News Flash: Study Published on Focused Ultrasound Treatment of OCD
DECEMBER 9, 2014
Current Treatment for OCD
Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by recurring anxiety-provoking thoughts (obsessions) that are alleviated only by ritualistic actions (compulsions) such as hand washing. OCD symptoms can be overwhelming and result in severe impairment and dysfunction. Patients also have a high risk for depression, with two-thirds of OCD patients developing major depression.
Although a large portion of OCD patients improve with drug therapy, some patients have debilitating symptoms that are resistant to treatment. For these patients, psychosurgery can be performed to destroy (ablate) a targeted region of the brain (anterior internal capsule) associated with the disorder. The currently available ablative approaches are invasive or involve radiation:
Radiofrequency ablation requires drilling into the skull and inserting a probe through the brain.
Stereotactic radiosurgery takes months to achieve an effect and may be associated with side effects of radiation.
Deep brain stimulation has been used as a reversible and adjustable alternative to ablation, but it involves the risks and complications of surgery to implant the system and additional operations for battery changes.
Potential of Focused Ultrasound for OCD
Focused ultrasound has the potential to be a completely non-invasive approach for treating patients whose OCD is resistant to medical therapy. The target is an area of the brain that is easily reached and relatively small. If the positive results of Dr. Chang's proof-of-concept study are confirmed, then a larger pivotal study would be warranted to assess the definitive safety, effectiveness, and long-term durability of focused ultrasound to treat OCD.
In a study of feasibility, safety and preliminary efficacy, four patients with disabling OCD unresponsive to medical therapy were treated by ablating small targets deep in the brain (anterior internal capsule) using the InSightec ExAblate Neuro MR-guided focused ultrasound system. This proof-of-concept study is being conducted with 12 patients by Jin Woo Chang, MD, PhD, at the Yonsei University Medical Center in Seoul, Korea. The results of the first four patients with six months follow-up were published.
All four patients had the targeted areas of the brain successfully ablated. The procedures were accomplished without complications or side effects and resulted in gradual improvement in obsessive-compulsive thoughts and behaviors as well as showing the nearly immediate and sustained improvement in depression and anxiety over six months.
"There is a need for non-invasive treatment options for patients with OCD that cannot be managed through medication," says Dr. Chang. "Using focused ultrasound, we were able to reduce the symptoms for these patients and help them get some of their life back without the risks or complications of the more invasive surgical approaches that are currently available."
"If these initial results are confirmed in the remaining eight patients in this study as well as in a larger pivotal trial of safety and efficacy, focused ultrasound could emerge as an alternative to surgery for improving quality of life in a cost-effective manner for patients with OCD," said Foundation Chairman Neal F. Kassell, MD. "This could also serve as the predicate for non-invasive therapy for other psychiatric disorders."
Dr. Chang plans to start a study using focused ultrasound to treat depression in 2015.
Dr. Cosgrove, Adjunct Professor of Neurosurgery at Brown University, has been performing psychiatric surgery for over 20 years. He is interested in using focused ultrasound as a non-invasive method to treat patients with severe OCD and depression and will hopefully begin studies soon.
"Surgery remains an important therapeutic option for patients with severe, disabling OCD and is probably underutilized." – Dr. Rees Cosgrove
Focused Ultrasound: A Possible New Non-Invasive Psychosurgical Approach?
Commentary by Dr. Rees Cosgrove, MD, FRCSC
The preliminary results of bilateral anterior capsulotomy performed using focused ultrasound in four patients with severe, treatment refractory OCD is very encouraging. Although a very small series, the results are completely consistent with larger studies in similar OCD patients who have undergone either radiofrequency ablation or stereotactic radiosurgery.
Using clinically validated rating scales, Dr. Chang’s team observed early and sustained improvement in symptoms of anxiety and depression followed by a more delayed improvement in OCD symptoms. Interestingly, this latency between the acute lesioning effect and subsequent therapeutic benefit has been observed in larger studies of anterior capsulotomy with longer follow-up. This improvement continues over subsequent years, and I would expect that the overall improvement will be even better at one and two years.
Even more importantly, they found no acute complications from the procedure, and there was no change in neuropsychological test results at six months as compared to baseline. Many of the criticisms of any sort of surgical intervention for psychiatric illness suggest that while the procedures may be effective, they are often accompanied by unwanted cognitive or neuropsychological changes. This seems not to be the case with focused ultrasound.
It must be emphasized that any surgical intervention for OCD should not be considered as curative, only as an important adjunct to facilitate the other proven therapies of behavioral and psychopharmacological treatments. In order for it to be applied more widely, focused ultrasound must be proven in larger studies to be both safe and effective.
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