Deep brain stimulation for chronic, severe, treatment-resistant obsessive-compulsive disorder in adults

Evidence-based recommendations on deep brain stimulation for chronic, severe, treatment-resistant obsessive-compulsive disorder in adults. This involves implanting an electrode in the brain and an electrical stimulator under the skin on the chest.

# Recommendations
Evidence on the safety and efficacy of deep brain stimulation for chronic, severe, treatment-resistant obsessive-compulsive disorder (OCD) in adults is inadequate in quality and quantity. Therefore, this procedure should only be used in the context of research. Find out what only in research means on the NICE interventional procedures guidance page.
Patient selection should be done by a multidisciplinary team experienced in managing OCD. It should include experts in psychiatry, neuropsychiatry, clinical psychology, neurology, neurosurgery and deep brain stimulation.
The procedure should only be done in centres with expertise in deep brain stimulation and experience in managing OCD.
Further research should primarily be randomised controlled trials. It should clearly define the area of the brain that should be targeted in this procedure. It should also describe details of patient selection, comorbidities, and use of adjunctive therapies. Outcomes should include reduction in OCD symptoms, improvement in quality of life and any neuropsychiatric and cognitive effects.# The condition, current treatments and procedure

# The condition
Obsessive-compulsive disorder (OCD) is a mental health condition in which a person has obsessive thoughts (repeated, unwanted and unpleasant thoughts, images or urges). The person feels compelled to carry out compulsive (repetitive) behaviours to try to relieve the unpleasant feelings brought on by the obsessive thoughts.

# Current treatments
NICE's guideline on obsessive-compulsive disorder and body dysmorphic disorder describes the treatment of OCD. Treatment options include psychological interventions and drug treatment (usually selective serotonin reuptake inhibitors).

# The procedure
Deep brain stimulation for OCD is done under general or local anaesthesia. A stereotactic frame may be used. MRI or CT imaging, or both, are used to identify the target area of the brain (commonly, the anterior limb of the internal capsule). Two small holes are drilled in the skull and electrodes are implanted into the target area. The electrodes are connected to an implantable neurostimulator by leads, which are tunnelled under the skin of the neck and scalp. The neurostimulator is surgically placed into a subcutaneous pocket below the clavicle. Postoperative imaging is usually used to confirm the location of the electrodes. A handheld remote-control programming unit is used to turn the neurostimulator on or off and adjust stimulation parameters to find the right level of stimulation.
Although the mechanisms of action of deep brain stimulation are not fully understood, the aim of the procedure is to reduce the obsessive-compulsive thoughts and behaviours. A potential advantage of the procedure is that the stimulation can be adjusted according to the clinical effect and if necessary, stopped completely. It can be used as an adjunct to medication and as an alternative to neurosurgery for treatment-resistant OCD.