- Email: [email protected]
Repetitive transcranial magnetic stimulation on supplementary motor area in the treatment of refractory obsessive-compulsive disorder: open-label pilot study
P.4.d. Anxiety disorders, OCD, stress related disorders and treatment − Treatment (clinical)
P.4.d. Anxiety disorders, OCD, stress related disorders and treatment − Treatment (clinical) P.4.d.001 Evaluation of benzodiazepines use for sleep disturbances in post-traumatic stress disorder A. Oumaya1 ° , M.W. Krir1 , C. Ben Cheikh1 , H. Kefi1 , S. Edhif1 1 Military Hospital of Tunis, psychiatric department, Tunis, Tunisian Republic Introduction: Sleep disturbances, including insomnia and nightmares, are among the most common and chronic symptoms of post-traumatic stress disorder (PTSD). Considered as a main component of the disorder, these disturbances would be closely linked to its onset and maintenance [1]. They are also associated with impaired daytime functioning [2], adverse psychological effects [3], neurocognitive alterations [4] and even neuroendocrine abnormalities [5]. Therefore, effective treatment of these nighttime symptoms of PTSD is of critical importance and can contribute to improving the overall functioning and well-being of patients. Benzodiazepines are commonly used to achieve this goal, however, these drugs are not without risks and side effects and very few studies have examined their efficacy in this indication. Aim of the study: This study aimed to evaluate the use of benzodiazepines in the treatment of sleep disturbances in PTSD. Methods: This was a prospective study, conducted from April 1st, 2015 to June 30, 2015. Patients were recruited among those consulting the outpatient department of psychiatry at the military hospital of Tunis and having a diagnosis of PTSD according to the DSM-5 criteria. The variables studied were sociodemographic characteristics, duration and treatment of PTSD, and benzodiazepines use (with type, dose and duration of treatment for patients under benzodiazepines). Patients were also evaluated using the following scales: PTSD Check-List for DSM-5 (PCL-5), Hospital Anxiety and Depression Scale (HADS), Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI). Results: The study population consisted of 85 patients. All of them were male with a mean age of 27.73±0.41 years. The mean duration of PTSD was 13.85±0.92 months and its management (regardless of sleep distrubances) consisted of antidepressants alone in 79.76% of cases, cognitive behavioral therapy alone in 7.14% of cases and EMDR alone in 5.95% of cases. Fifty-one patients (60%) were having benzodiazepines (clorazepate in 20% of cases; prazepam in 16.5% of cases and lorazepam in 14.1% of cases). The average dose of benzodiazepines was 11.74±6.9 mg (equivalent dose of diazepam). The duration of benzodiazepine use was 6.1±5.33 months. The scales scores were as follows: 55.01±1.33 for the PCL-5; 32.18±3.84 for the HADS; 17.73±6.2 for the ISI and 10.79±0.61 for the PSQI. In univariate and multivariate analysis, there was no significant difference between patients having and those not having benzodiazepines, in terms of ISI score (17.88±6.21 vs 17.5±6.3; p = 0.78) and PSQI score (11.08±5.73 vs 10.35±5.55, p = 0.56). Conclusions: Results of this study, in accordance with the literature data, showed no significant positive effect of benzodiazepines on posttraumatic sleep disorders. Randomized controlled trials evaluating benzodiazepines, other molecules and eventually combinations of pharmacological and behavioral interventions are
S619
needed in order to better answer the question of how to treat insomnia and nightmares in PTSD. References [1] Germain, A., Buysse, D.J., Nofzinger, E., 2008. Sleep-specific mechanisms underlying posttraumatic stress disorder: integrative review and neurobiological hypotheses. Sleep Med Rev 12(3):185−95. [2] Kramer, T.L., Booth, B.M., Han, X., Williams, D.K., 2003. Service utilization and outcomes in medically ill veterans with posttraumatic stress and depressive disorders. J Trauma Stress 16(3):211−9. [3] Nishith, P., Resick, P.A., Mueser, K.T., 2001. Sleep difficulties and alcohol use motives in female rape victims with posttraumatic stress disorder. J Trauma Stress 14(3):469−79. [4] Drummond, S., Paulus, M.P., Tapert, S.F., 2006. Effects of two nights sleep deprivation and two nights recovery sleep on response inhibition. J Sleep Res 15(3):261−5. [5] Knutson, K.L., Van Cauter, E., 2008. Associations between sleep loss and increased risk of obesity and diabetes. Ann N Y Acad Sci 1129(1):287–304.
P.4.d.002 Repetitive transcranial magnetic stimulation on supplementary motor area in the treatment of refractory obsessive-compulsive disorder: open-label pilot study B.H. Koo1 ° , W.S. Seo1 , E.J. Cheon1 , H.K. Kim1 , Y.J. Lee1 , S.W. Lee1 , S.H. Yun1 , G.W. Lee1 , J.H. Choi1 , M.S. Keum1 , W.S. Choi1 1 Yeungnam University Hospital, Psychiatry, Daegu, South-Korea Background and Purpose: The use of selective serotonin reuptake inhibitor (SSRI) and cognitive behavior therapy (CBT) has been reported to have therapeutic values in the treatment of obsessive-compulsive disorder (OCD). However, significant proportion of OCD patients fail to improve with these treatment methods. Repetitive transcranial magnetic stimulation (rTMS) have been proposed for another option of OCD treatment [1]. Functional neuroimaging studies indicate that OCD is associated with increased activity in the supplementary motor area (SMA), playing an important role in the pathophysiology of OCD [1]. Nevertheless, there were only a few studies of OCD treatment, using low frequency rTMS over SMA, and those results are not confirmed [2]. In this study, we assessed efficacy of augmentation with 1 Hz rTMS over SMA in SSRI-refractory OCD patients. Methods: We examined 13 patients diagnosed with OCD according to the Diagnostic and Statistical Manual of Mental Disorders version IV, test revision (DSM-IV-TR). The patients reported Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score greater than 16, which is typically used for inclusion in drug trials and voluntarily participated with informed consent. The participants received 1 Hz rTMS over SMA for 20 daily sessions for 4 weeks. Y-BOCS, clinical global impression (CGI), Beck Depression Index (BDI), Beck Anxiety Index (BAI), The Symptom Checklist-90-Revised (SCL-90-R), mini-mental state examination (MMSE), and adverse effects were administered at baseline, second and fourth week of treatment. The changes in baseline, second and fourth week of treatment by each rating scale were assessed by means of one way repeated measures analysis of variance (ANOVA). Results: Mean scores on Y-BOCS were 27 at baseline, 24.38 at the second week, and 22.45 at the fourth week of treatment. There was no significant change in Y-BOCS from the baseline to the second week, however, significant reduction was noticed at the fourth week of treatment (<0.05). The reduction of compulsion
S620
P.4.d. Anxiety disorders, OCD, stress related disorders and treatment − Treatment (clinical)
contributed to the reduction of global Y-BOCS rather than that of obsession. There was significant reduction in Y-BOCS for compulsion (<0.05), but no significant change in Y-BOCS for obsession. CGI at the second week of treatment (3.17) and CGI at the end of treatment (3.23) also showed significant changes, in comparison with CGI at baseline (4.38). Additional significant changes in BDI, BAI, SCL-90-R, and MMSE were not seen. Any significant adverse effects were not reported. Conclusion: These findings suggest that 1 Hz rTMS over the SMA can be an efficient and safe therapeutic tool as an add-on therapy in treatment-refractory patients of OCD. Also, there was no significant change in cognitive function after rTMS. However, there are several limitations of this study including a small number of participants and lack of control group. Further controlled studies in larger samples are required to confirm the effect of rTMS in OCD. References [1] Kumar, N., Chadda, RK., 2011 Augmentation effect of repetitive transcranial magnetic stimulation over the supplementary motor cortex in treatment refractory patients with obsessive compulsive disorder. Indian J Psychiatry 53, 340−2. [2] Pallanti, S., Marras, A., Salerno, L., Makris, N., Hollander, E., 2016 Better than treated as usual: Transcranial magnetic stimulation augmentation in selective serotonin reuptake inhibitorrefractory obsessive– compulsive disorder, mini-review and pilot open-label trial. J Psychopharmacol. 3, 1−11.
P.4.d.003 Cost-effectiveness of deep brain stimulation versus treatment as usual for obsessivecompulsive disorder P. Ooms1 ° , M. Blankers1 , I. Bergfeld1 , M. Figee1 , P. Van den Munckhof2 , P. Schuurman2 , D. Denys1 1 Academic Medical Center, Psychiatry, Amsterdam, The Netherlands; 2 Academic Medical Center, Neurosurgery, Amsterdam, The Netherlands Introduction: Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by intrusive, fear inducing thoughts (obsessions) and repetitive behaviors aimed at reducing anxiety (compulsions). Left untreated, OCD can cause severe harm in functioning and quality of life to patient and relatives [1]. Despite exhaustive treatment, 10% of patients remain refractory [2], for which Deep Brain Stimulation (DBS) has been suggested. Over the past decade, DBS trials for OCD demonstrate an responder rate (Yale-Brown obsessive compulsive scale (Y-BOCS) reduction of >35%) of 50% with mostly transient side-effects [3]. Given its efficacy, DBS has been accepted by several countries as last resort treatment. Though health insurance companies in various countries worldwide reimburse DBS, surprisingly, nothing is known about its actual costs and cost-effectiveness. Aim: To perform the first economic evaluation of DBS in comparison with treatment as usual (TAU) for therapy refractory OCD. Methods: We performed a prospective open study, comparing the costs and effects of DBS for OCD (n = 17) with TAU (n = 11) over a period of two years. The economic evaluation adopted a societal perspective, including all healthcare costs and patients’ productivity costs. For our base-case, or primary analysis, we used healthcare cost, cost for research and innovation and QualityAdjusted-Life-Years (QALYs), to calculate cost per QALY gained. Additionally, to estimate the economic potential of DBS, we conducted two practice-based scenarios: (1) standard care scenario, without research and innovation costs, and (2) rechargeable
scenario, in which we assume the use of a recently developed rechargeable battery. Base-case and both scenarios were extrapolated to four years to estimate long-term cost-effectiveness. To handle stochastic uncertainty in the cost and effect data, we extracted 5000 nonparametric bootstrapped samples with replacement. For each of these samples, we calculated the incremental costs, incremental effects, and incremental cost effectiveness ratio (ICER). The ICERs were plotted on a cost-effectiveness plane and based on their distribution, a cost-effectiveness acceptability curve (CEAC) was drawn to indicate the probability of DBS being cost-effective given a certain willingness to pay [4]. Results: Compared to TAU, DBS provides an additional 0.26 QALY (SD = 0.16) at higher cost. Median cost per QALY gained is estimated at €141,446 for base-case, €115,916 for standard care and €65,394 for the rechargeable scenario. Extending the time-horizon to four years results in a median cost per QALY of €80,313 for base-case, €69,287 for standard care, and turned out to be cost-saving at €4,678 per QALY for the rechargeable scenario. Assuming a willingness to pay threshold of €80,000 per QALY, DBS, under base-case and standard care had 25% and 35% probability of being more cost-effective than TAU. With the rechargeable scenario and in all scenarios extrapolated to four years, the probability of cost-effectiveness was equal or higher than TAU. Conclusions: Taken together, DBS for OCD is an effective but expensive treatment modality. However, DBS has an advantageous probability of being cost-effective when evaluated over four years, especially when rechargeable batteries are used. Based on these results, we think DBS should be implemented in standard care for treatment refractory OCD patients. References [1] Subramaniam, M., Soh, P., Vaingankar, J.A., Picco, L., & Chong, S.A., 2013. Quality of life in obsessive compulsive disorder: impact of the disorder and of treatment. CNS Drugs, 27(5), 367−83. [2] Denys, D., 2006. Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders. The Psychiatric Clinics of North America, 29(2), 553−84, xi. [3] De Koning, P.P., Figee, M., Van Den Munckhof, P., Schuurman, P.R., & Denys, D., 2011. Current status of deep brain stimulation for obsessivecompulsive disorder: A clinical review of different targets. Current Psychiatry Reports, 13(4), 274–282. [4] Drummond, M.F., Sculpher, M.J., Torrance, G.W., O’Brien, & Stoddart, B.J. and G.L., 2005. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press.-05 (3rd ed.).
P.4.d.004 Enhancing cognitive-behavioral therapy for obsessive-compulsive disorder with transcranial magnetic stimulation: a proof of concept G. Grassi1 ° , S. Pacini2 , C. Cecchelli2 , S. Pallanti1 1 University of Florence, Neuroscience, Florence, Italy; 2 Institute of Neuroscience, Neuroscience, Florence, Italy Background: Cognitive behavioral therapy (CBT) is a well established first line treatment for obsessive compulsive disorder (OCD). It consists of a cognitive and a behavioral treatment (exposure and response prevention therapy (ERP)) [1]. The goal of the cognitive treatment is the cognitive restructuring of metacognitions while the goal of exposure therapy is enhancing and facilitating patients’ fear extinction processes in front of the feared object, situation or thought/obsession. Several studies have tried to enhance fear extinction through pharmacological agents with
P.4.d. Anxiety disorders, OCD, stress related disorders and treatment − Treatment (clinical) P.4.d.001 Evaluation of benzodiazepines use for sleep disturbances in post-traumatic stress disorder A. Oumaya1 ° , M.W. Krir1 , C. Ben Cheikh1 , H. Kefi1 , S. Edhif1 1 Military Hospital of Tunis, psychiatric department, Tunis, Tunisian Republic Introduction: Sleep disturbances, including insomnia and nightmares, are among the most common and chronic symptoms of post-traumatic stress disorder (PTSD). Considered as a main component of the disorder, these disturbances would be closely linked to its onset and maintenance [1]. They are also associated with impaired daytime functioning [2], adverse psychological effects [3], neurocognitive alterations [4] and even neuroendocrine abnormalities [5]. Therefore, effective treatment of these nighttime symptoms of PTSD is of critical importance and can contribute to improving the overall functioning and well-being of patients. Benzodiazepines are commonly used to achieve this goal, however, these drugs are not without risks and side effects and very few studies have examined their efficacy in this indication. Aim of the study: This study aimed to evaluate the use of benzodiazepines in the treatment of sleep disturbances in PTSD. Methods: This was a prospective study, conducted from April 1st, 2015 to June 30, 2015. Patients were recruited among those consulting the outpatient department of psychiatry at the military hospital of Tunis and having a diagnosis of PTSD according to the DSM-5 criteria. The variables studied were sociodemographic characteristics, duration and treatment of PTSD, and benzodiazepines use (with type, dose and duration of treatment for patients under benzodiazepines). Patients were also evaluated using the following scales: PTSD Check-List for DSM-5 (PCL-5), Hospital Anxiety and Depression Scale (HADS), Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI). Results: The study population consisted of 85 patients. All of them were male with a mean age of 27.73±0.41 years. The mean duration of PTSD was 13.85±0.92 months and its management (regardless of sleep distrubances) consisted of antidepressants alone in 79.76% of cases, cognitive behavioral therapy alone in 7.14% of cases and EMDR alone in 5.95% of cases. Fifty-one patients (60%) were having benzodiazepines (clorazepate in 20% of cases; prazepam in 16.5% of cases and lorazepam in 14.1% of cases). The average dose of benzodiazepines was 11.74±6.9 mg (equivalent dose of diazepam). The duration of benzodiazepine use was 6.1±5.33 months. The scales scores were as follows: 55.01±1.33 for the PCL-5; 32.18±3.84 for the HADS; 17.73±6.2 for the ISI and 10.79±0.61 for the PSQI. In univariate and multivariate analysis, there was no significant difference between patients having and those not having benzodiazepines, in terms of ISI score (17.88±6.21 vs 17.5±6.3; p = 0.78) and PSQI score (11.08±5.73 vs 10.35±5.55, p = 0.56). Conclusions: Results of this study, in accordance with the literature data, showed no significant positive effect of benzodiazepines on posttraumatic sleep disorders. Randomized controlled trials evaluating benzodiazepines, other molecules and eventually combinations of pharmacological and behavioral interventions are
S619
needed in order to better answer the question of how to treat insomnia and nightmares in PTSD. References [1] Germain, A., Buysse, D.J., Nofzinger, E., 2008. Sleep-specific mechanisms underlying posttraumatic stress disorder: integrative review and neurobiological hypotheses. Sleep Med Rev 12(3):185−95. [2] Kramer, T.L., Booth, B.M., Han, X., Williams, D.K., 2003. Service utilization and outcomes in medically ill veterans with posttraumatic stress and depressive disorders. J Trauma Stress 16(3):211−9. [3] Nishith, P., Resick, P.A., Mueser, K.T., 2001. Sleep difficulties and alcohol use motives in female rape victims with posttraumatic stress disorder. J Trauma Stress 14(3):469−79. [4] Drummond, S., Paulus, M.P., Tapert, S.F., 2006. Effects of two nights sleep deprivation and two nights recovery sleep on response inhibition. J Sleep Res 15(3):261−5. [5] Knutson, K.L., Van Cauter, E., 2008. Associations between sleep loss and increased risk of obesity and diabetes. Ann N Y Acad Sci 1129(1):287–304.
P.4.d.002 Repetitive transcranial magnetic stimulation on supplementary motor area in the treatment of refractory obsessive-compulsive disorder: open-label pilot study B.H. Koo1 ° , W.S. Seo1 , E.J. Cheon1 , H.K. Kim1 , Y.J. Lee1 , S.W. Lee1 , S.H. Yun1 , G.W. Lee1 , J.H. Choi1 , M.S. Keum1 , W.S. Choi1 1 Yeungnam University Hospital, Psychiatry, Daegu, South-Korea Background and Purpose: The use of selective serotonin reuptake inhibitor (SSRI) and cognitive behavior therapy (CBT) has been reported to have therapeutic values in the treatment of obsessive-compulsive disorder (OCD). However, significant proportion of OCD patients fail to improve with these treatment methods. Repetitive transcranial magnetic stimulation (rTMS) have been proposed for another option of OCD treatment [1]. Functional neuroimaging studies indicate that OCD is associated with increased activity in the supplementary motor area (SMA), playing an important role in the pathophysiology of OCD [1]. Nevertheless, there were only a few studies of OCD treatment, using low frequency rTMS over SMA, and those results are not confirmed [2]. In this study, we assessed efficacy of augmentation with 1 Hz rTMS over SMA in SSRI-refractory OCD patients. Methods: We examined 13 patients diagnosed with OCD according to the Diagnostic and Statistical Manual of Mental Disorders version IV, test revision (DSM-IV-TR). The patients reported Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score greater than 16, which is typically used for inclusion in drug trials and voluntarily participated with informed consent. The participants received 1 Hz rTMS over SMA for 20 daily sessions for 4 weeks. Y-BOCS, clinical global impression (CGI), Beck Depression Index (BDI), Beck Anxiety Index (BAI), The Symptom Checklist-90-Revised (SCL-90-R), mini-mental state examination (MMSE), and adverse effects were administered at baseline, second and fourth week of treatment. The changes in baseline, second and fourth week of treatment by each rating scale were assessed by means of one way repeated measures analysis of variance (ANOVA). Results: Mean scores on Y-BOCS were 27 at baseline, 24.38 at the second week, and 22.45 at the fourth week of treatment. There was no significant change in Y-BOCS from the baseline to the second week, however, significant reduction was noticed at the fourth week of treatment (<0.05). The reduction of compulsion
S620
P.4.d. Anxiety disorders, OCD, stress related disorders and treatment − Treatment (clinical)
contributed to the reduction of global Y-BOCS rather than that of obsession. There was significant reduction in Y-BOCS for compulsion (<0.05), but no significant change in Y-BOCS for obsession. CGI at the second week of treatment (3.17) and CGI at the end of treatment (3.23) also showed significant changes, in comparison with CGI at baseline (4.38). Additional significant changes in BDI, BAI, SCL-90-R, and MMSE were not seen. Any significant adverse effects were not reported. Conclusion: These findings suggest that 1 Hz rTMS over the SMA can be an efficient and safe therapeutic tool as an add-on therapy in treatment-refractory patients of OCD. Also, there was no significant change in cognitive function after rTMS. However, there are several limitations of this study including a small number of participants and lack of control group. Further controlled studies in larger samples are required to confirm the effect of rTMS in OCD. References [1] Kumar, N., Chadda, RK., 2011 Augmentation effect of repetitive transcranial magnetic stimulation over the supplementary motor cortex in treatment refractory patients with obsessive compulsive disorder. Indian J Psychiatry 53, 340−2. [2] Pallanti, S., Marras, A., Salerno, L., Makris, N., Hollander, E., 2016 Better than treated as usual: Transcranial magnetic stimulation augmentation in selective serotonin reuptake inhibitorrefractory obsessive– compulsive disorder, mini-review and pilot open-label trial. J Psychopharmacol. 3, 1−11.
P.4.d.003 Cost-effectiveness of deep brain stimulation versus treatment as usual for obsessivecompulsive disorder P. Ooms1 ° , M. Blankers1 , I. Bergfeld1 , M. Figee1 , P. Van den Munckhof2 , P. Schuurman2 , D. Denys1 1 Academic Medical Center, Psychiatry, Amsterdam, The Netherlands; 2 Academic Medical Center, Neurosurgery, Amsterdam, The Netherlands Introduction: Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by intrusive, fear inducing thoughts (obsessions) and repetitive behaviors aimed at reducing anxiety (compulsions). Left untreated, OCD can cause severe harm in functioning and quality of life to patient and relatives [1]. Despite exhaustive treatment, 10% of patients remain refractory [2], for which Deep Brain Stimulation (DBS) has been suggested. Over the past decade, DBS trials for OCD demonstrate an responder rate (Yale-Brown obsessive compulsive scale (Y-BOCS) reduction of >35%) of 50% with mostly transient side-effects [3]. Given its efficacy, DBS has been accepted by several countries as last resort treatment. Though health insurance companies in various countries worldwide reimburse DBS, surprisingly, nothing is known about its actual costs and cost-effectiveness. Aim: To perform the first economic evaluation of DBS in comparison with treatment as usual (TAU) for therapy refractory OCD. Methods: We performed a prospective open study, comparing the costs and effects of DBS for OCD (n = 17) with TAU (n = 11) over a period of two years. The economic evaluation adopted a societal perspective, including all healthcare costs and patients’ productivity costs. For our base-case, or primary analysis, we used healthcare cost, cost for research and innovation and QualityAdjusted-Life-Years (QALYs), to calculate cost per QALY gained. Additionally, to estimate the economic potential of DBS, we conducted two practice-based scenarios: (1) standard care scenario, without research and innovation costs, and (2) rechargeable
scenario, in which we assume the use of a recently developed rechargeable battery. Base-case and both scenarios were extrapolated to four years to estimate long-term cost-effectiveness. To handle stochastic uncertainty in the cost and effect data, we extracted 5000 nonparametric bootstrapped samples with replacement. For each of these samples, we calculated the incremental costs, incremental effects, and incremental cost effectiveness ratio (ICER). The ICERs were plotted on a cost-effectiveness plane and based on their distribution, a cost-effectiveness acceptability curve (CEAC) was drawn to indicate the probability of DBS being cost-effective given a certain willingness to pay [4]. Results: Compared to TAU, DBS provides an additional 0.26 QALY (SD = 0.16) at higher cost. Median cost per QALY gained is estimated at €141,446 for base-case, €115,916 for standard care and €65,394 for the rechargeable scenario. Extending the time-horizon to four years results in a median cost per QALY of €80,313 for base-case, €69,287 for standard care, and turned out to be cost-saving at €4,678 per QALY for the rechargeable scenario. Assuming a willingness to pay threshold of €80,000 per QALY, DBS, under base-case and standard care had 25% and 35% probability of being more cost-effective than TAU. With the rechargeable scenario and in all scenarios extrapolated to four years, the probability of cost-effectiveness was equal or higher than TAU. Conclusions: Taken together, DBS for OCD is an effective but expensive treatment modality. However, DBS has an advantageous probability of being cost-effective when evaluated over four years, especially when rechargeable batteries are used. Based on these results, we think DBS should be implemented in standard care for treatment refractory OCD patients. References [1] Subramaniam, M., Soh, P., Vaingankar, J.A., Picco, L., & Chong, S.A., 2013. Quality of life in obsessive compulsive disorder: impact of the disorder and of treatment. CNS Drugs, 27(5), 367−83. [2] Denys, D., 2006. Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders. The Psychiatric Clinics of North America, 29(2), 553−84, xi. [3] De Koning, P.P., Figee, M., Van Den Munckhof, P., Schuurman, P.R., & Denys, D., 2011. Current status of deep brain stimulation for obsessivecompulsive disorder: A clinical review of different targets. Current Psychiatry Reports, 13(4), 274–282. [4] Drummond, M.F., Sculpher, M.J., Torrance, G.W., O’Brien, & Stoddart, B.J. and G.L., 2005. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press.-05 (3rd ed.).
P.4.d.004 Enhancing cognitive-behavioral therapy for obsessive-compulsive disorder with transcranial magnetic stimulation: a proof of concept G. Grassi1 ° , S. Pacini2 , C. Cecchelli2 , S. Pallanti1 1 University of Florence, Neuroscience, Florence, Italy; 2 Institute of Neuroscience, Neuroscience, Florence, Italy Background: Cognitive behavioral therapy (CBT) is a well established first line treatment for obsessive compulsive disorder (OCD). It consists of a cognitive and a behavioral treatment (exposure and response prevention therapy (ERP)) [1]. The goal of the cognitive treatment is the cognitive restructuring of metacognitions while the goal of exposure therapy is enhancing and facilitating patients’ fear extinction processes in front of the feared object, situation or thought/obsession. Several studies have tried to enhance fear extinction through pharmacological agents with