Accelerated rTMS in Hospitalized Patients With OCD: a Feasibility and Mechanistic Study

This study aims to explore the combination of specialized inpatient care for Obsessive-Compulsive Disorder (OCD) with treatment using repetitive Transcranial Magnetic Stimulation (rTMS) in patients diagnosed with OCD. Specifically, the investigators seek to assess the feasibility, desirability, and tolerability of this combined approach, as well as its clinical and neural effects.

The study protocol consists of three arms. All arms include Exposure and Response Prevention (ERP), an established psychotherapeutic treatment for OCD. Two arms will investigate two different types of rTMS: conventional deep TMS (dTMS) and intermittent theta burst stimulation (iTBS). Both rTMS treatments will be administered using an accelerated protocol, involving four sessions per day. The third arm consists of ERP without any form of neuromodulation (i.e., treatment-as-usual).

Study Design:

This is a randomized clinical trial (RCT) evaluating the feasibility, efficacy, safety, and suitability of the two types of accelerated rTMS protocols, in addition to ERP therapy in patients with OCD. The study also aims to investigate the neural mechanisms underlying these treatment approaches.

Patients will be randomly assigned by a computer program to one of three treatment groups. All groups will receive ERP. Two groups will receive either iTBS or dTMS combined with ERP, and the third group will receive ERP without rTMS.

Participant Requirements:

Questionnaires: Completion of surveys before treatment, immediately after treatment, and four weeks post-treatment.

MRI & EEG: Undergo functional and structural brain imaging (MRI) and high-definition electroencephalography (hdEEG) before and after the treatment period.

Adverse Effects Diary: Maintain a daily log of any side effects experienced during the treatment period.

Study Duration:

The total expected duration of participation is ten weeks. Magnetic stimulation treatment will take place over two weeks, within a standard hospitalization of twelve weeks in an OCD inpatient department. Participation does not require additional hospital visits compared to usual treatment.

Study Location:

The study will be conducted at UZ Gent, Building K12F, Corneel Heymanslaan 10, 9000 Ghent, Belgium. A total of 60 patients will participate, with 40 patients receiving rTMS treatment. All procedures will take place within Belgium.

Participant Involvement:

During the twelve-week hospitalization, rTMS treatment will commence approximately two weeks after admission. The initial two-week period allows for familiarization with the department and ERP therapy. Prior to inclusion, eligibility will be assessed through a 60-minute consultation, a semi-structured diagnostic interview (MINI-5), and a structured assessment of OCD symptoms (Y-BOCS symptom checklist) to identify any exclusion criteria or contraindications.

Eligible patients will undergo two brain imaging procedures: functional and structural MRI and hdEEG. Additionally, five questionnaires will be administered collectively.

The rTMS protocol will then be implemented over a two-week period, with four sessions per day, four days per week, totaling 32 sessions. During this period, patients will complete a daily adverse effects questionnaire. Immediately after treatment, post-treatment assessments will include questionnaires and repeated fMRI and hdEEG scans. Four weeks later, follow-up questionnaires assessing OCD symptoms and related measures will be completed.

Certain visits and procedures described in the study will be part of standard care at the hospital, while others are specific to the research protocol. Throughout the twelve-week hospitalization, all groups will receive standard care, including medication optimization and evidence-based psychotherapeutic interventions for OCD. rTMS will be offered as an adjunctive treatment to this standard care.

Inclusion criteria

• Age between 18 and 65
• Hospitalization for Obsessive-Compulsive Disorder (OCD)
• Participation in Exposure and Response Prevention Therapy
• Significant OCD, as measured by a Y-BOCS score of 20 or higher (moderate to severe OCD symptoms)

Exclusion criteria

• Acute suicidality: Individuals presenting with current suicidal ideation or behavior are excluded to ensure participant safety.
• Psychotic disorder: patients with active psychotic disorders are excluded due to the complexity of their condition and potential interactions with the study protocol.
• Current substance use disorder: active substance use disorders are exclusionary to prevent confounding effects on study outcomes.
• Deep Brain Stimulation (DBS) for OCD: participants with an implanted DBS device for OCD are excluded due to potential interference with the study's interventions and safety concerns.