Obsessive-compulsive disorder (OCD) is a frequent, disabling disorder with high rates of treatment resistance. Transcranial direct current stimulation (tDCS) is a safe, tolerable noninvasive neuromodulation therapy with scarce evidence for OCD. This double-blind, randomized, and sham-controlled study investigates the efficacy of tDCS as add-on treatment for treatment-resistant OCD (failure to respond to at least one previous pharmacological treatment). On 20 consecutive weekdays (4 weeks), 43 patients with treatment-resistant OCD underwent 30 min active or sham tDCS sessions, followed by a 8 week follow-up. The cathode was positioned over the supplementary motor area (SMA) and the anode over the left deltoid. The primary outcome was the change in baseline Y-BOCS score at week 12. Secondary outcomes were changes in mood and anxiety and the occurrence of adverse events. Response was evaluated considering percent decrease of baseline Y-BOCS scores and the Improvement subscale of the Clinical Global Impression (CGI-I) between baseline and week 12. Patients that received active tDCS achieved a significant reduction of OCD symptoms than sham, with mean (SD) Y-BOCS score changes of 6.68 (5.83) and 2.84 (6.3) points, respectively (Cohen’s d: 0.62 (0.06–1.18), p = 0.03). We found no between-group differences in responders (four patients in the active tDCS and one in the sham group). Active tDCS of the SMA was not superior to sham in reducing symptoms of depression or anxiety. Patients in both groups reported mild adverse events. Our results suggest that cathodal tDCS over the SMA is an effective add-on strategy in treatment-resistant OCD.
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Gillan CM, Fineberg NA, Robbins TW. A trans-diagnostic perspective on obsessive-compulsive disorder. Psychol Med. 2017;47:1528–48.
Skapinakis P, Caldwell DM, Hollingworth W, Bryden P, Fineberg NA, Salkovskis P, et al. Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2016;3:730–9.
Erzegovesi S, Cavallini MC, Cavedini P, Diaferia G, Locatelli M, Bellodi L. Clinical predictors of drug response in obsessive-compulsive disorder. J Clin Psychopharmacol. 2001;21:488–92.
Ravizza L, Barzega G, Bellino S, Bogetto F, Maina G. Predictors of drug treatment response in obsessive-compulsive disorder. J Clin Psychiatry. 1995;56:368–73.
Simpson HB, Huppert JD, Petkova E, Foa EB, Liebowitz MR. Response versus remission in obsessive-compulsive disorder. J Clin Psychiatry. 2006;67:269–76.
Carmi L, Tendler A, Bystritsky A, Hollander E, Blumberger DM, Daskalakis J, et al. Efficacy and safety of deep transcranial magnetic stimulation for obsessive-compulsive disorder: a prospective multicenter randomized double-blind placebo-controlled trial. Am J Psychiatry. 2019. https://doi.org/10.1176/appi.ajp.2019.18101180.
Shafi MM, Westover MB, Fox MD, Pascual-Leone A. Exploration and modulation of brain network interactions with noninvasive brain stimulation in combination with neuroimaging. Eur J Neurosci. 2012;35:805–25.
Milad MR, Rauch SL. Obsessive-compulsive disorder: beyond segregated cortico-striatal pathways. Trends Cogn Sci. 2012;16:43–51.
Rǎdulescu A, Herron J, Kennedy C, Scimemi A. Global and local excitation and inhibition shape the dynamics of the cortico-striatal-thalamo-cortical pathway. Sci Rep. 2017;7:1–21.
Brunelin J, Mondino M, Bation R, Palm U, Saoud M, Poulet E. Transcranial Direct Current Stimulation for Obsessive-Compulsive Disorder: A Systematic Review. Brain Sci. 2018;8:37.
Da Silva RDMF, Brunoni AR, Miguel EC, Shavitt RG. Transcranial direct current stimulation for obsessive- compulsive disorder: patient selection and perspectives. Neuropsychiatr Dis Treat. 2019;15:2663–9.
Kumar S, Kumar N, Verma R. Safety and efficacy of adjunctive transcranial direct current stimulation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Indian J Psychiatry. 2019;61:327–34.
D’Urso G, Brunoni AR, Anastasia A, Micillo M, de Bartolomeis A, Mantovani A. Polarity-dependent effects of transcranial direct current stimulation in obsessive-compulsive disorder. Neurocase. 2016;22:60–4.
Palm U, Leitner B, Kirsch B, Behler N, Kumpf U, Wulf L, et al. Prefrontal tDCS and sertraline in obsessive compulsive disorder: a case report and review of the literature. Neurocase. 2017;23:173–7.
de Wit SJ, de Vries FE, van der Werf YD, Cath DC, Heslenfeld DJ, Veltman EM, et al. Presupplementary motor area hyperactivity during response inhibition: a candidate endophenotype of obsessive-compulsive disorder. Am J Psychiatry. 2012;169:1100–8.
Yücel M, Harrison BJ, Wood SJ, Fornito A, Wellard RM, Pujol J, et al. Functional and biochemical alterations of the medial frontal cortex in obsessive-compulsive disorder. Arch Gen Psychiatry. 2007;64:946–55.
Gowda SM, Narayanaswamy JC, Hazari N, Bose A, Chhabra H, Balachander S, et al. Efficacy of pre-supplementary motor area transcranial direct current stimulation for treatment resistant obsessive compulsive disorder: a randomized, double blinded, sham controlled trial. Brain Stimul. 2019. https://doi.org/10.1016/j.brs.2019.02.005.
D’Urso G, Brunoni AR, Mazzaferro MP, Anastasia A, de Bartolomeis A, Mantovani A. Transcranial direct current stimulation for obsessive–compulsive disorder: a randomized, controlled, partial crossover trial. Depress Anxiety. 2016;33:1132–40.
Senço NM, Huang Y, D’Urso G, Parra LC, Bikson M, Mantovani A, et al. Transcranial direct current stimulation in obsessive-compulsive disorder: emerging clinical evidence and considerations for optimal montage of electrodes. Expert Rev Med Devices. 2015;12:381–91.
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006–11.
World Medical Association. World Medical Association Declaration of Helsinki. JAMA. 2013;310:2191.
Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P, CONSORT NPT Group. CONSORT Statement for randomized trials of nonpharmacologic treatments: a 2017 update and a CONSORT extension for nonpharmacologic trial abstracts. Ann Intern Med. 2017;167:40.
Stein DJ, Costa DLC, Lochner C, Miguel EC, Reddy YCJ, Shavitt RG, et al. Obsessive–compulsive disorder. Nat Rev Dis Prim. 2019;5:1–21.
Fossaluza V, Diniz JB, Pereira B de B, Miguel EC, Pereira CA de B. Sequential allocation to balance prognostic factors in a psychiatric clinical trial. Clinics. 2009;64:511–8.
Costa DLC, Diniz JB, Requena G, Joaquim MA, Pittenger C, Bloch MH, et al. Randomized, double-blind, placebo-controlled trial of N-acetylcysteine augmentation for treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2017;78:e766–73.
Diniz JB, Shavitt RG, Fossaluza V, Koran L, Pereira CA de B, Miguel EC. A double-blind, randomized, controlled trial of fluoxetine plus quetiapine or clomipramine versus fluoxetine plus placebo for obsessive-compulsive disorder. J Clin Psychopharmacol. 2011;31:763–8.
Pallanti S, Quercioli L. Treatment-refractory obsessive-compulsive disorder: methodological issues, operational definitions and therapeutic lines. Prog Neuro-Psychopharmacology. Biol Psychiatry. 2006;30:400–12.
Fregni F, El-Hagrassy MM, Pacheco-Barrios K, Carvalho S, Leite J, Simis M, et al. Evidence-based guidelines and secondary meta-analysis for the use of transcranial direct current stimulation (tDCS) in neurological and psychiatric disorders. Int J Neuropsychopharmacol. 2020. https://doi.org/10.1093/ijnp/pyaa051.
McLaren ME, Nissim NR, Woods AJ. The effects of medication use in transcranial direct current stimulation: A brief review. Brain Stimul. 2018;11:52–8.
Lefaucheur J-P, Antal A, Ayache SS, Benninger DH, Brunelin J, Cogiamanian F, et al. Evidence-based guidelines on the therapeutic use of transcranial direct current stimulation (tDCS). Clin Neurophysiol. 2017;128:56–92.
Brunoni AR, Schestatsky P, Lotufo PA, Benseñor IM, Fregni F. Comparison of blinding effectiveness between sham tDCS and placebo sertraline in a 6-week major depression randomized clinical trial. Clin Neurophysiol. 2014;125:298–305.
Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry. 2007;4:28–37.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561.
Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. Journal of consulting and clinical psychology. 1988;56:893–7.
Clyde DJ. SAFTEE: data system for side effect assessment scale. Psychopharmacol Bull. 1986;22:287.
Berlim MT, Neufeld NH, Van, den Eynde F. Repetitive transcranial magnetic stimulation (rTMS) for obsessive–compulsive disorder (OCD): an exploratory meta-analysis of randomized and sham-controlled trials. J Psychiatr Res. 2013;47:999–1006.
Bates D, Mächler M, Bolker B, Walker S. Fitting linear mixed-effects models using lme4. J Stat Softw. 2015;67:1–48.
Feingold A. Effect sizes for growth-modeling analysis for controlled clinical trials in the same metric as for classical analysis. Psychol Methods. 2009;14:43–53.
Mataix-Cols D, Fernández de la Cruz L, Nordsletten AE, Lenhard F, Isomura K, Simpson HB. Towards an international expert consensus for defining treatment response, remission, recovery and relapse in obsessive-compulsive disorder. World Psychiatry. 2016;15:80–1.
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.
Harika-Germaneau G, Heit D, Chatard A, Thirioux B, Langbour N, Jaafari N. Treating refractory obsessive-compulsive disorder with transcranial direct current stimulation: An open label study. Brain Behav. 2020;10:e01648.
Brunoni AR, Valiengo L, Baccaro A, Zanão TA, de Oliveira JF, Goulart A, et al. The sertraline vs electrical current therapy for treating depression clinical study. JAMA Psychiatry. 2013;70:383.
Brunoni AR, Moffa AH, Sampaio-Junior B, Borrione L, Moreno ML, Fernandes RA, et al. Trial of electrical direct-current therapy versus escitalopram for depression. N Engl J Med. 2017;376:2523–33.
Matsunaga H, Nagata T, Hayashida K, Ohya K, Kiriike N, Stein DJ. A long-term trial of the effectiveness and safety of atypical antipsychotic agents in augmenting SSRI-refractory obsessive-compulsive disorder. J Clin Psychiatry. 2009;70:863–8.
Rapinesi C, Kotzalidis GD, Ferracuti S, Sani G, Girardi P, Del Casale A. Brain stimulation in obsessive-compulsive disorder (OCD): a systematic review. Curr Neuropharmacol. 2019;17:787–807.
Batsikadze G, Moliadze V, Paulus W, Kuo MF, Nitsche MA. Partially non-linear stimulation intensity-dependent effects of direct current stimulation on motor cortex excitability in humans. J Physiol. 2013;591:1987–2000.
Kuo HI, Paulus W, Batsikadze G, Jamil A, Kuo MF, Nitsche MA. Chronic enhancement of serotonin facilitates excitatory transcranial direct current stimulation-induced neuroplasticity. Neuropsychopharmacology. 2016;41:1223–30.
Esmaeilpour Z, Marangolo P, Hampstead BM, Bestmann S, Galletta E, Knotkova H, et al. Incomplete evidence that increasing current intensity of tDCS boosts outcomes. Brain Stimul. 2018;11:310–21.
Beam W, Borckardt JJ, Reeves ST, George MS. An efficient and accurate new method for locating the F3 position for prefrontal TMS applications. Brain Stimul. 2009;2:50–4.
We thank Rosa Rios, BS, Marinês Joaquim, BS, and Ivanil Moraes, BS for administrative support.
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Silva, R.d.M.F.d., Brunoni, A.R., Goerigk, S. et al. Efficacy and safety of transcranial direct current stimulation as an add-on treatment for obsessive-compulsive disorder: a randomized, sham-controlled trial. Neuropsychopharmacol. (2021). https://doi.org/10.1038/s41386-020-00928-w