and after each sequence, as well as one month after the end of the last session | Results of this preliminary study suggest that the OFC is a possible neuroanatomical target for OCD treatment, especially rTMS | Nil |
| Donse et al. (2017) | The Netherlands | An open-label design | 22 patients | Bilateral SMA and right dorsolateral prefrontal cortex (DLPFC) | Role of sleep disturbances in OCD and its predictive value for rTMS treatment nonresponse | Y-BOCS, BDI, PSQI | 10 sessions | Using a figure-eight-coil with a frequency of 1 Hz, 1,000 pulses per session, 110% MT.10 sessions over the SMA | Study confirms that some sleep disturbances are more prevalent in OCD patients than healthy subjects | Baseline and after the 10 sessions | Findings suggest that CRSD variables can predict treatment non-response to rTMS in a sample of treatment-resistant OCD patients | Nil |
| Lee et al. (2017) | Republic of Korea | An open–label pilot study | 9 adults aged 18 or older | SMA | Obsession and compulsion symptoms of OCD | BAI Y-BOCS, BDI CGI-GI SCL-90-R |
Five days a week for four weeks | 70 mm, 8 shaped coils.1 Hz, 20 min train (1,200 stimuli/day) at 90–100% RMT, once a day, 5 days a week, for 4 weeks, in 20 sessions | Symptoms in treatment-resistant OCD patients significantly decreased after 20 sessions of 1 Hz rTMS over the SMA | Baseline, after two weeks and after four weeks of rTMS treatment | Findings suggest that 1 Hz rTMS over the SMA can be an efficient and safe add-on therapeutic method in treatment-resistant patients with OCD | Mild headache and mild dizziness |
| Kumar et al. (2018) | India | A retrospective open study | 25 patients | LF-rTMS over left-OFC | Symptoms of OCD, factors affecting response to rTMS | Y-BOCS | Four weeks | 1-Hz at 110% TM 5-s train duration, intertrain interval of 10 s and 240 trains per session. 20 sessions 5 days per wk. for 4 wks | Significant reduction in the mean YBOCS scores after completion of 20 sessions of rTMS from baseline, whereas no further significant change in YBOCS scores one month after completion of rTMS treatment | Baseline and one month after the treatment | There is a role of applying LF-rTMS over Lt-OFC as an augmentation strategy in ameliorating clinical symptoms among patients with medication-refractory OCD | Localized scalp discomfort, headache |
| Arumugham et al. (2018) | India | A randomized controlled trial | 40 patients with 36 patients in analysis-19 received active rTMS and 17 received sham | Low-frequency rTMS over pre-SMA | Reduction in clinical symptoms, as measured on the Y-BOCS | HAM-D YBOCS CGI-S HAM-A |
Three weeks | Fluid cooled figure-of-eight coil (MCF-B70 butterfly coil. 1,200 stimuli per day at 1 Hz in 4 trains of 300 s, with intertrain interval of 2 min, at 100% MT | Low-frequency rTMS over pre-SMA was not superior to placebo in reducing symptoms of OCD in partial/poor responders to SSRIs | 0, 1, 2, 3 and 12 weeks using YBOCS | Low-frequency rTMS over pre-SMA may not be effective as an augmenting agent in partial/poor responders to SRIs | Headache, sedation, concentration difficulties and failing memory |
| Singh et al. (2019) | India | Retrospective review and analysis of records | 79 patients | Left-OFC and over bilateral SMA | Reduction in clinical symptoms, as measured on the Y-BOCS | YBOCS | Four weeks | 70-mm figure of-eight air-film coil.1-Hz at 110% RMT, 5-s train duration, intertrain interval of 10 s and 240 trains per session. Each session consisted of 1,200 pulses/d delivered in 3,590 s. A total of 20 sessions of rTMS 5 days per week for 4 weeks | Significant reduction in the mean YBOCS score after 20 sessions of rTMS, as compared with baseline YBOCS score | First day before the beginning of rTMS session and after the completion of 20th rTMS session | This study provided evidence for overall effectiveness of adjunctive 1-Hz rTMS treatment over either SMA or OFC in patients with medication-refractory OCD | Nil |
| Mansur et al. (2011) | Brazil | Parallel, double-blind randomized trial | 30 patients 18– 65 years | R-DLPFC | Scores on the YBOCS and CGI-I scale | HAM-D YBOCS CGI-S HAM-A CGI-I |
Six weeks | Figure-of-eight coil 10 Hz and at 110% MT. 30 sessions (1/d, 5 d/wk.).40 trains – 5 s per train, with a 25-s intertrain interval. Total 60,000 pulses | rTMS, over rDLPFC, was not found to be superior to sham rTMS in relieving OC symptoms, reducing clinical severity or improving treatment response | Baseline; after 2 and 6 wk. treatment; and after 2 and 6 wk. follow-up | Active rTMS over the rDLPFC does not appear to be superior to sham rTMS in relieving OC symptoms, reducing clinical severity or improving treatment response | Mild headache, scalp discomfort, cervical pain, mood swings |
| Rostami et al. (2020) | Asia | Retrospective study | 65 patients | DLPFC or SMA | Y-BOCS | Y-BOCS BDI-II CGI-I BAI |
Three days per week for seven weeks | 70-mm figure-of-eight-coil (air film coil). 120% of AMT 1 Hz, for 30 min, total of 1,800 pulses per session. once a day, 3 days per week for 7 weeks, in 20 sessions (36,000 pulses) | Significant reduction in OCD symptoms and anxiety/depressive states were observed after 20 sessions of rTMS | Baseline and after the 20th session of rTMS | An overall significant reduction in OCD symptoms and anxiety/depressive states were observed after 20 sessions of rTMS | Headache and dizziness |
| Ruffini et al. (2009) | Italy | A randomized controlled investigation | 23 patients 18–75 years | Left OFC | OCD symptoms, mood and anxiety | YBOCS, HDRS, HARS | Five sessions per week for three weeks | 70-mm 8-shaped coil.10 min 1 Hz left-sided subthreshold rTMS 80% MT. 15 sessions (1 per day, 5 per week for 3 weeks) | Significant improvement in OCD symptoms in OCD patients with benefits lasting up to 10 weeks after the end of rTMS treatment | Baseline, after 15 rTMS sessions and every 2 weeks for 3 months after the end of rTMS | Low-frequency rTMS of the left OFC produced significant but time-limited improvement in OCD patients compared to sham treatment | Nil |
| Mantovani et al. (2006) | USA | Open-label pilot study | 10 right handed outpatients | SMA | YBOCS, CGI | YBOCS, YGTSS, CGI, HARS HDRS, SAD, BDI SCL-90 | 10 days | 70-mm figure-of-eight coil, SMA for 10 daily sessions at 1 Hz, 100% MT, 1,200 stimuli/day | Significant improvement in OCD and TS symptoms with benefits lasting up to three months. Improvements in depression and anxiety were also seen | Baseline and after 1 and 2 wk. of stimulation and 1 and 3 months follow up on CGI | Slow rTMS to SMA resulted in a significant clinical improvement and a normalization of the right hemisphere hyperexcitability, thereby restoring hemispheric symmetry in motor threshold | Nil |
| Praško et al. (2006) | Czech Republic | A randomized, double blind, sham controlled study | 33 right-handed patients | Left DPLFC | General psychopathology | CGI, HAMA, Y-BOCS BAI | Two weeks | Air cooled, figure-of-eight 70-mm coil.1 Hz at 110% MT. 10 sessions. 30 min (5 per week for 2 weeks. 1,800 pulses per session | Low frequency rTMS of left prefrontal cortex had no impact on the symptomatology in the patients suffering with SSRIs resistant OCD | Week 0, week 2 and week 4 | Low frequency rTMS administered over the left DPLFC during 10 daily sessions did not differ from sham rTMS in facilitating the effect of serotonin reuptake inhibitors in OCD patients | Nil |
| Elbeh et al. (2016) | Egypt | Double blind randomized clinical trial | 45 patients | Right DLPFC | Effects of 1 Hz and 10 Hz on scales | Y-BOCS, HAM-A, CGI-S | Two weeks | 70 mm figure-of-eight coil 1 Hz-rTMS at 100% RMT, 4 trains, each of 500 pulses with a 40 s and 10 Hz rTMS at 100% RMT applied in 10 trains of 200 pulses, with 20 s. total of 2,000 pluses (5 days/week) 2 weeks | 1 Hz rTMS over the right DLPFC has medium term effect on obsessive-compulsive symptoms and anxiety | Before and after the last treatment session and three months later | There was a significantly larger percentage change in GCI-S in the 1 Hz group versus either 10 Hz or sham. We conclude that 1 Hz-rTMS, targeting right DLPFC is a promising tool for treatment of OCD | Transient headache |
| Pelissolo et al. (2016) | France | Sham-controlled trial | 40 patients | Pre-SMA | Efficacy of 1-Hz rTMS over pre-SMA | Y-BOCS, CGI-S | Four weeks | 70-mm figure-of-eight coil.1 Hz, 26-min sessions (four 5-min trains interval of 2 min, 1,500 pulses/d), at 100% of RMT | Low-frequency rTMS delivered to pre-SMA during four weeks had no better effects on drug refractory OCD patients than sham stimulation | Baseline and four weeks and follow-up (week 12) | Low-frequency rTMS applied to the pre-SMA seems ineffective for the treatment of OCD patients at least in severe and drug-refractory cases such as those included in this study | Headache |
| Seo et al. (2016) | Korea | A randomized controlled trial | 27 patients | Right DLPFC | OCD symptoms, mood and anxiety symptoms | YBOCS, CGI-S HAMD |
Three weeks | TAMAS stimulator with a figure-eight coil.1 Hz, 20-min trains (1,200 pulses/ day) at 100% MT once per day 5 days per week. for 3 weeks | LF rTMS over the right DLPFC appeared to be superior to sham rTMS for relieving OCD symptoms and depression in patients with treatment-resistant OCD | Baseline and every week during the treatment period | LF rTMS over the right DLPFC appeared to be superior to sham rTMS for relieving OCD symptoms and depression in patients with treatment-resistant OCD | Localized scalp pain, headache |
| Talaei et al. (2009) | Iran | A case report | 40-year-old female | SMA | OCD symptoms, mood and anxiety symptoms | Y-BOCS | 10 sessions | 10 sessions with 110%, 1 Hz and of 30 min per day (a total of 1,200 pulses per day | Significant decrease in compulsive behaviors | Before the first rTMS session and after every session | Significant decrease in compulsive behaviors and obsessive thoughts | Nil |
| Badawy et al. (2010) | Egypt | Randomized control trial | 60 patients | LDLPFC | Mixed OCD symptoms and compulsive symptoms only | Y-BOCS | 15 sessions | High frequency r-TMS (20 Hz).5 sessions per week for 3 weeks. high frequency r-TMS (20 Hz) | While r-TMS was not effective as a single treatment for OCD patients, it was effective as add-on treatment for OCD patients | Before the first r-TMS session and after completion of the 15 sessions | While r-TMS was not effective as a single treatment for OCD patients, it was effective as add-on treatment for OCD patients | Nil |
| Elmedany et al. (2014) | Egypt | Randomized control trial | 20 patients (9 men and 1 female) | Left prefrontal area of the brain | OCD symptoms | Y-BOCS CGI |
20 Hz 2 s for 20 min in 8 sessions every 48 h | Figure-of-eight or butterfly-shape coil. 5 cm forward and 2 cm to the below the center of the head. MT 90%; 20 Hz 2 s for 20 min in 8 sessions every 48 h | OCD patients have better response to r TMS for obsession symptoms more than compulsions especially those on pharmacological treatment | Before the first r-TMS session and after completion of the last | OCD patients after r-TMS has a better response especially those accompanied with pharmacological treatment | Nil |
| Greenberg et al. (1997) | USA | Brief report | 12 patients | Right lateral prefrontal, a left lateral prefrontal and midoccipital site on separate days, randomized | Obsessive compulsive symptoms | Y-BOCS HARS |
20 Hz/2 s per min for 20 min | Cadwell High Speed Magnetic Stimulator and a figure-eight-shaped coil. 80%MT, 20 Hz/2 s per min for 20 min | Results suggest that right prefrontal rTMS might affect prefrontal mechanisms involved in OCD | Baseline and post-stimulation | Results suggest that right prefrontal repetitive transcranial magnetic stimulation might affect prefrontal mechanisms involved in OCD | Nil |
| Hegde et al. (2016) | India | Retrospective analysis study | 17 patients | Pre-SMA | OCD symptoms | Y-BOCS CGI-S |
Three weeks | 70-mm figure-of-eight coil 1-Hz at 100% MT over the pre-SMA 20 min, in 4 trains of 300 s (1,200 pulses per sitting | Only 1 patient met the criteria for response after one month of treatment initiation | Baseline and one month after initiation | Low-frequency rTMS over the pre-SMA may not be effective in treatment refractory OCD | Mild headache |
| Carmi et al. (2019) | Israel | Prospective multicenter randomized double-Blind placebo-controlled trial | 100 patients | Dorsal mPFC | Safety, tolerability and efficacy of dTMS in OCD | YBOCS, CGI-S HAMD CGI-I |
Six weeks | H-shaped coil design, 100% RMT. 20 Hz dTMS 2-s pulse trains and 20-s intertrain intervals, for a total of 50 trains and 2,000 pulses per session | Significant differences between the groups were maintained at follow-up | Baseline and I month follow up | High-frequency dTMS over the mPFC and anterior cingulate cortex significantly improved OCD symptoms and may be considered as a potential intervention for patients who do not respond adequately to pharmacological and psychological interventions | One patient had suicidal thoughts |
| Haghighi et al. (2015) | Iran | Randomized, single-blind, sham, controlled clinical trial with cross-over design | 21 patients | L-DLPFC | OCD symptoms | Y-BOCS, CGI | Four weeks | 70 mm double air film coil. 100% RMT at 20 Hz, in 750 total pulse. 25 min per cortex site, totaling 50 min for a session | Both self- and expert-reported symptom severity reduced in the rTMS condition as compared to the sham condition. Full- and partial responses were observed in the rTMS-condition, but not in the sham-condition | Baseline, after two and after four weeks of treatment | The pattern of results from this single-blind, sham- and cross-over design suggests that rTMS is a successful intervention for patients suffering from treatment-resistant OCD | Nil |
| Modirrousta et al. (2015) | Canada | Open-label study | 10 patients | mPFC | Effect of low-frequency deep rTMS over the mPFC of patients with OCD | Y-BOCS | Two weeks | Double-cone coil at 110% RMT 1 Hz, 150 pulses (overall 1,200 pulses in one session) for 10 sessions | Significant reduction in OCD symptoms | Baseline, after 10 sessions same day as last rTMS treatment, 1 month after last session | Results suggest the use of low frequency deep rTMS as a promising and robust intervention in OCD symptom reduction | Electric shocking sensation and insomnia |
Notes: MT = motor threshold, SMA = supplementary motor area Y-BOCS = Yale–Brown Obsessive-Compulsive Scale; Ham-D–24 = Hamilton Rating Scale for Depression–24-item; BDI–II, DLPFC = dorsal lateral prefrontal cortex, OFC = orbitofrontal cortex, RMT = resting motor threshold, CGI-I = clinical global impression. HAMA = Hamilton Anxiety Rating Scale, HRSD = Hamilton Rating Scale for Depression, YMRS = Young Mania Rating Scale, GAF = global assessment of functioning, MCCB = MATRICS Consensus Cognitive Battery. QIDS = quick inventory of depressive symptomatology, CAPS = clinician administered PTSD scale, BNCE = brief neurobehavioral cognitive examination, STAI = state trait anxiety inventory, SC-Q = self-administered comorbidity questionnaire, SCID = structured clinical interview for DSM-IV, IPF = inventory of psychosocial functioning, BRMAS = Bech-Rafaelsen mania scale, CRSD = circadian rhythm sleep disorder, SCL-90-R = Symptom Checklist-90-Revised, mPFC = medial prefrontal cortex