The use of repetitive transcranial magnetic

stimulation for treatment of obsessive-

compulsive disorder: a scoping review
Medard Kofi Adu, Ejemai Eboreime, Adegboyega Oyekunbi Sapara, Andrew James Greenshaw, Pierre Chue and
Vincent Israel Opoku Agyapong
Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada

Abstract
Purpose – This paper aims to explore the relevant literature available regarding the use of repetitive transcranial magnetic stimulation (rTMS) as a
mode of treatment for obsessive-compulsive disorder (OCD); to evaluate the evidence to support the use of rTMS as a treatment option for OCD.
Design/methodology/approach – The authors electronically conducted data search in five research databases (MEDLINE, CINAHL, Psych INFO,
SCOPUS and EMBASE) using all identified keywords and index terms across all the databases to identify empirical studies and randomized controlled
trials. The authors included articles published with randomized control designs, which aimed at the treatment of OCD with rTMS. Only full-text
published articles written in English were reviewed. Review articles on treatment for conditions other than OCD were excluded. The Covidence
software was used to manage and streamline the review.
Findings – Despite the inconsistencies in the published literature, the application of rTMS over the supplementary motor area and the orbitofrontal cortex
has proven to be promising in efficacy and tolerability compared with other target regions such as the prefrontal cortex for the treatment of OCD. Despite
the diversity in terms of the outcomes and clinical variability of the studies under review, rTMS appears to be a promising treatment intervention for OCD.
Research limitations/implications – The authors of this scoping review acknowledge several limitations. First, the search strategy considered only
studies published in English and the results are up to date as the last day of the electronic data search of December 10, 2020. Though every effort
was made to identify all relevant studies for the purposes of this review per the eligibility criteria, the authors still may have missed some relevant
studies, especially those published in other languages.
Originality/value – This review brought to bare the varying literature on the application of rTMS and what is considered gaps in the knowledge in
this area in an attempt to evaluate and provide information on the potential therapeutic effects of rTMS for OCD.
Keywords Post-traumatic stress disorder, Bipolar disorders, Repetitive transcranial magnetic stimulations, Treatment, Obsessive-compulsive disorder
Paper type Literature review

Introduction flexible and, depending on the site and frequency, it can inhibit
or induce local and remote brain activity (Liu et al., 2007).
Transcranial magnetic stimulation (TMS) is a non-invasive
Typical rTMS comprises a train of repetitive pulses with similar
neuromodulatory intervention, which affects neural activity
stimulus intervals (Dhaliwal et al., 2015; Sandrini et al., 2011).
through rapidly alternating magnetic fields. The stimulation
Barker (1985) originally introduced TMS as a safe, and
operates through Faraday’s law of electromagnetic induction,
painless non-invasive means of applying focal brain stimulation,
where the rapidly alternating electric current in the stimulating
coil placed over the scalp generates a magnetic field that moves
across the skull and produces electric currents in the neural © Medard Kofi Adu, Ejemai Eboreime, Adegboyega Oyekunbi Sapara,
tissue beneath (Wagner et al., 2009). This magnetic field has Andrew James Greenshaw, Pierre Chue and Vincent Israel Opoku
the capacity to penetrate the bone of the skull to stimulate Agyapong. Published by Emerald Publishing Limited. This article is
published under the Creative Commons Attribution (CC BY 4.0) licence.
cortical activity. Pulses can be delivered in a repeated manner
Anyone may reproduce, distribute, translate and create derivative works of
to induce long-term changes in neural activity (Dhaliwal et al., this article (for both commercial & non-commercial purposes), subject to full
2015) as an increase or a decrease in cortical excitability attribution to the original publication and authors. The full terms of this
through relatively high (>5 Hz) or low frequency (1 Hz) licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode
stimulation (Rossi et al., 2009; Wassermann et al., 1996).
Support for the project was received from Alberta Health Services and the
Repetitive transcranial magnetic stimulation (rTMS) is very
University of Alberta.

Funding: This study was supported by grants from the Alberta Mental
Health Foundation. The sponsor had no role in the design, execution,
The current issue and full text archive of this journal is available on Emerald
interpretation, preparing the manuscript or the decision to submit the
Insight at: https://www.emerald.com/insight/2036-7465.htm
manuscript for publication.

Conflicts of interest: The authors declare no conflict of interest.

Mental Illness
13/1 (2021) 1–13 Received 20 May 2021
Emerald Publishing Limited [ISSN 2036-7465] Revised 4 June 2021
[DOI 10.1108/MIJ-05-2021-0002] Accepted 4 June 2021

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 Transcranial magnetic stimulation Mental Illness
Medard Kofi Adu et al. Volume 13 · Number 1 · 2021 · 1–13

to stimulate the motor cortex and to assess human central motor section and the different stimulating parameters such as the
pathways (Barker et al., 1985). rTMS has become an integral frequency, design and the potency of stimulations (Lefaucheur,
research tool in psychiatric treatment as method to exert explicit 2008; Lefaucheur, 2012). Many studies including a meta-
effects on a range of measures of brain function (Hallett, 2000; analysis confirm the antidepressant effects of rTMS of the
Rossini and Rossi, 2007). rTMS has been evaluated quite DLFPC (Burt et al., 2002; Couturier, 2005), but there seems
extensively as a therapeutic tool for several psychiatric disorders to be conflicting outcomes in relation to anxiety disorders
and is accepted as a brain-system-based, neuromodulation (Herwig et al., 2007; O’Reardon et al., 2007).
treatment for impacting direct targets involved in the neural Although antidepressants or psychotherapy help the
circuitry of these disorders (Nahas et al., 2001). symptoms of patients with OCD, this condition can be very
A previous review of rTMS studies identified limitations in debilitating and presents with a greater degree of non-response
earlier clinical trials and recommended further research to conventional treatments (Ressler and Mayberg, 2007).
(Daskalakis et al., 2008). Results of more recent studies report Despite the wide use of rTMS for the management of mental
improved rTMS outcomes through higher or accelerated dosing disorders and the continuous interest in research for newer
regimens (Hadley et al., 2011; Holtzheimer et al., 2010), extended treatments for OCD, the therapeutic use of rTMS is still
treatment durations (McDonald et al., 2011), patient centered focused in the domain of depression (Schoenfeldt-Lecuona
stimulation frequencies (Speer et al., 2009) and bilateral et al., 2010), and much less is known and evaluated for its use in
stimulation (Blumberger et al., 2012). Further, they define more the management of OCD.
accurate and advanced neuro-navigational technologies In view of the above considerations, the clinical effectiveness
(Fitzgerald et al., 2009) and more precise techniques for detecting of rTMS should be assessed in relation to its potential to
the dorsolateral prefrontal cortex (DLPFC) (Herbsman et al., provide OCD patients with safe, and lasting improvement in
2009) with newer coil geometries (Levkovitz et al., 2007). With quality of life (Machado et al., 2012; Grant and Booth, 2009).
these advancements, new rTMS studies have reported higher This scoping review aims to identify what we know and to
scores in remission and response, ranging from 30%–35% and consider gaps in our knowledge in this area in an attempt to
40%–55%, respectively (Holtzheimer et al., 2010; Galletly et al., evaluate and provide information on the potential therapeutic
2012; Levkovitz et al., 2009). effects of rTMS for OCD.
Generally, rTMS treatments are comparatively simple and
relatively easy to administer, are non-invasive and are typically Methods
well-tolerated by patients (Pink et al., 2021). A major benefit of
rTMS is its relative safety being devoid of any major adverse We developed an operationalized search strategy, which was
side-effects (Machii et al., 2006). It is a highly cost-effective applied to an electronically conducted data search in five
alternative to other more expensive treatment methods such as research databases (MEDLINE, CINAHL, Psych INFO,
electroconvulsive therapy (Coles et al., 2018). The most SCOPUS and EMBASE) using relevant keywords and index
frequent negative effect noticed by patients is temporary pain in terms across all the databases to identify empirical studies and
the scalp, although with a moderate increase in the intensity of randomized controlled trials (RCTs).
rTMS, it should be normalized (Perera et al., 2016). Vasovagal Key terms included: rTMS, OCD, Post-traumatic stress
syncope may also manifest at the initial stages of the treatment disorder, Bipolar disorders and Treatment. This was a larger
and caution is taken to not avoid having the patient stand up, in search strategy involving results for the use of rTMS for the
addition, earplugs can help reduce the clicking sound treatment of three major mental disorders (OCD, PTSD and
experienced during rTMS administration (Tringali et al., Bipolar Disorders). This paper reports only on and discusses
2012). rTMS was approved in Canada in 2002 and in the USA the results specifically for OCD. Table 1 shows a sample of the
in 2008 (Kennedy et al., 2009; Höflich et al., 1993). In 2015, it search strategy, for Medline.
was also approved by the National Institute for Health and Two independent reviewers (Medard Adu and Ejemai
Care Excellence for treatment-resistant depression in the UK Eboreime) conducted the title and abstract screening, as well as
(Fregni et al., 2005; Hara et al., 2016). the full text screening and came out with relevant articles that
The large literature on superficial brain stimulation for conformed to the objectives of the scoping review. Thematic
mental disorders is based on rTMS for major depressive classifications were done by the first reviewer (MA), with
disorder (Cristancho et al., 2013a). Based on its versatility and decisions analyzed by the second reviewer (EE). Where conflicts
efficacy, rTMS use has now been investigated in other in classification arose, the articles in question were scrutinized
psychiatric conditions including bipolar disorders, psychotic and consensus was reached between the two reviewers.
disorders, anxiety disorders, obsessive-compulsive disorder
(OCD) and post traumatic stress disorders (PTSD) Inclusion and exclusion criteria
(Cristancho et al., 2013b). Evidence-based guidelines for the Inclusion criteria included studies involving a completed RCT
therapeutic use of rTMS (Lefaucheur et al., 2014) drew of rTMS as a treatment intervention for OCD. Open label trials
attention to the analgesic effect of high frequency (HF) rTMS on OCD using rTMS as a treatment intervention were also
of the motor cortex and the antidepressant effect of HF rTMS included. The review only covered full text articles and studies
of the DLFPC. Similar encouraging outcomes have been published in English. Studies involving rTMS as a form of
reported for neuropsychiatric conditions such as schizophrenia treatment for PTSD, Bipolar disorders, OCD with
and motor stroke. It has also been revealed that rTMS is comorbidities or studies involving any other conditions other
capable of regulating cortical plasticity and brain network than OCD, as well as those examining rTMS as a combined
movements. The outcome depends on the selected cortical therapy with pharmacotherapy or any other interventions were

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Medard Kofi Adu et al. Volume 13 · Number 1 · 2021 · 1–13

Table 1 Medline search strategy abstract only, yielding 182 remaining records for full text
screening. In total, 154 studies were excluded in the full text
# Search strategy Results
screening phase, leaving a final pool of 28 studies that were

1 exp stress disorders, post-traumatic/ or (PTSD or 46,596 eligible for inclusion in this scoping review (Figure 1).
((posttraumatic or post traumatic or combat or war or Many of the studies examined rTMS as a stand-alone
trauma ) adj1 (stress or neurosis or neuroses or treatment intervention for OCD with most of them comparing
nightmare )) or ((traumatic or acute) adj (stress the use and efficacy of rTMS to sham treatment. Relevant and
disorder or stress symptom )) or shell shock or detailed methodological information was extracted and
shellshock ).mp summarized from the various studies and presented in Table 2.
2 exp obsessive-compulsive disorder/ or bipolar disorder/ 54,776 We examined the geographical distribution of studies
3 (Bipolar or bi-polar or manic-depress or mania or 102,961 conducted on rTMS treatment for OCD globally, as presented
obsessive-compulsive disorder or OCD).mp in Figure 2. Out of the total of 28 studies included in our
4 1 or 2 or 3 147,991 review, 12 (43%) were conducted in Asia, North America and
5 Transcranial magnetic stimulation/ 11,653 South America had 4 (14%) and 2 (7%) studies, respectively,
6 (repetitive transcranial magnetic stimulation or rTMS). 5,423 Europe had 5 (18%), Africa had 3 (11%) and Australia had 2
mp (7%) studies. This indicates that research on rTMS in OCD is
7 5 or 6 13,372 being conducted across all continents, but the quantity and
8 4 and 7 492 scope vary widely across geographical jurisdictions. Table 2
summarizes the main findings for these included studies.
Study designs vary widely, including 18 RCTs, 4 open-label
excluded. Systematic reviews, meta-analysis and study trials, 4 retrospective analysis, 1 brief report and 1 case report.
protocols and experiments with rTMS that were not designed All these studies sought to evaluate the efficacy and
for treatment for OCD were not included. effectiveness of rTMS for the treatment of OCD. Sample sizes
ranged from 10 to 100 subjects across included studies with a
Results mean sample size of 31.68. The studies were heterogeneous in
terms of features of clinical variability such as the severity of
Through the search strategy and the use of the Covidence OCD symptoms, duration of sickness and rate of resistance to
software, we identified a total of 2,373 studies from the pharmacotherapy. Location of rTMS stimulation, varied
electronic databases searched. The Covidence software among studies, as did treatment duration and stimulus
automatically screened and removed 872 studies as duplicates. intensity. Of the 28 studies included, 19 used 70 mm figure-of-
The remaining items (1,501) were screened against the eight shaped coils because of their ability to induce more focal
eligibility criteria set by the authors based on the title and current compared to circular coils. The remaining studies

Figure 1 Prisma flow diagram summarizing search process and results

3
 Table 2 Summary of studies using rTMS for the treatment of OCD
Targeted Duration Assessment
Author Country of Study No. of brain Targeted of Coil/ rTMS parameters/ Outcome/significant and follow-
(year) origin design participants region symptom Measurement treatment stimulation method improvements up Conclusion Side effects

Sachdev Australia Double-blind, 18 adults Left DLPFC Obsessive YBOCS TWO weeks Focal 8-shaped 70 mm coil, This study did not Weekly Two weeks of rTMS over the Transient
et al. (2007) randomized, symptoms MADRS with 30 trains of 5 s each, at support the efficacy of throughout left DLPFC is ineffective for headache,
sham BDI 10 Hz and 110% MT, with 25- high frequency the study and treatment-resistant OCD localized
controlled STAI-I s inter-train intervals (1,500 Left DLPFC rTMS given after one and scalp pain
followed by stimuli per session) over two weeks six months of
open-label In OCD, as there was no the last
phase improvement in treatment
obsession scores
Kang et al. Republic of A double- 21 patients Right DLPFC Effect of rTMS on YBOCS 10 days Focal 8-shaped 70 mm coil, The study did not show At baseline, The study did not show any Transient
(2009) Korea blind sham- cognitive MADRS with daily sessions for the any clinically meaningful after one and clinically meaningful efficacy headache,
controlled functions first 2 weeks efficacy of sequentially two weeks of of sequentially applied low- localized
investigation Anxiety At 1 Hz and (100% and applied low-frequency stimulation frequency rTMS over a right scalp pain
symptoms 110%) RMT, at 10 min (1,200 rTMS over a right DLPFC and DLPFC and SMA of patients
Obsessive stimuli/d) and SMA of patients with two weeks with OCD
compulsive OCD after the final
Medard Kofi Adu et al.

symptoms session
Mantovani USA This trial 21 Patients Coil was Increases in right HAMD 24, 4-wk double A vacuum cooled 70-mm There was an average of Every There was an average of 25% nil
Transcranial magnetic stimulation

et al. (2010) consisted of with 8 positioned hemisphere MT YBOCS blind and 4- figure-of-eight coil. 25% reduction in the two weeks reduction in the YBOCS
two phases, women over pre- and CGI-S, BDI-II wk open- Stimulation of 1-Hz, 20-min YBOCS compared to a and self- compared to a 12% reduction
namely, 4-wk SMA normalization of HAMA-14 label train at 100% MT, once a 12% reduction in those rating forms in those receiving sham. For
double blind baseline day, 5 d/wk., for 4 wk. (in receiving sham. For the 4 filled at the the 4 wks. and for the 8 wks.
and 4-wk hemispheric Phase 1) to 8 wk. (in Phase 2 wk. and for the 8 wks. end of every 28.2 1 5.8 to 14.5 1 3.6
open-label asymmetry of 28.2 1 5.8 to 14.51 week
cortical 3.6
excitability
Sachdev Australia Single-blind, 12 patients Right DLPFC To compare the YBOCS, Two weeks Active RDLPFC10 sessions, Global reduction in At baseline, Significant improvement in Nil
et al. (2001) randomized, And L DLPFC efficacy of both MADRS, RDLPFC, YBOCS score _ 40% from two weeks, relieving OC symptoms,
non sham RDLPFC and BDI, STAI-I 10 Hz, 110% MT, 15 min, 30 baseline to wk. 2 and wk. six weeks reducing clinical severity or

4
controlled LDLPFC trains, 5 s on, 25 s off, fi g-8 6 improving treatment
coil response; for both LDLPFC and
Active LDLPFC LDLPFC
idem, LDLPFC
Gomes et al. Brazil Randomized 22 right- Coil To assess the HAMD YBOCS Two weeks Focal 8-shaped,70-mm coil No significant reduction baseline, No significant reduction in Y- Mild
(2012) double-blind handed positioned efficacy of low- with 1-Hz, 20-min trains in Y-BOCS for baseline after rTMS BOCS for baseline but at 2 headache,
trial outpatients over pre- frequency rTMS (1,200 pulses/day) at 100% but at 2 wks, there was a treatment wks, there was a significant scalp
(women: 13; SMA to the SMA in MT. once per day, five days significant reduction for and 14 weeks reduction for the active group. discomfort,
men: 9), age treatment- per week, for two weeks the active group. No after the end No significant difference cervical pain
18 to resistant OCD significant difference of rTMS between groups for anxiety
60 years and further between groups for treatment and depression symptoms
examine the anxiety and depression
duration of a symptoms
significant clinical
effect
Ma et al. China Double blind 46 patients Bilateral Obsessive, HAMD YBOCS Two weeks A 9 cm circular coil. 80% MT. The result showed that Baseline, aEEG-guided TMS may be an Mild
(2014) sham- completed DLPFC depressive and HRSD, CGI Daily for 5 sessions a wk. for there were changes in after the 5th effective treatment for OCD headache
controlled after 2 anxiety 2 wks. with 20 min. each min scores of YBOCS, HRSD and 10th and related anxiety
study treatments9 symptoms in OCD included 4 s of active and HAMA over time sessions of
inpatients patients stimulation and 56 s of rest following both a-TMS treatment
Mental Illness

and 37 and sham treatments and 1 wk.

outpatients. after
Aged completing
between 18 the entire
and 60 treatment
Volume 13 · Number 1 · 2021 · 1–13

Nauczyciel France A 19 patients Right Reduction in YBOCS Two per day DB-80 butterfly double-cone At day 7, a significant Assessments Results of this preliminary Nil
et al. (2014) randomized, orbitofrontal clinical MADRS for coil with 120% MT, 1 Hz, decrease in Y-BOCS were study suggest that the OFC is
double-blind, cortex (OFC) symptoms, as CGI one week 1,200 pulses per session over scores, was observed performed a possible neuroanatomical
crossover measured on the the right OFC. 10 sessions, compared with baseline, before and target for OCD treatment,
design Y-BOCS two per day over one week at day 35, no difference after each especially rTMS
was observed in this sequence, as
decrease from the Y- well as
(continued)
 Table 2
Targeted Duration Assessment
Author Country of Study No. of brain Targeted of Coil/ rTMS parameters/ Outcome/significant and follow-
(year) origin design participants region symptom Measurement treatment stimulation method improvements up Conclusion Side effects

BOCS baseline between one month

active and sham after the end
stimulations of the last
session
Donse et al. The An open-label 22 patients Bilateral Role of sleep Y-BOCS, BDI, 10 sessions Using a figure-eight-coil with Study confirms that some Baseline and Findings suggest that CRSD Nil
(2017) Netherlands design SMA and disturbances in PSQI a frequency of 1 Hz, 1,000 sleep disturbances are after the 10 variables can predict
right OCD and its pulses per session, 110% more prevalent in OCD sessions treatment non-response to
dorsolateral predictive value MT.10 sessions over the SMA patients than healthy rTMS in a sample of
prefrontal for rTMS subjects treatment-resistant OCD
cortex treatment patients
(DLPFC) nonresponse
Lee et al. Republic of An open– 9 adults SMA Obsession and BAI Y-BOCS, Five days a 70 mm, 8 shaped coils.1 Hz, Symptoms in treatment- Baseline, Findings suggest that 1 Hz Mild
(2017) Korea label pilot aged 18 or compulsion BDI week for 20 min train (1,200 stimuli/ resistant OCD patients after rTMS over the SMA can be an headache and
study older symptoms of CGI-GI four weeks day) at 90–100% RMT, once significantly decreased two weeks efficient and safe add-on mild dizziness
OCD SCL-90-R a day, 5 days a week, for after 20 sessions of 1 Hz and after therapeutic method in
Medard Kofi Adu et al.

4 weeks, in 20 sessions rTMS over the SMA four weeks of treatment-resistant patients
rTMS with OCD
treatment
Transcranial magnetic stimulation

Kumar et al. India A 25 patients LF-rTMS over Symptoms of Y-BOCS Four weeks 1-Hz at 110% TM 5-s train Significant reduction in Baseline and There is a role of applying LF- Localized
(2018) retrospective left-OFC OCD, factors duration, intertrain interval of the mean YBOCS scores one month rTMS over Lt-OFC as an scalp
open study affecting 10 s and 240 trains per after completion of 20 after the augmentation strategy in discomfort,
response to rTMS session. 20 sessions 5 days sessions of rTMS from treatment ameliorating clinical headache
per wk. for 4 wks baseline, whereas no symptoms among patients
further significant change with medication-refractory
in YBOCS scores OCD
one month after
completion of rTMS
treatment

5
Arumugham India A randomized 40 patients Low- Reduction in HAM-D YBOCS Three weeks Fluid cooled figure-of-eight Low-frequency rTMS over 0, 1, 2, 3 and Low-frequency rTMS over pre- Headache,
et al. (2018) controlled with 36 frequency clinical CGI-S coil (MCF-B70 butterfly coil. pre-SMA was not 12 weeks SMA may not be effective as sedation,
trial patients in rTMS over symptoms, as HAM-A 1,200 stimuli per day at 1 Hz superior to placebo in using YBOCS an augmenting agent in concentration
analysis-19 pre-SMA measured on the in 4 trains of 300 s, with reducing symptoms of partial/poor responders to difficulties
received Y-BOCS intertrain interval of 2 min, at OCD in partial/poor SRIs and failing
active rTMS 100% MT responders to SSRIs memory
and 17
received
sham
Singh et al. India Retrospective 79 patients Left-OFC and Reduction in YBOCS Four weeks 70-mm figure of-eight air-film Significant reduction in First day This study provided evidence Nil
(2019) review and over bilateral clinical coil.1-Hz at 110% RMT, 5-s the mean YBOCS score before the for overall effectiveness of
analysis of SMA symptoms, as train duration, intertrain after 20 sessions of rTMS, beginning of adjunctive 1-Hz rTMS
records measured on the interval of 10 s and 240 trains as compared with rTMS session treatment over either SMA or
Y-BOCS per session. Each session baseline YBOCS score and after the OFC in patients with
consisted of 1,200 pulses/d completion of medication-refractory OCD
delivered in 3,590 s. A total of 20th rTMS
20 sessions of rTMS 5 days session
per week for 4 weeks
Mansur Brazil Parallel, 30 patients R-DLPFC Scores on the HAM-D YBOCS Six weeks Figure-of-eight coil 10 Hz and rTMS, over rDLPFC, was Baseline; Active rTMS over the rDLPFC Mild
et al. (2011) double-blind 18– 65 years YBOCS and CGI-I CGI-S at 110% MT. 30 sessions (1/ not found to be superior after 2 and 6 does not appear to be superior headache,
randomized scale HAM-A to sham rTMS in relieving wk. to sham rTMS in relieving OC scalp
Mental Illness

d, 5 d/wk.).40 trains – 5 s per

trial CGI-I train, with a 25-s intertrain OC symptoms, reducing treatment; symptoms, reducing clinical discomfort,
interval. Total 60,000 pulses clinical severity or and after 2 severity or improving cervical pain,
improving treatment and 6 wk. treatment response mood swings
response follow-up
Volume 13 · Number 1 · 2021 · 1–13

Rostami Asia Retrospective 65 patients DLPFC or Y-BOCS Y-BOCS Three days 70-mm figure-of-eight-coil Significant reduction in Baseline and An overall significant Headache and
et al. (2020) study SMA BDI-II per week (air film coil). 120% of AMT OCD symptoms and after the 20th reduction in OCD symptoms dizziness
CGI-I for 1 Hz, for 30 min, total of anxiety/depressive states session of and anxiety/depressive states
BAI seven weeks 1,800 pulses per session. were observed after 20 rTMS were observed after 20
once a day, 3 days per week sessions of rTMS sessions of rTMS
for 7 weeks, in 20 sessions
(36,000 pulses)
(continued)
 Table 2
Targeted Duration Assessment
Author Country of Study No. of brain Targeted of Coil/ rTMS parameters/ Outcome/significant and follow-
(year) origin design participants region symptom Measurement treatment stimulation method improvements up Conclusion Side effects

Ruffini et al. Italy A randomized 23 patients Left OFC OCD symptoms, YBOCS, HDRS, Five 70-mm 8-shaped coil.10 min Significant improvement Baseline, Low-frequency rTMS of the Nil
(2009) controlled 18–75 years mood and HARS sessions per 1 Hz left-sided subthreshold in OCD symptoms in OCD after 15 rTMS left OFC produced significant
investigation anxiety week for rTMS 80% MT. 15 sessions (1 patients with benefits sessions and but time-limited improvement
three weeks per day, 5 per week for lasting up to 10 weeks every 2 weeks in OCD patients compared to
3 weeks) after the end of rTMS for 3 months sham treatment
treatment after the end
of rTMS
Mantovani USA Open-label 10 right SMA YBOCS, CGI YBOCS, 10 days 70-mm figure-of-eight coil, Significant improvement Baseline and Slow rTMS to SMA resulted in Nil
et al. (2006) pilot study handed YGTSS, CGI, SMA for 10 daily sessions at in OCD and TS symptoms after 1 and 2 a significant clinical
outpatients HARS HDRS, 1 Hz, 100% MT, 1,200 with benefits lasting up wk. of improvement and a
SAD, BDI SCL- stimuli/day to three months. stimulation normalization of the right
90 Improvements in and 1 and hemisphere hyperexcitability,
depression and anxiety 3 months thereby restoring hemispheric
were also seen follow up on symmetry in motor threshold
CGI
Medard Kofi Adu et al.

Praško et al. Czech A 33 right- Left DPLFC General CGI, HAMA, Y- Two weeks Air cooled, figure-of-eight 70- Low frequency rTMS of Week 0, week Low frequency rTMS Nil
(2006) Republic randomized, handed psychopathology BOCS BAI mm coil.1 Hz at 110% MT. 10 left prefrontal cortex had 2 and week 4 administered over the left
double blind, patients sessions. 30 min (5 per week no impact on the DPLFC during 10 daily
Transcranial magnetic stimulation

sham for 2 weeks. 1,800 pulses per symptomatology in the sessions did not differ from
controlled session patients suffering with sham rTMS in facilitating the
study SSRIs resistant OCD effect of serotonin reuptake
inhibitors in OCD patients
Elbeh et al. Egypt Double blind 45 patients Right DLPFC Effects of 1 Hz Y-BOCS, HAM- Two weeks 70 mm figure-of-eight coil 1 Hz rTMS over the right Before and There was a significantly Transient
(2016) randomized and 10 Hz on A, CGI-S 1 Hz-rTMS at 100% RMT, 4 DLPFC has medium term after the last larger percentage change in headache
clinical trial scales trains, each of 500 pulses effect on obsessive- treatment GCI-S in the 1 Hz group versus
with a 40 s and 10 Hz rTMS at compulsive symptoms session and either 10 Hz or sham. We
100% RMT applied in 10 and anxiety three months conclude that 1 Hz-rTMS,
trains of 200 pulses, with later targeting right DLPFC is a

6
20 s. total of 2,000 pluses promising tool for treatment
(5 days/week) 2 weeks of OCD
Pelissolo France Sham- 40 patients Pre-SMA Efficacy of 1-Hz Y-BOCS, CGI-S Four weeks 70-mm figure-of-eight Low-frequency rTMS Baseline and Low-frequency rTMS applied Headache
et al. (2016) controlled rTMS over pre- coil.1 Hz, 26-min sessions delivered to pre-SMA four weeks to the pre-SMA seems
trial SMA (four 5-min trains interval of during four weeks had no and follow-up ineffective for the treatment of
2 min, 1,500 pulses/d), at better effects on drug (week 12) OCD patients at least in severe
100% of RMT refractory OCD patients and drug-refractory cases such
than sham stimulation as those included in this study
Seo et al. Korea A randomized 27 patients Right DLPFC OCD symptoms, YBOCS, CGI-S Three weeks TAMAS stimulator with a LF rTMS over the right Baseline and LF rTMS over the right DLPFC Localized
(2016) controlled mood and HAMD figure-eight coil.1 Hz, 20-min DLPFC appeared to be every week appeared to be superior to scalp pain,
trial anxiety trains (1,200 pulses/ day) at superior to sham rTMS during the sham rTMS for relieving OCD headache
symptoms 100% MT once per day 5 days for relieving OCD treatment symptoms and depression in
per week. for 3 weeks symptoms and period patients with treatment-
depression in patients resistant OCD
with treatment-resistant
OCD
Talaei et al. Iran A case report 40-year-old SMA OCD symptoms, Y-BOCS 10 sessions 10 sessions with 110%, 1 Hz Significant decrease in Before the Significant decrease in Nil
(2009) female mood and and of 30 min per day (a total compulsive behaviors first rTMS compulsive behaviors and
anxiety of 1,200 pulses per day session and obsessive thoughts
symptoms after every
session
Mental Illness

Badawy Egypt Randomized 60 patients LDLPFC Mixed OCD Y-BOCS 15 sessions High frequency r-TMS While r-TMS was not Before the While r-TMS was not effective Nil
et al. (2010) control trial symptoms and (20 Hz).5 sessions per week effective as a single first r-TMS as a single treatment for OCD
compulsive for 3 weeks. high frequency r- treatment for OCD session and patients, it was effective as
symptoms only TMS (20 Hz) patients, it was effective after add-on treatment for OCD
Volume 13 · Number 1 · 2021 · 1–13

as add-on treatment for completion of patients

OCD patients the 15
sessions
Elmedany Egypt Randomized 20 patients Left OCD symptoms Y-BOCS 20 Hz 2 s for Figure-of-eight or butterfly- OCD patients have better Before the OCD patients after r-TMS has Nil
et al. (2014) control trial (9 men and 1 prefrontal CGI 20 min in 8 shape coil. 5 cm forward and response to r TMS for first r-TMS a better response especially
female) area of the sessions 2 cm to the below the center obsession symptoms session and those accompanied with
brain every 48 h of the head. MT 90%; 20 Hz 2 more than compulsions after pharmacological treatment
(continued)
 Table 2
Targeted Duration Assessment
Author Country of Study No. of brain Targeted of Coil/ rTMS parameters/ Outcome/significant and follow-
(year) origin design participants region symptom Measurement treatment stimulation method improvements up Conclusion Side effects

s for 20 min in 8 sessions especially those on completion of

every 48 h pharmacological the last
treatment
Greenberg USA Brief report 12 patients Right lateral Obsessive Y-BOCS 20 Hz/2 s Cadwell High Speed Magnetic Results suggest that right Baseline and Results suggest that right Nil
et al. (1997) prefrontal, a compulsive HARS per min for Stimulator and a figure-eight- prefrontal rTMS might post- prefrontal repetitive
left lateral symptoms 20 min shaped coil. 80%MT, 20 Hz/ affect prefrontal stimulation transcranial magnetic
prefrontal 2 s per min for 20 min mechanisms involved in stimulation might affect
and OCD prefrontal mechanisms
midoccipital involved in OCD
site on
separate
days,
Medard Kofi Adu et al.

randomized
Hegde et al. India Retrospective 17 patients Pre-SMA OCD symptoms Y-BOCS Three weeks 70-mm figure-of-eight coil 1- Only 1 patient met the Baseline and Low-frequency rTMS over the Mild
(2016) analysis study CGI-S Hz at 100% MT over the pre- criteria for response after one month pre-SMA may not be effective headache
Transcranial magnetic stimulation

SMA 20 min, in 4 trains of one month of treatment after in treatment refractory OCD
300 s (1,200 pulses per sitting initiation initiation
Carmi et al. Israel Prospective 100 patients Dorsal mPFC Safety, YBOCS, CGI-S Six weeks H-shaped coil design, 100% Significant differences Baseline and I High-frequency dTMS over the One patient
(2019) multicenter tolerability and HAMD RMT. 20 Hz dTMS 2-s pulse between the groups were month follow mPFC and anterior cingulate had suicidal
randomized efficacy of dTMS CGI-I trains and 20-s intertrain maintained at follow-up up cortex significantly improved thoughts
double-Blind in OCD intervals, for a total of 50 OCD symptoms and may be
placebo- trains and 2,000 pulses per considered as a potential
controlled session intervention for patients who
trial do not respond adequately to
pharmacological and

7
psychological interventions
Haghighi Iran Randomized, 21 patients L-DLPFC OCD symptoms Y-BOCS, CGI Four weeks 70 mm double air film coil. Both self- and expert- Baseline, The pattern of results from Nil
et al. (2015) single-blind, 100% RMT at 20 Hz, in 750 reported symptom after two and this single-blind, sham- and
sham, total pulse. 25 min per cortex severity reduced in the after four cross-over design suggests
controlled site, totaling 50 min for a rTMS condition as weeks of that rTMS is a successful
clinical trial session compared to the sham treatment intervention for patients
with cross- condition. Full- and suffering from treatment-
over design partial responses were resistant OCD
observed in the rTMS-
condition, but not in the
sham-condition
Modirrousta Canada Open-label 10 patients mPFC Effect of low- Y-BOCS Two weeks Double-cone coil at 110% Significant reduction in Baseline, Results suggest the use of low Electric
et al. (2015) study frequency deep RMT 1 Hz, 150 pulses (overall OCD symptoms after 10 frequency deep rTMS as a shocking
rTMS over the 1,200 pulses in one session) sessions promising and robust sensation and
mPFC of patients for 10 sessions same day as intervention in OCD symptom insomnia
with OCD last rTMS reduction
treatment,
1 month after
last session

Notes: MT = motor threshold, SMA = supplementary motor area Y-BOCS = Yale–Brown Obsessive-Compulsive Scale; Ham-D–24 = Hamilton Rating Scale for Depression–24-item; BDI–II, DLPFC = dorsal
Mental Illness

lateral prefrontal cortex, OFC = orbitofrontal cortex, RMT = resting motor threshold, CGI-I = clinical global impression. HAMA = Hamilton Anxiety Rating Scale, HRSD = Hamilton Rating Scale for Depression,
YMRS = Young Mania Rating Scale, GAF = global assessment of functioning, MCCB = MATRICS Consensus Cognitive Battery. QIDS = quick inventory of depressive symptomatology, CAPS = clinician
administered PTSD scale, BNCE = brief neurobehavioral cognitive examination, STAI = state trait anxiety inventory, SC-Q = self-administered comorbidity questionnaire, SCID = structured clinical interview
Volume 13 · Number 1 · 2021 · 1–13

for DSM-IV, IPF = inventory of psychosocial functioning, BRMAS = Bech-Rafaelsen mania scale, CRSD = circadian rhythm sleep disorder, SCL-90-R = Symptom Checklist-90-Revised, mPFC = medial
prefrontal cortex
 Transcranial magnetic stimulation Mental Illness
Medard Kofi Adu et al. Volume 13 · Number 1 · 2021 · 1–13

Figure 2 Number of studies extracted from the various continents (n = identified in this review is its versatility, which allows for the
28) development and adaption of protocols addressing similar
symptoms from different conditions with potentially positive
Connental distribuon of data on rTMS for OCD outcomes.

Targeted brain regions of repetitive transcranial

EUROPE NORTH AMERICA
14%
magnetic stimulation
18%
The pathophysiology of OCD according to structural and
functional neuroimaging studies is linked with the dysfunction
SOUTH AMERICA of the orbitofronto-striato-pallido-thalamic circuitry, which
7%
AUSTRALIA includes the orbitofrontal cortex (OFC), Dorsolateral
7% prefrontal cortex (DLPFC) and the medial PFC, as well as the
thalamus (Saxena and Rauch, 2000; Van Den Heuvel et al.,
2005). Modulation of this circuitry by neurosurgical
AFRICA
11% mechanisms and by means of deep brain stimulation has
proven to be effective in reducing symptoms of OCD (Mallet
et al., 2008). Bearing in mind the possibility of rTMS in
ASIA modulating cortical and subcortical structures of the brain, the
43% possible therapeutic effects of rTMS have been extensively
studied and evaluated in literature in the quest to normalizing
hyper- or hypoactive brain regions by targeting dysfunctional
NORTH AMERICA SOUTH AMERICA ASIA AFRICA AUSTRALIA EUROPE
cortico- subcortical circuits in people with OCD.
For many of the studies extracted, the locus of rTMS
variously used the 9 cm circular coil, DB-80 butterfly double- stimulation was at either the left-DLPFC or the right-DLPFC
cone coil and the H-shaped coil design. Duration of treatment and with high or low frequency rTMS. The overall accepted
varied across studies, from two weeks to seven weeks. In total, rationale is that the DLPFC could be a possible starting point
19 studies applied rTMS with a low frequency and eight for the induction of remote stimulation in the cortico-
applied HF ranging from 10 Hz to 20 Hz, the one remaining subcortical circuits connected. For most of the trials, the left-
study of the 28 compared effects of low and HF treatment dorsolateral prefrontal cortex (LDLPFC) and right-
protocols. dorsolateral prefrontal cortex (RDLPFC) were stimulated with
In total, 19 studies (68%) reported significant positive the “5 cm method” where the figure-of-eight coil was centered
outcomes and the other 9 studies reported no significant on a point at 5 cm rostral to and in the same sagittal line as the
symptom improvement. In each of the included studies, rTMS optimal area for activating the right or left abductor pollicis
application was reported as well-tolerated with no significant brevis muscles during motor threshold (MT) assessment
side-effects, although there were a few reports of mild side- (Sachdev et al., 2007; Praško et al., 2006; Greenberg et al.,
effects such as mild headache, dizziness and scalp pain, across 1997). As prefrontal mechanisms are implicated in OCD,
the studies. Greenberg et al. (1997) undertook a non-sham-controlled,
single-blind rTMS study on the evidence of PFC
Discussion hypermetabolism and hyperperfusion in untreated OCD
patients. The preliminary results suggest that DLPFC rTMS
The 28 studies under review suggest that rTMS has potential as had modest, lateralized effects on compulsions but not
a safe and clinically efficacious treatment intervention for obsessions.
OCD. Despite the diverse outcome measures included in this From the data extracted, another brain region studied for the
selection of studies, there were some consistent significant administration of rTMS is the OFC. As indicated earlier, the
OCD symptom improvements. OFC performs a very important function in the pathophysiology
Many factors may have accounted for the varying of OCD and because obsessions and compulsions are deemed to
effectiveness of the application of rTMS across the studies and be mediated at least in part by the hyperactivity in the
major domains of outcomes. For instance, rTMS treatment orbitofrontal-subcortical circuits and the increase in functional
protocols and stimulation parameters vary greatly across activity in the OFC. Inspired by the fact that OFC rTMS may
studies, with poorly defined intervention protocols. Another seem OCD-specific, a randomized, single blind sham-controlled
factor is that different measuring tools are used to evaluate study was conducted by Ruffini et al. (2009). The researchers
similar outcomes across studies, making a comparative evaluated the efficacy of LF-rTMS over the left OFC with a low
evaluation of results difficult. It also makes it difficult to frequency (1 Hz) rTMS at 80% RMT for 3 weeks. There was a
understand which rTMS parameters lead to the most significant reduction in Yele-Brown obsessive compulsive scale
significant outcomes and treatment response. (YBOCS) scores for the active group after the 3rd and 10th weeks
However, due to the diverse nature and presentation of compared to sham treatment.
mental conditions, it may seem unrealistic to think uniquely of The supplementary motor area (SMA) is one of the most
an optimal or even a standardized rTMS protocol that will recent brain targets used for the application of rTMS and
work across studies of the different conditions even if they evidence suggests that the motor and premotor cortex are
target similar symptoms. One important aspect of rTMS, as hyperexcitable in OCD. An open-label trial conducted by

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Medard Kofi Adu et al. Volume 13 · Number 1 · 2021 · 1–13

Mantovani et al. (2006) sought to evaluate whether low- In contrast to the contradictory results from other studies,
frequency rTMS to the SMA could normalize overactive motor most of the trials that presented with major clinically
cortical regions and thereby improve symptoms of patients with insignificant improvements in OCD symptoms were the studies
OCD. There was clinical improvement at the end of the first with the targeted brain regions over the SMA with low frequency
week of the treatment with rTMS and by the second week, rTMS (Donse et al., 2017; Lee et al., 2017; Arumugham et al.,
there was a statistically significant improvement in the 2018; Singh et al., 2019; Pelissolo et al., 2016; Talaei et al., 2009;
reductions seen in Yele-Brown obsessive compulsive scale Hegde et al., 2016; Mantovani et al., 2010; Gomes et al., 2012;
(YBOCS), Clinical Global Impression, Beck depression Rostami et al., 2020) and also the left OFC with LF-rTMS
inventory (BDI), Hamilton depression rating scale (HDRS), (Kumar et al., 2018; Singh et al., 2019; Ruffini et al., 2009).
Hamilton anxiety rating scale (HARS) and Symptom These studies suggest that rTMS had a specific and significant
Checklist-90. Following the publication of this study, many of clinically effective influence on OCD symptoms: specifically in
the most recent trials on rTMS application for the treatment of relation to the SMA stimulation site.
drug resistant OCD focused on the SMA (Lee et al., 2017; Poor study outcomes as witnessed in most of the studies could
Arumugham et al., 2018; Singh et al., 2019; Pelissolo et al., be partly attributed to differences in stimulation parameters,
2016; Talaei et al., 2009; Hegde et al., 2016; Mantovani et al., shorter treatment durations (as many used two weeks), the levels of
2010). Results suggest that 1 Hz rTMS over the SMA could be frequencies used and, in some cases, the use of the circular coil,
an efficient and safe add-on therapeutic method in treatment- which typically induces less focal current compared to the figure-
resistant patients with OCD. of-eight shape coil. Differences may also be attributed to the choice
of whether left or right prefrontal cortices of targets for stimulations
Treatment modality and stimulation frequencies and the severity of the drug resistance of the subjects used for the
In regard to differences in low and HFs of rTMS, results from the purposes of the studies.
extracted studies suggest that, administration of HF (10 Hz)
rTMS at either 100% or 110% MT over the RDLPFC did not Other factors affecting therapeutic outcomes
differ from sham rTMS in terms of efficacy in relieving symptoms, Many factors may have accounted for the varied effectiveness of the
reducing clinical severity or improving responses in treatment- application of rTMS across the studies and major domains of
outcomes. For instance, rTMS treatment protocols and stimulation
resistant OCD (Mansur et al., 2011; Elbeh et al., 2016). By
parameters vary greatly across studies, with poorly defined
contrast, another study indicated that low frequency (1 HZ)
intervention protocols. Another factor is the different measurement
rTMS delivered to the RDLPFC appeared to be superior to sham
tools used for the evaluation of similar outcomes across studies, and
rTMS for relieving OCD symptoms and depression, in patients
therefore, making comparison and evaluation of results difficult.
with treatment-resistant OCD. Based on the results from the
These inconsistencies also make it difficult to understand which
selected studies in this review, there is no evidence for a statistically
rTMS parameters lead to the most significant outcomes and
significant difference between low or HF rTMS over RDLPFC
treatment responses. It remains possible that positive outcomes may
and LDLPFC for the treatment of OCD.
also be attributed partially to the therapeutic contributions of
The different study designs did not contribute to any
concurrent medications taken by the subjects although most of the
differences in the outcomes for treatment between the sham
subjects have been on these medications for a long time without
and active subjects. A study conducted (Sachdev et al., 2007;
yielding improvements in their OCD symptoms.
Praško et al., 2006) using the double-blind, randomized, sham- Additionally, the varied clinical significance and effectiveness of
controlled trial with the application of low or HF rTMS over rTMS across studies can also be partly attributed to factors such
the left or right PFC presented with a significant reduction in as, variations in coil type and coil positions, the different cortical
YBOCS scores in both sham and active subjects with no targets and the variations in motor thresholds. In the case of the
significant statistical difference in the two groups at the end of application of rTMS for the treatment of OCD, a majority of the
the treatment intervention. The results also failed to depict any studies applied rTMS to normalize frontal dysfunction associated
meaningful therapeutic efficacy in treatment non-responder with OCD symptoms, choosing to stimulate the left/right DLPFC
OCD patients from either of the groups (Kang et al., 2009). or the SMA. For example, in the case of the cortical target, the
Sachdev et al. (2001) compared effects of active HF-RDLPFC SMA was consistently used to relieve subjects of their OCD
rTMS to active HF-LDLPFC rTMS. The evaluation yielded symptoms with consistent and clinically significant treatment
notable improvement in the symptoms of the OCD in study responses noted. Thus, from the data gathered with respect to
subjects. Notwithstanding the significant improvement in YBOCS rTMS in OCD, it seems that the SMA may be a promising target
scores for the two arms of the study, it is possible that the positive region for the application of rTMS to treat the symptoms of OCD
results were because of the smaller sample size (N = 12) and also in contrast to either left or right DLPFC.
the absence of a control group. These same researchers six years Furthermore, an important factor noticed is the evaluation of
later conducted a similar study that confirmed the assertion of a the longevity and time course effects of rTMS. The majority of
smaller sample size and the lack of a sham control. Sachdev et al. studies reviewed evaluated the treatment outcomes of the
(2007) in their study with a larger sample size (N = 18) revealed various interventions immediately after the last session of
that the active and sham arms of the study did not show any rTMS with a few months of follow-up. Considering the
difference in the reduction in OCD symptoms after the treatment. chronic, debilitating and high prevalent nature of mental
These conflicting results indicate that prefrontal high or low conditions, evaluating the long-term therapeutic effects of
frequency rTMS may probably not be effective in the treatment of rTMS intervention is of great importance. Therefore, it would
OCD symptoms. be of high clinical significance and research value to estimate

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Medard Kofi Adu et al. Volume 13 · Number 1 · 2021 · 1–13

the sustainability of treatment effects, and specifically, World Journal of Biological Psychiatry, Vol. 13 No. 6,
maintenance strategies following response or remission with pp. 423-435.
rTMS. Burt, T., Lisanby, S.H. and Sackeim, H.A. (2002),
“Neuropsychiatric applications of transcranial magnetic
Limitations stimulation: a Meta analysis”, International Journal of
The authors of this scoping review acknowledge several Neuropsychopharmacology, Vol. 5 No. 1, pp. 73-103.
limitations. First, our search strategy considered only studies Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger,
published in English and the results are up to date as the last D.M., Daskalakis, J. and Zohar, J. (2019), “Efficacy and safety
day of the electronic data search of December 10, 2020. of deep transcranial magnetic stimulation for Obsessive-
Though every effort was made to identify all relevant studies for Compulsive disorder: a prospective multicenter randomized
the purposes of this review per our eligibility criteria, we still Double-Blind Placebo-Controlled trial”, American Journal of
may have missed some relevant studies, especially those Psychiatry, Vol. 176 No. 11, pp. 931-938.
published in other languages. Coles, A.S., Kozak, K. and George, T.P. (2018), “A review of
brain stimulation methods to treat substance use disorders”,
The American Journal on Addictions, Vol. 27 No. 2, pp. 71-91.
Conclusion
Couturier, J.L. (2005), “Efficacy of rapid-rate repetitive
Many of the studies included in this scoping review presented transcranial magnetic stimulation in the treatment of
with conflicting and inconsistent outcomes on the efficacy and depression: a systematic review and Meta-analysis”, Journal
utilization of rTMS as a treatment intervention for OCD. This of Psychiatry & Neuroscience: Jpn, Vol. 30 No. 2, p. 83.
makes it difficult to make definitive conclusions on the clinical Cristancho, M.A., Cristancho, P. and O’reardon, J.P. (2013a),
usefulness and the appropriate technique for rTMS treatment Brain Stimulation: Chapter 34. Other Therapeutic Psychiatric Uses of
interventions for OCD. Larger sample sizes for sufficiently Superficial Brain Stimulation, Vol. 116. Elsevier Inc. Chapters.
powered and preferably multi-centered sham-controlled trials Cristancho, M.A., Cristancho, P. and O’reardon, J.P. (2013b),
with the appropriate coil and stimulation parameters, well- “Other therapeutic psychiatric uses of superficial brain
defined stimulation targets and a longer treatment duration stimulation”, in Handbook of Clinical Neurology, Elsevier.
would be required to bring clarity to the therapeutic effect of pp. 415-422.
rTMS in the treatment of resistant OCD. Daskalakis, Z.J., Levinson, A.J. and Fitzgerald, P.B. (2008),
Despite the inconsistencies in the published literature, the “Repetitive transcranial magnetic stimulation for major
application of rTMS over the SMA and the OFC has proven to depressive disorder: a review”, The Canadian Journal of
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target regions such as PFC for the treatment of OCD. Despite Dhaliwal, S.K., Meek, B.P. and Modirrousta, M.M. (2015),
the diversity in terms of the outcomes and clinical variability “Non-invasive brain stimulation for the treatment of
of the studies under review, rTMS appears to be a promising symptoms following traumatic brain injury”, Frontiers in
treatment intervention for OCD. Psychiatry, Vol. 6, p. 119.
Donse, L., Sack, A.T., Fitzgerald, P.B. and Arns, M. (2017),
“Sleep disturbances in obsessive-compulsive disorder:
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Obsessive-Compulsive disorder”, The Journal of Ect, Vol. 35 Corresponding author
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