Journal: JAMA Psychiatry
Authors: Bello D, Jones IG, Williams NR, et al.
Background:
Current FDA-cleared TMS protocols for OCD include symptom provocation before stimulation, based on the idea that brain state may influence TMS effects. However, the size of any added clinical benefit from provocation had not been quantified across the literature.
Objective:
This systematic review and meta-analysis examined whether symptom provocation is associated with improved clinical response to TMS in OCD, while also comparing active TMS with sham treatment.
Methods:
The authors searched PubMed, CINAHL, Embase, PsycInfo, and related databases through August 30, 2024 for randomized clinical trials of TMS in OCD or nicotine dependence that reported clinical outcomes. Seventy-one studies met inclusion criteria, and 63 studies with 2,998 participants were included in the multilevel random-effects meta-analysis.
Results:
For OCD studies, active TMS was superior to sham both when symptom provocation was used (SMD = -0.51, 95% CI -0.96 to -0.07) and when it was not used (SMD = -0.29, 95% CI -0.40 to -0.17). Although the effect size was numerically larger with provocation, the estimated added effect of provocation in OCD was not statistically significant (SMD = -0.22, 95% CI -0.65 to 0.20; P = .22). The authors concluded that the existing evidence suggests a possible advantage with provocation, but that direct comparative trials remain limited.
Conclusions:
TMS is effective for OCD overall, and symptom provocation may enhance response, but the available evidence does not yet demonstrate a statistically significant incremental benefit. The study supports further head-to-head research specifically designed to test provocation.
