Neurosurgical treatments - an experts view

OCD Action is aware of a number of articles being published in recent months relating to neurosurgical procedures for the treatment of OCD. We were concerned that the different accounts might lead to confusion, both over the nature of procedures that might be used, and also as to their potential availability. Additionally, some reports also provided misleading background information, for example, stating that the NICE Guideline recommended treatment options for OCD - CBT (Cognitive Behaviour Therapy) / ERP (Exposure Response Prevention) and the use of SSRIs (Selective Serotonin Reuptake Inhibitors), do not work on 30% - 60 % of people affected by OCD.

To help us provide some accurate information about neurosurgical treatments we asked Dr Keith Matthews, Professor of Psychiatry and Director of the Neuroscience Division at the Medical Research Institute, University of Dundee for his assistance in explaining the current position.

Dr Matthews said that, contrary to some of the information provided in recent reports, it is clear that there is a strong evidence base to support the current preferred treatment options (CBT/ERP and SSRI’s) as benefitting most patients with OCD. There is, however, less reliable information on the long term effectiveness of these treatments and better research is required.

Importantly, despite best treatment efforts, there are small numbers of patients with severe and disabling OCD for whom neurosurgical treatments might be an appropriate option.  There has been limited study of a specific intervention called ‘Deep Brain Stimulation’ (DBS) which has been tested in small numbers of patients in several countries, including one trial recently in the UK.  To offer perspective on the numbers of those affected by OCD who might be suitable for this form of treatment, the recent UK clinical trial of DBS recruited only 6 participants over a period of four years. These were patients who were experiencing OCD of sufficient severity and who had received – but failed to benefit from - adequate trials of other therapies, including intensive residential CBT, such that it was appropriate for them to be considered for neurosurgery.  

Recruitment for this study has now closed so there are presently no further opportunities to engage with DBS in the UK. DBS should not be considered as a treatment option for patients with OCD unless as part of an ethically approved research study.

The treatments referred to in the various recent articles on neurosurgery often refer to ‘laser surgery’.  This is inaccurate and does not reflect the surgical methods used which usually involve focused heat or focused radiation. Lesion surgery of the type described has been around as a treatment for OCD since the 1960s. There are several countries that undertake forms of lesion surgery, notably the USA, Canada, Belgium and the UK. Lesion surgery for OCD – usually a procedure called an anterior cingulotomy – is made available to a small number of patients with the most severe and disabling forms of OCD each year. Dr Matthews says that evidence from its use suggests that it appears to be an effective treatment for the majority of patients who undergo surgery and there are several detailed case series with long term follow up. In 2014, using the strongest and most rigorous research design available, there was a double blinded, randomised, controlled trial of radiation lesion surgery that showed a clear beneficial effect of surgery. The adverse effects of lesion surgery have also been carefully studied and, for most patients, the procedures appear to be safe. Contrary to the concerns sometimes expressed by others who are unfamiliar with surgery as a treatment for OCD, there is no consistent evidence to suggest significant adverse effects such as memory difficulties, seizures or personality change.

The most important thing to emphasise is that any form of neurosurgical intervention in only ever considered appropriate for a small minority of OCD patients, and that CBT/ERP and SSRIs continue to be the most useful and effective treatment options for nearly all of those affected by OCD. Neurosurgery is never considered appropriate unless there have been sustained trials of medication AND psychological therapies – delivered and supervised by OCD expert clinicians – and where the OCD is very disabling.

More information about the work of the Advanced Intervention Service in Dundee can be found at here.