Deep brain stimulation for treatment-refractory obsessive-compulsive disorder should be an accepted therapy in Australia

Abstract

Deep brain stimulation has shown promise for the treatment of severe, treatment-refractory obsessive-compulsive disorder. With the recent publication of the first Australian, randomised, sham-controlled trial of deep brain stimulation for obsessive-compulsive disorder, there are now four placebo-controlled trials demonstrating the efficacy of this therapy. Together with recent data identifying a biological substrate of effective stimulation that can predict response and that has been successfully reproduced, studies comparing and finding equivalent efficacy among different targets, as well as recent, large, open trials supporting the long-term effectiveness of deep brain stimulation, we argue that this should now be considered an accepted therapy for a select group of patients in the Australasian setting. We call on the Royal Australian and New Zealand College of Psychiatrists to revise their memorandum describing deep brain stimulation for obsessive-compulsive disorder as an ‘ experimental’ treatment and recognise that it has proven efficacy. We stress that this should remain a therapy offered only to those with high treatment-refractory illnesses and only at specialised centres where there is an experienced multidisciplinary team involved in work-up, implantation and follow-up and also where frameworks are in place to provide careful clinical governance and ensure appropriate fully informed consent.

Clinical outcomes of deep brain stimulation for obsessive‐compulsive disorder: Insight as a predictor of symptom changes

“…Thus, sham methods were necessary in earlier investigations to establish a level of efficacy. However, we contend that a sufficient level of evidence has been reached to consider DBS an established therapy for TR-OCD, [9][10][11]67,68 and that closed label conditions do not satisfy ethical or validity requirements. The overall goal of DBS therapy is to improve outcomes for patients.…”

Call to revise the Royal Australian and New Zealand College of Psychiatrists’ clinical memorandum on deep brain stimulation for obsessive-compulsive disorder

“…Thus, the efficacy of DBS is comparable, or rather beyond that of pharmacological interventions for OCD. These reported outcomes have led several experts to argue that DBS is now an established therapy for refractory OCD ( Acevedo and Rossell, 2022 ; Gadot et al, 2022 ; Mosley et al, 2021 ; Müller et al, 2022 ; van Wingen et al, 2022 ). Although the memorandum identifies DBS as a potential treatment option for refractory OCD patients, it encourages applications solely within investigational contexts (clinical trials) and classifies DBS as an emerging therapy.…”

Clinical recommendations for the care of people with treatment-refractory obsessive-compulsive disorder when undergoing deep brain stimulation

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Deep brain stimulation (DBS) is a form of focal neurostimulation that modulates electrical activity in subcortical structures through the implantation of permanent stimulating electrodes. DBS for treatment-refractory obsessive-compulsive disorder (TR-OCD) can be accessed under a humanitarian exemption in the United States and Europe, yet remains unapproved in Australia, despite sufficient evidence for regulatory approval (Acevedo and Rossell, 2022;Mosley et al, 2022). The proposed changes to the Royal Australian and New Zealand College of Psychiatrists clinical memorandum on DBS for psychiatric conditions indicate that DBS for OCD may be acceptable outside of a clinical trial if performed by an appropriately experienced multi-disciplinary team, with rigorous assessments and monitoring.

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