Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Deep Brain Stimulations for Obsessive-Compulsive Disorder: Update of the 2014 Guidelines

The authors¹ have undertaken a 5-yr review of previously published evidence-based guidelines² for the use of deep brain stimulation (DBS) for the treatment of medically refractory obsessive compulsive disorder (OCD). The authors are to be commended both for following a rigorous process for developing the guidelines, as they have both updated the evidence tables with publications that have appeared since the previous paper, as well as repeating and broadening the previous literature search by including the EMBASE database. OCD DBS in the anterior limb of the internal capsule (ALIC) remains approved by the Food and Drug Administration (FDA) under a humanitarian device exemption (HDE),³ but continues to be listed as experimental/investigational by many insurance plans, thus, hindering access to the procedure for patients suffering from disabling symptoms. Documents such as these serve as signposts to the current state of the field, pointing us in the direction our future work needs to follow. It also, hopefully, allows us to present payors with summary of evidence that can serve as the basis for coverage appeals on behalf of our patients.

Unfortunately, while additional studies have appeared since the prior version of the guidelines, the recommendations have advanced little. The modern era of DBS for psychiatric disease is now over 20 yr old, yet we seem to be stalled. There are several issues at play that have led to this. It is difficult to obtain funding for trials such as these. Moreover, there are few centers with the multidisciplinary expertise to manage these patients, resulting in either low recruitment for studies or the need for patients to travel long distances to participate. This can leave these complicated patients without access to acute assistance should issues arise. Lastly, the studies that have appeared since the prior guidelines unfortunately continue to be of low quality, with either short follow-up periods, low numbers of patients, or poor design (case series).

These guidelines hopefully will serve as a motivating factor to all of us in the field to begin a coordinated effort to push the field forward. Organizations such as the American Society for Stereotactic and Functional Neurosurgery already have internal committees dedicated to psychiatric DBS but what is truly needed is a partnership between physicians (neurosurgery, psychiatry, neurology, and ethics), scientists, the FDA, and National Institutes of Health (NIH) to develop and fund high-quality research that combines what we have learned via advanced structural brain imaging and network connectivity with the advances in DBS device technology that have been approved in the last few years.

Without these efforts, it appears that the field will continue to spin its wheels and patients with severe refractory OCD will continue to remain disabled without access to this potentially affective therapy.

Funding

This study did not receive any funding or financial support.

Disclosures

The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Dr Rosenow has a consulting contract with Boston Scientific and research support from VA/DoD, NIH, Boston Scientific, SPR, Voyager Therapeutics, SetPoint Medical, and Prevail Therapeutics.