The promise and challenges of transcranial magnetic stimulation and deep brain stimulation as therapeutic options for obsessive-compulsive disorder

ABSTRACT

Introduction

Obsessive compulsive disorder (OCD) represents a complex and often difficult to treat disorder. Pharmacological and psychotherapeutic interventions are often associated with sub-optimal outcomes, and 40–60% of patients are resistant to first line therapies and thus left with few treatment options. OCD is underpinned by aberrant neurocircuitry within cortical, striatal, and thalamic brain networks. Considering the neurocircuitry impairments that underlie OCD symptomology, neurostimulation therapies provide an opportunity to modulate psychopathology in a personalized manner. Also, by probing pathological neural networks, enhanced understanding of disease states can be obtained.

Areas covered

This perspective discusses the clinical efficacy of TMS and DBS therapies, treatment access options, and considerations and challenges in managing patients. Recent scientific progress is discussed, with a focus on neurocircuitry and biopsychosocial aspects. Translational recommendations and suggestions for future research are provided.

Expert opinion

There is robust evidence to support TMS and DBS as an efficacious therapy for treatment resistant OCD patients supported by an excellent safety profile and favorable health economic data. Despite a great need for alternative therapies for chronic and severe OCD patients, resistance toward neurostimulation therapies from regulatory bodies and the psychiatric community remains. The authors contend for greater access to TMS and DBS for treatment resistant OCD patients at specialized sites with appropriate clinical resources, particularly considering adjunct and follow-up care. Also, connectome targeting has shown robust predictive ability of symptom improvements and holds potential in advancing personalized neurostimulation therapies.

KEYWORDS:

• Transcranial magnetic stimulation
• deep brain stimulation
• neurostimulation
• obsessive compulsive disorder
• treatment resistant
• clinical efficacy

Article highlights

• Neurostimulation offers a unique opportunity to modulate underlying psychopathological mechanisms and enhance neurobiological understanding of OCD

• Response rates of rTMS for OCD are inconclusive, real world clinical evidence of deep TMS and symptom provocation shows 50–100% response, yet long-term data is lacking

• DBS achieves response in at least 60% of treatment refractory OCD patients, which increases to 70% in the long term

• Despite high efficacy, and favorable safety and economic profiles of neurostimulation therapies for OCD, there is a crisis in access to care, predominantly related to regulatory approval and insurance coverage

• The authors advocate for greater access to care and personalised treatment protocols of TMS and DBS therapies for OCD patients

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

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

Additional information

Funding

This paper was not funded.