Comparative effectiveness of neuroablation and deep brain stimulation for treatment-resistant obsessive-compulsive disorder: a meta-analytic study

Kumar, Kevin K.; Appelboom, Geoffrey; Lamsam, Layton; Caplan, Arthur L.; Williams, Nolan; Bhati, Mahendra T.; Stein, Sherman C.; Halpern, Casey H.

doi:10.1136/jnnp-2018-319318

Cited by 40 publications

(46 citation statements)

References 36 publications

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“…Conversely, DBS is intended to be non-ablative, adjustable in case of side effects of overstimulation and reversible. Current guidelines and meta-analyses do not favor DBS over lesion surgery in the treatment of OCD 33,93. To our opinion, each method presents pros and cons, future researches should focus on identifying predictors of response.…”

Section: Dbs or Lesion Surgery For Ocd?mentioning

confidence: 85%

<p>Deep brain stimulation in the treatment of obsessive-compulsive disorder: current perspectives</p>

Tastevin¹,

Spatola²,

Régis³

et al. 2019

NDT

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Deep brain stimulation (DBS) is a neuro-psychosurgical technique widely accepted in movement disorders, such as Parkinson’s disease. Since 1999, DBS has been explored for severe, chronic and treatment-refractory psychiatric diseases. Our review focuses on DBS in obsessive-compulsive disorder (OCD), considered as a last treatment resort by most of learned societies in psychiatry. Two main stimulation areas have been studied: the striatal region and the subthalamic nucleus. But, most of the trials are open-labeled, and the rare controlled ones have failed to highlight the most efficient target. The recent perspectives are otherwise encouraging. Indeed, clinicians are currently considering other promising targets. A case series of 2 patients reported a decrease in OCD symptoms after DBS in the medial forebrain bundle and an open-label study is exploring bilateral habenula stimulation. New response criteria are also investigating such as quality of life, or subjective and lived-experience. Moreover, first papers about cost-effectiveness which is an important criterion in decision making, have been published. The effectiveness of tractography-assisted DBS or micro-assisted DBS is studying with the aim to improve targeting precision. In addition, a trial involving rechargeable pacemakers is undergoing because this mechanism could be efficient and have a positive impact on cost-effectiveness. A recent trial has discussed the possibility of using combined cognitive behavioral therapy (CBT) and DBS as an augmentation strategy. Finally, based on RDoc Research, the latest hypotheses about the understanding of cortico-striato-thalamo-cortical circuits could offer new directions including clinical predictors and biomarkers to perform adaptive closed-loop systems in the next future.

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Section: Dbs or Lesion Surgery For Ocd?mentioning

confidence: 85%

<p>Deep brain stimulation in the treatment of obsessive-compulsive disorder: current perspectives</p>

Tastevin¹,

Spatola²,

Régis³

et al. 2019

NDT

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“…As mentioned above, we previously generated a decision-making analytical model to estimate and compare utility and complication rates of DBS and ABL for treatment-refractory OCD (Kumar et al, 2019). In this model, utility is a measure of relative patient preference for a given healthcare outcome (Weinstein et al, 1996).…”

Section: Methodsmentioning

confidence: 99%

“…The mean response of Y-BOCS to RF capsulotomy was determined using random-effects and inverse variance-weighted meta-analysis of published observational data including mean age, sex distribution, duration of symptoms, and incidences of individual complications (Einarson, 1997; Nyman et al, 2001; Brown et al, 2016). Using meta-regression of studies measuring both changes in Y-BOCS and QOL, percent improvement in Y-BOCS was converted to mean improved utility (Bystritsky et al, 1999; Thompson and Higgins, 2002; Volpato Cordioli et al, 2003; Sousa et al, 2006; Besiroglu et al, 2007; Norberg et al, 2008; Ross et al, 2008; Huppert et al, 2009; Hollander et al, 2010; Huff et al, 2010; Reddy et al, 2010; Simpson et al, 2010; Andersson et al, 2011; Srivastava et al, 2011; Farris et al, 2013; Ooms et al, 2014; Kumar et al, 2019). In addition, a subtree of incidence of each reported complication and its effect on utility was constructed to determine the utility of the average patient with postoperative complications or surgical side effects from RF capsulotomy.…”

Section: Methodsmentioning

confidence: 99%

“…Alternatively, DBS for OCD alters the orbito-subcortical reward circuitry through electrical stimulation of targets, such as the anterior limb of the internal capsule, nucleus accumbens, ventral caudate, and/or ventral striatum (Abramowitz et al, 2009). Our group recently completed a meta-analysis of published data that revealed that ABL was more effective than DBS for OCD (Kumar et al, 2019). This analysis also identified non-significant trends indicating that capsulotomy was superior to cingulotomy and that RF ablation had greater efficacy than SRS.…”

Section: Introductionmentioning

confidence: 99%

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MR-Guided Focused Ultrasound Versus Radiofrequency Capsulotomy for Treatment-Refractory Obsessive-Compulsive Disorder: A Cost-Effectiveness Threshold Analysis

et al. 2019

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Meta-analytic techniques support neuroablation as a promising therapy for treatment-refractory obsessive-compulsive disorder (OCD). This technique appears to offer a more favorable complication rate and higher utility than deep brain stimulation. Moreover, these pooled findings suggest that bilateral radiofrequency (RF) capsulotomy has marginally greater efficacy than stereotactic radiosurgery or cingulotomy. MR-guided focused ultrasound (MRgFUS) capsulotomy is an emerging approach with a potentially more favorable profile than RF ablation and radiosurgery, with preliminary data suggesting safety and efficacy. As a clinical trial is being developed, our study examined the cost and clinical parameters necessary for MRgFUS capsulotomy to be a more cost-effective alternative to RF capsulotomy. A decision analytical model of MRgFUS with RF capsulotomy for OCD was performed using outcome parameters of percent surgical improvement in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score, complications, and side effects. The analysis compared measured societal costs, derived from Medicare reimbursement rates, and effectiveness, based on published RF data. Effectiveness was defined as the degree to which MRgFUS lowered Y-BOCS score. Given that MRgFUS is a new therapy for OCD with scant published data, theoretical risks of MRgFUS capsulotomy were derived from published essential tremor outcomes. Sensitivity analysis yielded cost, effectiveness, and complication rates as critical MRgFUS parameters defining the cost-effectiveness threshold. Literature search identified eight publications (162 subjects). The average reduction of preoperative Y-BOCS score was 56.6% after RF capsulotomy with a 22.6% improvement in utility, a measure of quality of life. Complications occurred in 16.2% of RF cases. In 1.42% of cases, complications were considered acute-perioperative and incurred additional hospitalization cost. The adverse events, including neurological and neurobehavioral changes, in the other 14.8% of cases did not incur further costs, although they impacted utility. Rollback analysis of RF capsulotomy yielded an expected effectiveness of 0.212 quality-adjusted life years/year at an average cost of $24,099. Compared to RF capsulotomy, MRgFUS was more cost-effective under a range of possible cost and complication rates. While further study will be required, MRgFUS lacks many of the inherent risks associated with more invasive modalities and has potential as a safe and cost-effective treatment for OCD.

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“…A recent meta-analysis of Kumar et al comparing ABL and DBS in OCD concluded that ablative surgery has a higher overall utility than DBS, mostly because of the lower complication rate of ablative surgery. 19 However, several overlapping samples were included in the analysis, 5,[20][21][22][23][24][25][26][27] which could have led to a distorted estimation of the actual effectiveness. Furthermore, no formal meta-regression was performed to determine systematic differences in variance between studies on ABL or DBS concerning efficacy and adverse events.…”

Section: Introductionmentioning

confidence: 99%

Deep brain stimulation versus ablative surgery for treatment‐refractory obsessive‐compulsive disorder: A meta‐analysis

Hageman

Rooijen

Bergfeld

et al. 2021

Acta Psychiatr Scand

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Objective: Ablative surgery (ABL) and deep brain stimulation (DBS) are lastresort treatment options for patients suffering from treatment-refractory obsessivecompulsive disorder (OCD). The aim of this study was to conduct an updated meta-analysis comparing the clinical outcomes of the ablative procedures capsulotomy and cingulotomy and deep brain stimulation. Methods: We conducted a PubMed search to identify all clinical trials on capsulotomy, cingulotomy, and DBS. Random effects meta-analyses were performed on 38 articles with a primary focus on efficacy in reducing OCD symptoms as measured by a reduction in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score and the responder rate (≥35% reduction in Y-BOCS score). Results: With responder rates of 48% and 53% after 12-16 months and 56% and 57% at last follow-up for ABL and DBS, respectively, and large effect sizes in the reduction in Y-BOCS scores, both surgical modalities show effectiveness in treating refractory OCD. Meta-regression did not show a statistically significant difference between ABL and DBS regarding these outcomes. Regarding adverse events, a statistically significant higher rate of impulsivity is reported in studies on DBS. Conclusion: This meta-analysis shows equal efficacy of ABL and DBS in the treatment of refractory OCD. For now, the choice of intervention should, therefore, rely on factors such as risk of developing impulsivity, patient preferences, and experiences of psychiatrist and neurosurgeon. Future research should provide more insight regarding differences between ABL and DBS and response prediction following direct comparisons between the surgical modalities, to enable personalized and legitimate choices between ABL and DBS.

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Comparative effectiveness of neuroablation and deep brain stimulation for treatment-resistant obsessive-compulsive disorder: a meta-analytic study

Cited by 40 publications

References 36 publications

<p>Deep brain stimulation in the treatment of obsessive-compulsive disorder: current perspectives</p>

<p>Deep brain stimulation in the treatment of obsessive-compulsive disorder: current perspectives</p>

MR-Guided Focused Ultrasound Versus Radiofrequency Capsulotomy for Treatment-Refractory Obsessive-Compulsive Disorder: A Cost-Effectiveness Threshold Analysis

Deep brain stimulation versus ablative surgery for treatment‐refractory obsessive‐compulsive disorder: A meta‐analysis

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