A network meta-analysis for rTMS in the treatment of Obsessive-Compulsive Disorder in Adults
Poster No:
128
Submission Type:
Abstract Submission
Authors:
Jiawen Tian1, Hailong Li1, Ping Wang1, Yingxue Gao1, Xiaoqi Huang1
Institutions:
1Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan
First Author:
Jiawen Tian
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Co-Author(s):
Hailong Li
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Ping Wang
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Yingxue Gao
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Xiaoqi Huang
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, Sichuan
Introduction:
Obsessive-compulsive disorder (OCD) detrimentally affects individuals' personal, social, and professional lives, making it a pressing psychiatric challenge. Although traditional cognitive-behavioral therapy and selective serotonin reuptake inhibitors provide relief, a significant proportion of patients respond inadequately[1-2]. The potential of adjunctive therapies like repetitive transcranial magnetic stimulation (rTMS), which may alleviate symptoms by modulating cortical activity, has gained attention[3]. Nevertheless, determining the optimal strategies for rTMS, including target areas and frequencies, is an ongoing area of research and debate. Our network meta-analysis aims to evaluate and rank rTMS modalities for OCD treatment, establishing a hierarchy of efficacy and tolerability.
Methods:
We focused on randomized controlled trials (RCTs) involving adults with OCD, this systematic review and network meta-analysis adhered to the PRISMA guidelines. The study conducted a comprehensive database search (Cochrane Central, PubMed, Web of Science, Embase) until November 15, 2023. Eligible studies compared various rTMS strategies against sham rTMS.
We performed pairwise meta-analyses to assess each direct comparison within a random-effects model, using the "metan" package in STATA14.0. Random-effects network meta-analyses were conducted to assess each direct and indirect comparison within a Bayesian framework using the "gemtc" and "rjags" packages in R4.3.1. Both methods indicated by changes in Y-BOCS scores before and after treatment.
On this basis, we also conducted a sensitivity analysis by sequentially removing individual studies from the pooled research in STATA.
We performed pairwise meta-analyses to assess each direct comparison within a random-effects model, using the "metan" package in STATA14.0. Random-effects network meta-analyses were conducted to assess each direct and indirect comparison within a Bayesian framework using the "gemtc" and "rjags" packages in R4.3.1. Both methods indicated by changes in Y-BOCS scores before and after treatment.
On this basis, we also conducted a sensitivity analysis by sequentially removing individual studies from the pooled research in STATA.
Results:
The search yielded 1877 references, ultimately including 33 RCTs totalling 1113 patients in the final analysis. (Figure 1a)
Regarding the efficacy, pairwise meta-analysis indicated that low-frequency rTMS (LF-rTMS) targeting the right/left dorsolateral prefrontal cortex (DLPFC) were significantly more efficacious than sham rTMS in reducing the Y-BOCS scores. Alternatively, no significant differences were found in the drop-out rates between active and sham rTMS of tolerability. (Figure 1b)
Network meta-analysis provided ranking through cumulative probability plots and SUCRA value. In terms of efficacy, high-frequency rTMS (HF-rTMS) applied over the bilateral DLPFC and LF-rTMS over right DLPFC achieved the highest efficacy ranks (SUCRA: 93.7 and 85.3%). Stimulation of the right DLPFC was generally better than the left side, regardless of LF/HF-rTMS, and LF-rTMS was more effective than HF-rTMS. In addition, LF-rTMS to the pre-supplementary motor area (pre-SMA) demonstrated higher efficacy to SMA. cTBS appears to be the least effective. In terms of tolerability, LF-rTMS applied over pre-SMA was the most tolerated. Sensitivity analysis, conducted by systematically excluding each study, confirmed the stability of the results. (Figure 2)
Regarding the efficacy, pairwise meta-analysis indicated that low-frequency rTMS (LF-rTMS) targeting the right/left dorsolateral prefrontal cortex (DLPFC) were significantly more efficacious than sham rTMS in reducing the Y-BOCS scores. Alternatively, no significant differences were found in the drop-out rates between active and sham rTMS of tolerability. (Figure 1b)
Network meta-analysis provided ranking through cumulative probability plots and SUCRA value. In terms of efficacy, high-frequency rTMS (HF-rTMS) applied over the bilateral DLPFC and LF-rTMS over right DLPFC achieved the highest efficacy ranks (SUCRA: 93.7 and 85.3%). Stimulation of the right DLPFC was generally better than the left side, regardless of LF/HF-rTMS, and LF-rTMS was more effective than HF-rTMS. In addition, LF-rTMS to the pre-supplementary motor area (pre-SMA) demonstrated higher efficacy to SMA. cTBS appears to be the least effective. In terms of tolerability, LF-rTMS applied over pre-SMA was the most tolerated. Sensitivity analysis, conducted by systematically excluding each study, confirmed the stability of the results. (Figure 2)
Conclusions:
In current study, we offer a comprehensive comparison of rTMS modalities, which is the largest sample size network meta-analysis of rTMS for adult OCD to date. Differing from previous studies, we further refined the stimulation targets into the right/left DLPFC, SMA/pre-SMA. Both pairwise and network meta-analyses revealed that LF-rTMS applied over the right DLPFC and HF-rTMS applied over the bilateral DLPFC were significantly more efficacious than sham rTMS, which appear to be the most promising rTMS strategy for OCD treatment. Building on previous studies, we further innovatively found that when targeting the DLPFC, the right side was generally better than the left side, and low frequencies were generally better than high frequencies, aligning with the preference for low-frequency stimulation of the right DLPFC in current clinical practice. Moreover, we noted that cTBS appears to be the least effective. Future research investigating the long-term effects of rTMS and more personalized protocols will be needed to advance treatment for OCD.
Brain Stimulation:
TMS 1
Disorders of the Nervous System:
Psychiatric (eg. Depression, Anxiety, Schizophrenia) 2
Keywords:
ADULTS
Obessive Compulsive Disorder
Treatment
Other - Network Meta-analysis, rTMS, Efficacy, Tolerability.
1|2Indicates the priority used for review
Provide references using author date format
[2]Khedr, E. M. (2022), 'A double blind randomized clinical trial of the effectiveness of low frequency rTMS over right DLPFC or OFC for treatment of obsessive-compulsive disorder'. Journal of psychiatric research, vol. 156, pp. 122-131.
[3]Carmi L (2019), 'Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial', Am J Psychiatry, vol. 176, no. 11, pp. 931-938.