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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