Introduction: Deep brain stimulation (DBS) has demonstrated efficacy in treating treatment-refractory OCD (trOCD). Despite receiving FDA Humanitarian Device Exemption approval in 2009, DBS for trOCD remains underutilized, with approximately 350 procedures performed globally between 2005 and 2021. Here, we present our experience managing a multi-disciplinary clinic providing integrated neurosurgical and psychiatric care for trOCD patients from a nationwide referral base.
Methods: We retrospectively analyzed 102 trOCD patients evaluated by our Psychiatric Neurosurgical Service in the past 6 years. The majority of patients were self-referred. Screening criteria involved documented failure of 3 selective serotonin reuptake inhibitor trials, one clomipramine trial, and an antipsychotic augmentation trial. Additional requirements included ≥5-year disease duration, Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score ≥28, and a full course of exposure and response prevention (ERP) therapy. Candidates underwent sequential virtual and in-person evaluation by 2-3 clinicians (psychiatrist, psychologist, neurosurgeon). Surgical options discussed included DBS (of the ventral capsule) and anterior capsulotomy (via laser ablation).
Results: From 102 initial inquiries, 75 patients proceeded to virtual consultation, 44 completed in-person evaluation, and 36 were offered surgery. Ultimately, 24 patients have undergone DBS, and 7 have received capsulotomy. Mean travel distance for DBS recipients was 700 +/- 530 miles. Identified barriers to treatment included limited provider awareness, insurance coverage challenges, and geographic access constraints. Among the 21 surgical candidates pursuing therapy through health insurance, initial denial rates were 29% for DBS and 71% for capsulotomy.
Conclusion : Challenges to establishing a psychiatric neurosurgery service for OCD are substantial, even with a highly experienced clinical team. We present strategies for efficiently triaging nationwide referrals to identify candidates who are most likely to benefit from therapy given constraints imposed by practical issues (financial, geographic, social, societal) and medical comorbidities (depression, body dysmorphic disorder).
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