Deep Brain Stimulation (DBS) for OCD by Wayne Goodman, MD & Sameer Sheth, MD, PhD
Deep brain stimulation (DBS) is a neurosurgical approach to electrical stimulation of the brain. It is used to treat some neurological disorders, including Parkinson’s disease (PD) and essential tremor. Now, it has been approved to treat some severe cases of OCD as well. It is considered a third-line treatment for OCD, only something to be tried in severe cases where first- and second-line options have not been successful.
In 1999, the first reports were published on the use of DBS in intractable OCD. Then, in 2009, after additional confirmatory studies were published, the FDA issued a Humanitarian Device Exemption (HDE) approval for DBS in severe and treatment-resistant cases of OCD. The area of the brain targeted by DBS is a deep region called the ventral capsule/ventral striatum (VC/VS). (In Europe, other areas of the brain may be implanted.)
Who is eligible for DBS treatment?
DBS for OCD is reserved for adult patients with severe OCD that has not improved with medications and exposure and response prevention (ERP). To be eligible to get DBS treatment, you must:
- Have had a primary diagnosis of OCD for at least five years;
- Be at least 18 years old;
- Have symptoms that are severe or extreme, with a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 28 or higher;
- Have tried at least three serotonin reuptake inhibitors (SRIs) including clomipramine, as well as augmentation with an antipsychotic medication and at least 20 sessions of ERP with a trained therapist;
- NOT have medical, neurological, or other psychiatric conditions that would increase risks associated with surgery or DBS treatment.
What does the procedure look like?
A DBS device is essentially a pacemaker for the brain. Like a heart pacemaker, it consists of a stimulator implanted under the skin of the upper chest. The stimulator is connected to thin wires that run under the skin, through small openings in the bone, and into a specific target region in the brain. The entire device is under the skin and not obviously visible externally.
How does DBS work?
This “brain pacemaker” helps regulate electrical signals in the brain that are abnormal in OCD. Restoring the appropriate balance of these signals helps reduce OCD symptoms. For DBS to work, your provider must identify the proper brain target for stimulation and deliver an electrical current over the course of several months. Using a hand-held tablet, the psychiatrist will program the DBS device by evaluating your mood, anxiety, and energy level while delivering the current.
Improvements in mood can happen right away, whereas improvement in symptoms of OCD generally takes longer — weeks to months.
What are potential benefits of DBS?
Approximately two-thirds of patients with OCD fully respond to DBS. These patients typically improve from severe to moderate or mild symptoms after three to six months. Symptoms of depression, which generally accompany severe OCD, often improve sooner. ERP, which by itself was insufficient in reducing symptoms prior to DBS, can augment the benefit of DBS when given together with DBS.
What are potential risks of DBS?
The most serious risk of surgery is injury to the brain, which is very uncommon (under 1% of patients). The other main surgical risk is infection, which is also very uncommon (under 1%).
The most common side effect during DBS programming is hypomania (i.e., elevated mood and energy). This side effect is usually temporary and goes away when the stimulation is lowered. Another common side effect is insomnia. Patients are given a hand-held programmer that allows them to adjust stimulation within a safe range. If they are having trouble sleeping, they can turn the stimulation down at bedtime and return it to therapeutic levels in the morning.
What should I look for in a treatment center?
DBS is best administered by a team consisting of 1) an OCD-expert psychiatrist who is skilled in programming the device once it is implanted, 2) a neurosurgeon with expertise in DBS surgery, and 3) a psychologist with expertise in ERP. The FDA requires that the clinical team have the patient review and sign an informed consent form that spells out in detail the possible benefits and risks of the treatment.
Will my insurance cover DBS surgery?
This depends on your insurance policy. Because DBS for OCD has an FDA approval under the Humanitarian Device Exemption (HDE), it should be covered. However, initial denials are commonplace, and you may need to appeal. See the article referenced below by Dr. Rachel Davis and colleagues for a discussion of this topic.
What if DBS isn’t beneficial?
If DBS treatment is unsuccessful after 12–18 months, the hardware can be removed with no lasting changes to the brain.
To learn more about DBS for OCD, see these articles:
- Goodman WK, Storch EA, Sheth SA. Harmonizing the Neurobiology and Treatment of Obsessive-Compulsive Disorder. American Journal of Psychiatry. 2021 Jan 1;178(1):17-29.
- Gadot R, Najera R, Hirani S, et al., Efficacy of Deep Brain Stimulation for Treatment-Resistant Obsessive-Compulsive Disorder: Systematic Review and Meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry 2022 Oct; 93:1166-1173
- Davis RA, Giordano J, Hufford DB, et al., Restriction of Access to Deep Brain Stimulation for Refractory OCD: Failure to Apply the Federal Parity Act. Front Psychiatry. 2021 Aug 12;12:706181.