Deep Brain Stimulation for Obsessive-Compulsive Disorder: Real World Experience Post-FDA-Humanitarian Use Device Approval

Abstract

Background: While case series have established the efficacy of deep brain stimulation (DBS) in treating obsessive-compulsive disorder (OCD), it has been our experience that few OCD patients present without comorbidities that affect outcomes associated with DBS treatment. Here we present our experience with DBS therapy for OCD in patients who all have comorbid disease, together with the results of our programming strategies. Methods: For this case series, we assessed five patients who underwent ventral capsule/ventral striatum (VC/VS) DBS for OCD between 2015 and 2019 at the University of Colorado Hospital. Every patient in this cohort exhibited comorbidities, including substance use disorders, eating disorder, tic disorder, and autism spectrum disorder. We conducted an IRB-approved, retrospective study of programming modifications and treatment response over the course of DBS therapy. Results: In addition to patients' subjective reports of improvement, we observed significant improvement in the Yale-Brown Obsessive-Compulsive Scale (44%), the Montgomery-Asberg Depression Rating Scale (53%), the Quality of Life Enjoyment and Satisfaction Questionnaire (27%), and the Hamilton Anxiety Rating scales (34.9%) following DBS. With respect to co-morbid disease, there was a significant improvement in a patient with tic disorder's Total Tic Severity Score (TTSS) (p = 0.005). Conclusions: DBS remains an efficacious tool for the treatment of OCD, even in patients with significant comorbidities in whom DBS has not previously been investigated. Efficacious treatment results not only from the accurate placement of the electrodes by the surgeon but also from programming by the psychiatrist.

Keywords: DBS programming; co-morbidity; deep brain stimulation; obsessive-compulsive disorder; psychiatric DBS.

Figure 1

(A) Violin plots showing group level representation of the percent change from pre-DBS surgery baseline across the five mood disorder scale metrics used for our cohort: Hamilton Anxiety Rating Scale (HAM-A), Montgomery-Åsberg Depression Rating Scale (MADRS), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Young Mania Rating Scale (YMRS). Dots represent post-surgery DBS programming sessions. Each scale plot represents all subjects and all post-surgery DBS programming sessions for the first year of follow-up. The solid line demarcates no change (0%) on the y-axis, and the dotted line indicates the median percent change. Red points indicate percent change in scale metrics for each individual patient from the final follow-up and the red dotted line represents the mean for all patients for the final follow up. (B) Individual and scale differences in the number of programming sessions necessary to achieve optimal therapeutic stimulation. Each scale plot denotes the number of days required to achieve optimal stimulation for each patient highlighted by a different color.

Figure 2

The individual time course representation for patient response to DBS programming modifications across the five mood disorder scale metrics. (A) Hamilton Anxiety Rating Scale (HAM-A). (B) Montgomery-Åsberg Depression Rating Scale (MADRS). (C) Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF). (D) Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). (E) Young Mania Rating Scale (YMRS).

Figure 3

Patient specific comorbidities. (A,B) A patient (P2) had a comorbid autism-spectrum disorder, tic disorder, which was measured at each DBS programming session using the (A) Total Tic Severity Score and the (B) Yale Global Tic Severity Scale (C–E). A patient (P4) had comorbid substance use (nicotine use disorder, daily cannabis use, and at-risk alcohol use), which was measured at each DBS programming session using craving scales for ETOH (C), marijuana (D), and cigarettes (E).

Figure 4

DBS electrode placement. (A) For each patient, localization of the bilateral DBS leads is visualized in the axial plane at the level of the anterior commissure (AC) – anterior limb of the internal capsule (ALIC) junction; marked in yellow. Axial slices depict co-registered pre-operative MRI and post-operative CT for cases 2–5 and co-registered pre- and post-operative MRI for case 1. Hyperintense circular artifacts in cases 2–5 represent the DBS lead from the post-operative CT; the hypointense circular artifacts in case 1 represent the DBS lead. Note that the axial images depicting lead location at the junction between AC and ALIC, do not necessarily depict the location of the active contact. (B) Visualization and analysis of the association between the distance from the active contact(s) at final follow-up to the AC-ALIC junction and charge density. A significant negative correlation was observed for the relationship between distance between the active contact(s) and the AC-ALIC junction and charge density (p = 0.037, r = −0.58).