Role of transcranial magnetic stimulation in the management of trichotillomania: A systematic review

Table 1 Characteristics of the included studies

Ref.	Title of the article	Journal name	Country	Type of study	Level of evidence
Chaudhary et al[18], 2024	Accelerated Continuous Theta Burst Stimulation in the Treatment of Trichotillomania: A Comprehensive Case Study From Acute Intervention to Maintenance Phase	The Journal of ECT	India	Case report	IV
Di Ponzio et al[19], 2023	rTMS investigation of resistant Obsessive-Compulsive Related Disorders: Efficacy of targeting the reward system	Frontiers in Psychiatry	Italy	Retrospective study	III
Aydin et al[17], 2020	Repetitive Transcranial Magnetic Stimulation for Treatment of Trichotillomania: Case Series	Clinical Psychopharmacology and Neuroscience	Turkey	Case series	IV
Kar et al[21], 2020	Successful treatment of trichotillomania with repetitive transcranial magnetic stimulation: A report of two cases with review of literature	Asian Journal of Psychiatry	India	Case series	IV

Table 2 Characteristics of participants

Ref.	Sample size	Psychiatric morbidities	Concurrent treatment		Past treatment		Outcome scale	Results	Side effects	Conclusion
			Psychotropics (mg/d)	Psychotherapy	Psychotropics (mg/d)	Psychotherapy
Chaudhary et al[18], 2024	1	Not mentioned	Fluoxetine 80 mg, Aripiprazole 2 mg	Not mentioned	Yes (details not mentioned)	Not mentioned	YBOCS, MGH-HPS, and CGI-I	56% and 80% reduction in YBOCS and MGH-HPS scores, respectively. CGI-I scores improved from moderately worse to moderately efficacious. After 6 sessions of maintenance acTBS over 6 weeks, improvement was sustained	NR	First case report for acute and maintenance acTBS which was well tolerated and effects sustained
Di Ponzio et al[19], 2023	14	7 major depressive disorder, 2 ADHD, 4 GAD, 1 bipolar disorder	Selective serotonin reuptake inhibitors: Fluoxetine equivalent of 30 mg	None	Yes (details not mentioned)	Cortical bone trajectory	MGH-HPS and SDQ	Mean percentage of improvement was 58.2% in MGH-HPS and 17.1% in SDQ. No significant reduction after 1 month follow-up. Linear regression analysis indicated no age effect between pre- and post-intervention. Worsening of MGH-HPS scores was at follow-up in older age group	NR	Positive outcomes suggest implications for reward circuits, which are usually used for addictions. This is consistent with the emerging view that obsessive-compulsive and related disorders are behavioral addictions. Worsening of MGH-HPS scores at follow-up in the older age group indicates reduced plasticity in elderly
Aydin et al[17], 2020	5	Case 1 ADHD; Case 2 none; Case 3 none; Case 4 GAD; Case 5 bipolar type II, obsessive-compulsive disorder, alcohol abuse, specific phobia	Case 1 Methylphenidate 36 mg; Case 2 no psychotropics; Case 3 Fluoxetine 80 mg; Case 4 Fluoxetine 20 mg; Case 5 Sertraline 100 mg, Aripiprazole 5 mg, Quetiapine 150 mg	None in all cases	Case 1 Fluoxetine 20 mg; Case 2 Escitalopram 20 mg; Case 3 Fluoxetine 80 mg, N-acetyl cystine 1200 mg; Case 4 no; Case 5 no	Yes in case 1 and case 3	MGH-HPS, Beck’s anxiety inventory, Beck’s depression inventory	Three patients had substantial benefit (100%, 75%, and 70% improvement in MGH-HSP), one patient had 33% improvement. The last patient experienced a mild increase in the severity	Transient flashes in eye for 2-3 session in one case	Repetitive transcranial magnetic stimulation was effective in 3 of 5 patients. One was a partial responder, and the other nonresponder might have been due to multiple comorbidities that acted as confounding factors
Kar et al[21], 2020	2	Not mentioned	Case 1 Escitalopram 30 mg; Case 2 Sertraline 200 mg	Habit reversal therapy	Not mentioned	Not mentioned	MGH-HPS	Reduction of 66.6% and 73.6% in both cases, respectively. Case 1 sustained benefits for 6 weeks, while case 2 was maintained well for 2 months then experienced worsening which improved with psychotherapy for 6 months	NR	Reduction in symptom severity and therapy was well tolerated

ADHD: Attention deficit hyperactivity disorder; acTBS: Accelerated continuous theta burst stimulation; CGI-I: Clinical global impression improvement; GAD: Generalized anxiety disorder; MGH-HPS: Massachusetts General Hospital Hair Pulling Scale; NR: None reported; SDQ: Symptoms of depression questionnaire; YBOCS: Yale-Brown Obsessive-Compulsive Scale.

Table 3 Parameters of protocols used

Ref.	Type of TMS intervention	Target area	Frequency (Hz)	Resting motor threshold (%)	Total no. of pulses	No. of sessions per day	Total no. of sessions	Duration of treatment (week)	Maintenance TMS
Chaudhary et al[18], 2024	Accelerated continuous theta burst stimulation	SMA	Not mentioned	Not mentioned	900	2 (15 min apart)	20	Not mentioned	Yes (6 > 6 weeks)
Di Ponzio et al[19], 2023	High frequency rTMS	Left dorsolateral prefrontal cortex	15	100	2400	1	24	4	No
Aydin et al[17], 2020	LF rTMS	Pre-SMA	1	100	1200	1	15	3	No
Kar et al[21], 2020	LF rTMS	SMA	1	Not mentioned	1200	1	20	4	No

LF: Low frequency; rTMS: Repetitive transcranial magnetic stimulation; SMA: Supplementary motor area; TMS: Transcranial magnetic stimulation.

Table 4 Risk of bias assessment of cohort study on Joanna Briggs Institute critical appraisal tool

Ref.	Were the two groups similar and recruited from the same population	Were the exposures measured similarly to assign people to both exposed and unexposed groups	Was the exposure measured in a valid and reliable way	Were confounding factors identified	Were strategies to deal with confounding factors stated	Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)	Were the outcomes measured in a valid and reliable way	Was the follow up time reported and sufficient to be long enough for outcomes to occur	Was follow up complete, and if not, were the reasons to loss to follow up described and explored	Were strategies to address incomplete follow up utilized	Was appropriate statistical analysis used	Score
Di Ponzio et al[19], 2023	Yes	NA	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	No	Yes	73%

Table 5 Risk of bias assessment of case series on Joanna Briggs Institute critical appraisal tool

Ref.	Were there clear criteria for inclusion in the case series	Was the condition measured in a standard, reliable way for all participants included in the case series	Were valid methods used for identification of the condition for all participants included in the case series	Did the case series have consecutive inclusion of participants	Did the case series have complete inclusion of participants	Was there clear reporting of the demographics of the participants in the study	Was there clear reporting of clinical information of the participants	Were the outcomes or follow up results of cases clearly reported	Was there clear reporting of the presenting site(s)/clinic(s) demographic information	Was statistical analysis appropriate	Score
Kar et al[21], 2020	Unclear	Unclear	Yes	Unclear	Unclear	Unclear	Yes	Yes	Unclear	NA	30%
Aydin et al[17], 2020	Unclear	Yes	Yes	Unclear	Unclear	Unclear	Yes	Yes	Unclear	NA	40%

Table 6 Risk of bias assessment of case reports on Joanna Briggs Institute critical appraisal tool

Ref.	Were patient’s demographic characteristics clearly described	Was patient’s history clearly described and presented as a timeline	Was current clinical condition of the patient on presentation clearly described	Were diagnostic tests or assessment methods and results clearly described	Was interventions or treatment procedure clearly described	Was post-intervention clinical condition clearly described	Were adverse events or unanticipated events identified and described	Does the case report provide takeaway lessons	Score
Chaudhary et al[18], 2024	Unclear	Yes	Unclear	Unclear	Yes	Yes	Yes	Yes	63%