TMS May Be More Effective With Symptom Provocation for OCD, Nicotine Dependence

Individuals with obsessive-compulsive disorder (OCD) or nicotine dependence may have an improved response to transcranial magnetic stimulation (TMS) when their symptoms are provoked through audio and/or visual cues, according to a report published yesterday in JAMA Psychiatry.

Daniel Bello, B.S., of Vanderbilt University Medical Center, and colleagues noted that “provoking symptoms may shift the brain into a state that is more susceptible to the effect of TMS.” For example, the FDA-cleared protocol for smoking cessation involves a five-minute procedure where patients imagine their greatest craving trigger, listen to a recording instructing them to handle a cigarette and lighter, and then view smoking images.

However, most trials using provocation have been small, and there have been no head-to-head comparisons of TMS with or without provocation, the researchers continued. “A major question for TMS treatment remains: does brain state affect clinical response?”

Bello and colleagues compiled data from 71 randomized clinical trials evaluating TMS in adults with OCD (n=44) or nicotine dependence (n=27)—either with or without symptom provocation. Approved TMS protocols for depression do not involve symptom provocation and were not included in the analysis.

For OCD studies, active TMS was associated with better clinical response (improvement on the Yale-Brown Obsessive-Compulsive Scale) than sham stimulation both with and without symptom provocation, though the effect size was larger in trials with provocation (0.51 versus 0.29). For nicotine dependence, however, active TMS was statistically associated with better clinical response (cravings, dependence severity, and/or cigarettes smoked) than sham stimulation only when used with symptom provocation (effect size of 0.56).

“Additional research is warranted to more accurately estimate any added benefit of symptom provocation,” Bello and colleagues wrote. “If beneficial, using symptom provocation with TMS protocols would be broadly accessible and could be readily implemented in TMS clinics across the globe.”

However, they cautioned that provoking symptoms is often uncomfortable for both the patient and the TMS technician and could cause some study participants to drop out or relapse. “Therefore, it is worth empirically determining if symptom provocation is safe and effective before it is applied universally in TMS protocols,” the researchers wrote. “Symptom provocation should be used where effective but avoided when there is no clear benefit.”

For more information, see the Psychiatric News article “From Heretical Idea to Mainstream Psychiatry: Brain Stimulation Has Ridden a Wave.”

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Researchers Look to Unlock GLP-1 Drugs’ Potential in Psychiatry

Researchers are exploring the potential of glucagon-like peptide 1 (GLP-1) receptor agonists to treat neuropsychiatric disorders such as cognitive dysfunction and alcohol use disorder, according to a panel held last week at the American Society of Clinical Psychopharmacology’s annual meeting in Phoenix.

GLP-1 receptor agonists such as semaglutide and tirzepatide mimic the effects of GLP-1, a peptide produced in the intestinal mucosa, and are known for leading to remarkable weight loss in both the general population and individuals with antipsychotic-induced weight gain.

GLP-1 medications do not increase resting metabolic rate or promote physical activity, but “they do have a very robust signal in reducing caloric intake,” explained Rodrigo Mansur, M.D., Ph.D., research scientist, psychiatrist at the University Health Network, and assistant professor of psychiatry at the University of Toronto. “Patients tell us, ‘They reduce feelings of hunger, they promote feelings of satiety.’”

These medications are believed to modulate the rewarding aspects of food—and potentially other substances. A recent Phase 2 trial found that weekly low-dose semaglutide significantly reduced the amount of alcohol consumed by adults with alcohol use disorder during a self-administration task taken after four weeks of treatment, according to panelist Christian Hendershot, Ph.D., a professor of population and public health sciences at Keck School of Medicine at the University of Southern California, who conducted the trial with colleagues.

Research on GLP-1 medications in animal models suggest the compounds also have neuroprotective and anti-inflammatory actions, which has led to expanded research on their potential to treat neuropsychiatric disorders, said Greg Nigel, Ph.D., chief of the drug design and development section at the Intramural Research Program at the National Institute on Aging. GLP-1 receptors are found throughout the brain, and studies are showing they may prove valuable in a host of neurodegenerative disorders that are prevalent in late life, such as Parkinson’s and Alzheimer’s disease.

Mansur discussed a recent randomized trial that he and colleagues undertook to explore semaglutide’s potential for improving executive function in individuals with major depressive disorder (MDD), 80% of whom had a lifetime history of suicidality. Over the 16-week trial, Mansur and colleagues found no difference in executive function scores between the semaglutide and placebo groups. However, the researchers did find a statistical improvement in global cognition for semaglutide compared with placebo—suggesting it may work in other cognitive domains.

For related information, see the Psychiatric News article “Award Winner Describes Efforts to Improve Cognition in People With Bipolar Disorder.”

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Just a Third of SUD Treatment Facilities Offer Perinatal Programs

Less than one-third of facilities that offer treatment for substance use disorder (SUD) or combined SUD and mental health disorders offer a perinatal program, a study in the Journal of Substance Use and Addiction Treatment has found.

Brooke N. Lombardi, Ph.D., M.S.W., of the University of North Carolina at Chapel Hill, and colleagues analyzed data from the 2022 National Substance Use and Mental Health Services Survey, an annual survey of all known public and private SUD and mental health treatment facilities in the United States. The sample consisted of 6,995 facilities providing only SUD treatment (SUD-only) and 9,134 facilities offering combined SUD and mental health treatment.

Overall, only 32.7% of SUD-only facilities and 31.1% of combined facilities reported offering a program or group that is specifically tailored for pregnant/postpartum women.

“While these percentages are relatively low, they represent an increase from those reported in previous research, suggesting that the availability of these essential programs may be growing,” Lombardi and colleagues wrote.

Services that were considered under-provided at these facilities included:

• Detoxification (31.9% of SUD-only, 24.3% of SUD and mental health)
• Integrated primary care (20.9% of SUD-only, 38.4% of SUD and mental health)
• Childcare (11.4% of SUD-only, 7.9% of SUD and mental health)
• Beds for children (8.8% of SUD-only, 4% of SUD and mental health)

However, the researchers noted that more than half of treatment facilities provided other services identified in prior research as particularly important for the perinatal population, including:

• Assistance with accessing social services (80.9% of SUD-only, 80.2% of SUD and mental health)
• Telehealth (75.4% of SUD-only, 87% of SUD and mental health)
• Trauma-related therapy (69.9% of SUD-only, 90.5% of SUD and mental health)
• Transportation assistance (52.2% of SUD-only, 56.3% of SUD and mental health)

Available services were primarily offered in outpatient settings, with less than 25% of facilities providing residential services and less than 10 % offering inpatient care.

“Effective care for perinatal SUDs and [mental health disorders] must extend beyond the provision of behavioral health treatment alone,” the researchers wrote. “To promote the health of both parents and children, facilities must also provide essential medical services such as integrated primary care and detoxification. Additionally, increasing the availability of childcare services and accommodations for clients’ children is crucial for maintaining the integrity of the parent-child relationship.”

For related information, see the Psychiatric News article “It Takes a Village: Mothers With SUDs Often Lack Support in Getting Treatment.”

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ACT-Based Group Therapy Improves Management of Comorbid Asthma and ADHD

A group intervention based on acceptance and commitment therapy can help parents of children with comorbid asthma and attention-deficit/hyperactivity disorder (ADHD) build resilience and self-efficacy—leading to better health outcomes for the children in the long term. These findings were published today in JAMA Pediatrics.

Yuen Yu Chong, Ph.D., of the Chinese University of Hong Kong, and colleagues enrolled 118 parents who had a child between ages 3 and 11 with a diagnosis of asthma and ADHD. Half the parents received usual asthma care, which included regular follow-ups, one group educational session on asthma management, and referrals for ADHD services. The other half received usual care along with six weeks of acceptance and commitment therapy for parenting in asthma management (ACT-PAM); this small-group therapy taught parents how to make action plans to manage their child’s asthma and ADHD using principles such as acceptance, mindfulness, and positive parenting.

Twelve months after the intervention ended, the parents who received ACT-PAM—and their children—showed significant improvements in a variety of measures. Children in the ACT-PAM group had about 67% fewer unscheduled health care visits for asthma exacerbations on average compared with the usual care group (0.5 versus 1.3). “While modest, this reduction is clinically meaningful, particularly for children with ADHD, who face exacerbation risk due to attentional and behavioral challenges,” the researchers wrote.

Parents in ACT-PAM also reported greater reductions in their child’s ADHD symptoms than the usual care group, as well as greater reductions in their own psychological inflexibility and greater confidence in managing their child’s asthma.

“Integrating positive parenting with ACT provided a holistic intervention that improved asthma management, behavioral outcomes, and parental resilience, which are often neglected in traditional single-diagnosis asthma care,” Chong and colleagues wrote. Further, “ACT helped parents shift from experiential avoidance to values-based caregiving, indirectly improving child ADHD outcomes.”

For related information, see the American Journal of Psychotherapy article “Acceptance and Commitment Therapy for Posttraumatic Psychopathology: A Group-Based Telehealth Intervention.”

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