Treatment Resistant OCD (Treatment Refractory OCD) Approach and Management. rTMS, DBS, Gamma knife & Psychosurgery for OCD
Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. This video focuses on novel promising research treatment tried across the world such as rTMS, DBS, Gamma Knife and neurosurgical approach.
Evidence-based guidelines recommend selective serotonin reuptake inhibitors and/or behavior therapy as first-line treatments for obsessive-compulsive disorder (OCD). However, around 40%-60% do not respond adequately to either treatment. Around 30% of such patients respond to augmentation with antipsychotics. It has been estimated that around 10%-20% of OCD patients are refractory to all available pharmacological and psychological treatments. Many of these patients have chronic, severe, and disabling symptoms causing significant social and economic burden. Neurosurgical treatments have a role in this population, that is, patients with chronic and severe OCD, who are refractory to available noninvasive treatment strategies.
The advent of stereotactic surgical techniques and advances in neuroimaging in the last few decades have greatly enhanced the specificity and accuracy of targeting in brain surgeries. This is in stark contrast to the earlier procedures such as prefrontal leukotomy and lobotomy, for which the term “psychosurgery” has unfortunately become synonymous with. Contemporary neurosurgical procedures involve either creation of small lesions in the order of millimeters (ablative surgery) or implantation of electrodes in very specific subcortical regions for neuromodulation (deep brain stimulation [DBS]). Refinements of targets based on the experience and understanding of neurobiology have improved the safety and efficacy of these procedures
Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.
This video will focus on the current status of treatment resistant/refractory OCD, neurosurgical treatment for OCD, providing an overview on clinical aspects including patient selection, consent/review process, a brief description of contemporary surgical procedures, and postoperative follow-up.