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 multi-site replication.

KEYWORDS:

• DBS
• OCD
• neuromodulation
• depression
• nucleus accumbens
• internal capsule
• ventral capsule
• ventral striatum
• subthalamic nucleus
• stria terminalis

Article highlights

• Sixty-two percent of patients with treatment-refractory OCD are estimated to experience clinically significant long-term treatment response from DBS

• DBS for OCD results in long-term significant reductions in depressive symptoms

• Rebounds of OCD and depressive symptoms following battery depletions or interruptions appear to be the most common adverse events

• Posterior targets along the striatum and at the bed nucleus of the stria terminalis may produce more symptom reduction than more anterior targets

• Preliminary studies suggest that individual patient neural connectivity data may help optimize target selection

Declaration of interest

E Storch is a consultant for Levo Therapeutics. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.