Improving long term patient outcomes from deep brain stimulation for treatment-refractory obsessive-compulsive disorder

Abstract

Introduction: Deep brain stimulation (DBS) has emerged as an effective treatment for patients with severe treatment-refractory obsessive-compulsive disorder (OCD). Over the past two decades, several clinical trials with multiple years of follow-up have shown that DBS offers long-term symptom relief for individuals with severe OCD, though a portion of patients do not achieve an adequate response. Areas covered: This review sought to summarize the literature on the efficacy and long-term effectiveness of DBS for OCD, and to identify strategies that have the potential to improve treatment outcomes. Expert opinion: Although this literature is just emerging, a small number of DBS enhancement strategies have shown promising initial results. More posterior targets along the striatal axis and at the bed nucleus of the stria terminalis appear to offer greater symptom relief than more anterior targets. Research is also beginning to demonstrate the feasibility of maximizing treatment outcomes with target selection based on neural activation patterns during symptom provocation and clinical presentation. Finally, integrating DBS with post-surgery exposure and response prevention therapy appears to be another promising approach. Definitive conclusions about these strategies are limited by a low number of studies with small sample sizes that will require multisite replication.

Effectiveness, Timing and Procedural Aspects of Cognitive Behavioral Therapy after Deep Brain Stimulation for Therapy-Resistant Obsessive Compulsive Disorder: A Systematic Review

“…An additional 19 of these were excluded due to the following reasons: not referring to CBT ( n = 11), not referring to DBS ( n = 1) and other reasons ( n = 7). Eventually, 9 papers were included in the review: three randomized controlled trials (RCTs) [ 13 , 14 , 15 ], one cohort study [ 16 ], one case series [ 12 ], one qualitative study [ 17 ], one systematic review [ 18 ] and 2 narrative reviews [ 19 , 20 ]. These reviews were focused on the efficacy of DBS for OCD and not on the efficacy of CBT after DBS for OCD.…”

“…Whereas it is a common practice to offer patients with therapy-resistant OCD treated with DBS a course of CBT after their operation, its effectiveness, timing and procedural aspects, such as the preferred way of delivery of such therapy, has hardly been studied. In spite of the fact that the importance of post-operative CBT is stressed by various authors [ 18 , 19 , 20 ], only two trials have specifically focussed on CBT added to DBS [ 13 , 14 , 15 ].…”

Deep Brain Stimulation for Intractable Obsessive-Compulsive Disorder: Progress and Opportunities

“…Unfortunately, there are no established clinical predictors informing us which patients are most likely to respond to DBS (5). We rely mostly on illness severity, chronicity, and welldocumented evidence of treatment resistance to determine eligibility for DBS in adults with a primary diagnosis of OCD.…”

“…This study adds to a growing body of evidence that DBS is generally safe and well tolerated for patients with intractable OCD (4,5). Adverse events were categorized as either related to surgery, the hardware, or programming.…”

Pressing ethical issues in considering pediatric deep brain stimulation for obsessive-compulsive disorder

“…A recent literature review examining the long-term effectiveness of DBS for OCD in adults identified seven randomized shamcontrolled trials all of which demonstrated a lower mean Y-BOCS severity in the active compared to sham group. Moreover, this review found that "sixty-two percent of patients with treatmentrefractory OCD are estimated to experience clinically significant long-term treatment response from DBS" [10]. In light of these findings, DBS may one day be considered for use among pediatric populations.…”