Considering Non-Pharmacological Treatments for Resistant OCD Patients

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Obsessive-compulsive disorder (OCD) is a chronic psychiatric condition affecting 1.2% of the population in the United States and between 1.1% and 1.8% of the world population. (Hollander et al., 2016). OCD patients suffer from debilitating uncontrollable, recurring thoughts accompanied by the urge to repeat specific behaviors in an effort to alleviate these intrusive thoughts, symptoms which greatly impact both their professional and personal life (Hollander et al., 2016). In addition to the debilitating nature of the disorder for patients themselves, OCD is associated with significant costs and burdens to society as a whole (Goodman, 2016). 

Over the years, the American Psychiatric Association has implemented an OCD treatment algorithm consisting of cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), or a combination of the two as first line treatment options (Koran et al., 2007). Unfortunately, many patients do not respond to first line treatments and there can be difficult side effects associated with these therapies.

OCD patients treated with exposure-response prevention therapy (ERP), a type of CBT specialized for treating OCD,  confront triggers that induce obsessive thoughts and work to reduce anxiety surrounding these triggers. Many patients find this therapy extremely anxiety-inducing and do not complete the full course. Those who do find success with ERP are still left with residual symptoms (Whittal et al., 2005).

SSRIs have been the first line pharmacologic option for the treatment of OCD since 1989 (Pittenger & Bloch, 2014). However, despite promising data surrounding this treatment, roughly half of patients treated with SSRIs do not respond (Jenike, 2004), leading clinicians to escalate the dose of the SSRI or try multiple different SSRIs before concluding that a patient is a non-responder (Reddy, Sundar, Narayanaswamy, & Math, 2017). This process can sometimes take years, leaving patients feeling hopeless as they try each new drug. The next line option is augmenting patients’ SSRI treatment with atypical antipsychotics, but the side effects associated with adding an antipsychotic to the treatment regimen are significantly worse than those associated with treatment with an SSRI alone (Haverkampf, 2014).



At this point in the treatment algorithm, the additional treatment options are scarce and may involve invasive brain surgery such as deep brain surgery or ventral capsulotomy. Brain surgery is certainly not an ideal option in any patient population, but it is particularly anxiety-provoking for OCD patients and very few are willing to take the risk. It is clear that psychiatrists need additional treatment options for OCD patients, and the recent FDA approval of a noninvasive technology known as Deep transcranial magnetic stimulation (dTMS) could be a beneficial alternative. This new treatment option has the potential to vastly improve treatment outcomes and quality of life for patients who often think all hope is lost in their search for an effective therapy.   

Deep TMS treatment targets deep brain structures by using directed electromagnetic fields that generate excitation or inhibition of neurons deep inside the brain. This device targets the medial prefrontal cortex and anterior cingulate cortex, integral nodes in the circuit that has been found to play a considerable role in the etiology of OCD (Dougherty et al., 2018).

Clinical trial results show that daily TMS treatment for a 6-week period results in a statistically significant, 30% reduction in symptom severity as measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the gold standard measure of OCD symptom severity(Tendler, Zohar, Carmi, Roth, & Zangen, 2018). Further, at a 10 week follow up visit, the response rate increased, demonstrating a positive treatment effect over time. Side effects were limited; the most frequent adverse reaction was headache, which was resolved shortly after treatment (Tendler et al., 2018).

Many patients who have never experienced relief from their symptoms with pharmacological treatment or therapy see significant improvement and are able to function at a high level following dTMS treatment, without the side effects associated with pharmacological treatment options. However, in order for dTMS to have broad impact, it is crucial that psychiatrists understand the incredible value of this treatment and integrate it into their practices. Clinicians must work to bring cutting edge technologies such as dTMS into our toolbox in order to continue helping patients in the best manner possible.

References:

Dougherty, D. D., Brennan, B. P., Stewart, S. E., Wilhelm, S., Widge, A. S., & Rauch, S. L. (2018). Neuroscientifically Informed Formulation and Treatment Planning for Patients With Obsessive-Compulsive Disorder: A Review. JAMA Psychiatry, 75(10), 1081–1087. https://doi.org/10.1001/jamapsychiatry.2018.0930

Hollander, E., Doernberg, E., Shavitt, R., Waterman, R. J., Soreni, N., Veltman, D. J., … Fineberg, N. A. (2016). The cost and impact of compulsivity: A research perspective. European Neuropsychopharmacology, 26(5), 800–809. https://doi.org/10.1016/j.euroneuro.2016.02.006

Janardhan Reddy, Y. C., Sundar, A. S., Narayanaswamy, J. C., & Math, S. B. (2017). Clinical practice guidelines for Obsessive-Compulsive Disorder. Indian Journal of Psychiatry, 59(Suppl 1), S74–S90. https://doi.org/10.4103/0019-5545.196976

Jenike, M. A. (2004). Obsessive–Compulsive Disorder. New England Journal of Medicine, 350(3), 259–265. https://doi.org/10.1056/NEJMcp031002

Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., Simpson, H. B., & American Psychiatric Association. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. The American Journal of Psychiatry, 164(7 Suppl), 5–53.

Pittenger, C., & Bloch, M. H. (2014). Pharmacological Treatment of Obsessive-Compulsive Disorder. Psychiatric Clinics of North America, 37(3), 375–391. https://doi.org/10.1016/j.psc.2014.05.006

Tendler, A., Zohar, J., Carmi, L., Roth, Y., & Zangen, A. (2018). O14. Deep TMS of the Medial Prefrontal and Anterior Cingulate Cortices for OCD: A Double-Blinded Multi-Center Study. Biological Psychiatry, 83(9, Supplement), S113–S114. https://doi.org/10.1016/j.biopsych.2018.02.299

Whittal, M. L., Thordarson, D. S., & McLean, P. D. (2005). Treatment of obsessive–compulsive disorder: Cognitive behavior therapy vs. exposure and response prevention. Behaviour Research and Therapy, 43(12), 1559–1576. https://doi.org/10.1016/j.brat.2004.11.012

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