OCD May Respond to Deep-Brain Stimulation

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OCD May Respond to Deep-Brain Stimulation

By , North American Correspondent, MedPage Today

October 04, 2010

MedPage Today Action Points

* Explain to interested patients that a small study found that treatment

refractory obsessive-compulsive disorder (OCD) improved after bilateral deep

brain stimulation in the nucleus accumbens.

* Note that the study was performed in only 16 patients -- of whom nine

responded to the treatment.

Review

Electrical stimulation of the brain may be effective for severe,

treatment-refractive obsessive-compulsive disorder (OCD), according to a small

study from the Netherlands.

The study, of 16 OCD patients who had not responded to various therapies, found

that so-called deep-brain stimulation of the nucleus accumbens led to an average

46% improvement in symptoms on a standard scale after eight months (P<0.001),

reported Damiaan Denys, MD, PhD, of the University of Amsterdam, and colleagues.

Only nine of the 16 were actually counted as " responders " to deep-brain

stimulation -- but among those patients, symptoms improved by an average of 72%,

Denys and co-authors wrote in the October issue of the Archives of General

Psychiatry.

In the U.S., deep-brain stimulation -- implanting electrodes in parts of the

brains and supplying a trickle of current -- is approved to treat essential

tremor, Parkinson's disease, and dystonia. It is under study for other

conditions, including depression.

OCD, a disorder characterized by persistent thoughts (obsessions) and repetitive

ritualistic behaviors (compulsions), has an estimated lifetime prevalence of 2%

and affects men and women equally, according to background provided in the

paper.

Approved treatments for OCD include pharmacotherapy and cognitive behavior

therapy (CBT), but these treatments may only provide a 40% to 60% reduction in

symptoms in half of patients, Denys and colleagues noted. And even when the best

available therapies are used, around 10% of OCD patients remain severely

affected and treatment-refractive, they added.

Other researchers have also looked at deep-brain stimulation for OCD, but Denys

and colleagues said their's was the first double-blind, sham-controlled study

targeting the nucleus accumbens.

The 16 study patients had severe OCD -- defined as a score of 28 or greater on

the 40-point Yale-Brown Obsessive Compulsive Scale -- and had been

unsuccessfully treated with various therapies, including selective serotonin

reuptake inhibitors, clomipramine hydrochloride (Anafranil), and CBT.

All patients were treated for eight months with deep-brain stimulation, followed

by a double-blind phase in which patients were randomly assigned to active or

sham stimulation for two weeks and then crossed over to the other group.

Finally, the stimulation was turned on in all patients and they were followed

for another year.

Response to the electrical treatment was defined as a 35% drop on the Yale-Brown

score after the eight-month initial phase.

The researchers found:

* In the open phase, the average score on the Yale-Brown scale fell from

33.7 at baseline to 18, a 46% reduction that was significant at P<0.001.

* Among the nine patients defined as responders, the decrease was 23.7

points on average (72%) and six patients reached a final score below 10 (where 7

or below is regarded as subclinical) -- an average drop of 81%.

* In the double-blind phase, which included only 14 of the 16 original

patients, the average difference between scores with active and sham stimulation

was 8.3 points, or 25%, which was significant at P=0.004.

* In most patients, depression and anxiety decreased significantly (at

P=0.001 for each) during the open period.

* The symptomatic improvements over baseline were maintained during the

12-month follow-up.

The only difference between responders and nonresponders, Denys and colleagues

reported, was the content of the symptoms. Four patients with egosyntonic

symptoms such as perfectionism, need for symmetry, seeking reassurance, and

hoarding saw their scores fall on average by only 10% on the Yale-Brown scale.

Also, at baseline, those four scored significantly higher on a scale measuring

the delusional characteristics of symptoms, the researchers found.

Denys and colleagues reported that two patients refused to enter the

double-blind phase -- one didn't want to risk losing the improvements gained in

the open phase, and one was disappointed at a lack of efficacy.

Adverse effects included mild forgetfulness and word-finding problems, the

researchers reported, but no permanent events were seen.

One limitation of the study, they reported, is that the double-blind phase

consisted of two-week periods, rather than the three-months originally planned.

The change was made because patients did not tolerate long " off " periods, the

investigators reported.

This study was supported by Medtronic and by the Netherlands Organization for

Scientific Research ZON-MW VENI program. The senior author, Rick Schuurman, MD,

PhD, of the University of Amsterdam, reported financial links with Medtronic. No

other authors reported conflicts.

Primary source: Archives of General Psychiatry

Source reference:

Denys D, et al " Deep brain stimulation of the nucleus accumbens for

treatment-refractory obsessive-compulsive disorder " Arch Gen Psychiatr 2010;

67(10): 1061-1068.

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