For untreatable OCD, a deep-brain solution
February 18th, 2011
05:16 PM ET

For untreatable OCD, a deep-brain solution

Obsessive-compulsive disorder can be a severely disabling illness. People with this condition tend to have troubling, unwanted thoughts and engage in compulsive behaviors to try to neutralize those feelings.

About 2.2 million Americans over age 18 have it, according to the National Institutes of Mental Health. But in some cases, no medical or behavioral therapy intervention works, and patients' lives become entirely consumed with anxiety and obsessive rituals.

A more radical solution for those who don't improve with conventional methods is gaining support. It's called deep brain stimulation, and it involves implanting an electrode deep into the brain to deliver an electrical current directly in the circuitry scientists believe is involved in the disorder.

Dr. Benjamin Greenberg, a psychiatrist at Brown University and at Butler Hospital, presented the latest results from his research on deep brain stimulation Friday at the American Association for the Advancement of Science annual meeting in Washington, D.C.

Deep brain stimulation therapy for OCD involves an implanted device designed to be worn for life, somewhat akin to a cardiac pacemaker for someone with heart problems, except the wires go through a hole in the skull into the brain instead of the heart, he says.

In the United States, there are about 60 or 70 patients who have had deep brain stimulation for OCD since 2000, Greenspan said. But the technology has been used for Parkinson's disease and other disorders; about 70,000 people have deep brain stimulation devices worldwide, said Michael Okun, neurologist at the University of Florida.

Greenspan is doing a small NIH-supported controlled trial to investigate deep brain stimulation. His newest results using Medtronic electrodes suggest in eight or more years of followup, patients who showed initial improvement and continued the deep brain stimulation have less severe symptoms than they did initially. It is not an instant cure, but it improves functioning, he said.

"They gain a lot more time in the day where what they’re doing is not OCD," he said.

A device slightly different from Greenspan's can be obtained under a U.S. Food and Drug Administration "humanitarian device exemption." That means when there are less than 4,000 patients yearly who have a specific condition - in this case, untreatable OCD - the FDA can approve a device for which research and development costs may be bigger than market returns if full clinical trials were run.

But the technique is still controversial. Dr. Joseph Fins, chief of medical ethics at NewYork-Presbyterian/Weill Cornell Hospital, argued that there is not enough evidence to support having this therapy approved, and that its approval is putting patients at risk, in addition to restricting further scientific inquiry and benefiting the device manufacturers.

There are also, of course, documented side effects. Whenever you put something in the brain, there can be bleeding, which can have transient or permanent side effects. The rate of these is low, but it's still possible, Greenberg said. Infection and seizures at the time of the operation are also possible, and there's even the potential for seizures to emerge later in treatment. Behavioral side effects may include too much energy and trouble sleeping. And when a battery dies or a wire breaks or the patient goes through a metal detector, OCD symptoms get worse, sometimes very suddenly.

Deep brain stimulation is about as effective as permanent surgeries involving making lesions in the brain, although that's still being studied, Greenberg said. The advantage of deep brain stimulation is that the device is removable and adjustable, so the electrical current can be changed to suit the individual's treatment. But about half of patients who could choose this route instead elect surgical lesions because permanent surgery doesn't require maintaining a device or remaining connected to a specialized treatment center.

Deep brain stimulation is also being used in depression, targeted at the same brain circuits: Connecting the front part of the brain with deeper regions. These circuits are recognized as being key to behavioral disorders. There's a lot of commonality in the pharmacological treatments used in OCD and other mood disorders already, so it makes sense that deep brain stimulation would also target the same areas, Greenberg said.

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