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Effectiveness, Timing and Procedural Aspects of Cognitive Behavioral Therapy after Deep Brain Stimulation for Therapy-Resistant Obsessive Compulsive Disorder: A Systematic Review.

ABSTRACT: Background and aim: Deep brain stimulation (DBS) is an effective treatment for patients with severe therapy-resistant obsessive-compulsive disorder (OCD). After initiating DBS many patients still require medication and/or behavioral therapy to deal with persisting symptoms and habitual behaviors. The clinical practice of administering postoperative cognitive behavioral therapy (CBT) varies widely, and there are no clinical guidelines for this add-on therapy. The aim of this review is to assess the efficacy, timing and procedural aspects of postoperative CBT in OCD patients treated with DBS. Method: Systematic review of literature. Results: The search yielded 5 original studies, one case series and three reviews. Only two clinical trials have explicitly focused on the effectiveness of CBT added to DBS in patients with therapy-resistant OCD. These two studies both showed effectiveness of CBT. However, they had a distinctly different design, very small sample sizes and different ways of administering the therapy. Therefore, no firm conclusions can be drawn or recommendations made for administering CBT after DBS for therapy-resistant OCD. Conclusion: The effectiveness, timing and procedural aspects of CBT added to DBS in therapy-resistant OCD have hardly been studied. Preliminary evidence indicates that CBT has an added effect in OCD patients being treated with DBS. Since the overall treatment effect is the combined result of DBS, medication and CBT, future trials should be designed in such a way that they allow quantification of the effects of these add-on therapies in OCD patients treated with DBS. Only in this way information can be gathered that contributes to the development of an algorithm and clinical guidelines for concomittant therapies to optimize treatment effects in OCD patients being treated with DBS.

SUBMITTER: Gormezoglu M

PROVIDER: S-EPMC7464329 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Effectiveness, Timing and Procedural Aspects of Cognitive Behavioral Therapy after Deep Brain Stimulation for Therapy-Resistant Obsessive Compulsive Disorder: A Systematic Review.

Görmezoğlu Meltem M Bouwens van der Vlis Tim T Schruers Koen K Ackermans Linda L Polosan Mircea M Leentjens Albert F G AFG

Journal of clinical medicine 20200726 8

<i>Background and aim:</i> Deep brain stimulation (DBS) is an effective treatment for patients with severe therapy-resistant obsessive-compulsive disorder (OCD). After initiating DBS many patients still require medication and/or behavioral therapy to deal with persisting symptoms and habitual behaviors. The clinical practice of administering postoperative cognitive behavioral therapy (CBT) varies widely, and there are no clinical guidelines for this add-on therapy. The aim of this review is to a ...[more]

PMID: 32722565

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Project description:BACKGROUND: In spite of advances in psychotherapy and pharmacotherapy, there are still a significant number of patients with depression and obsessive-compulsive disorder that are not aided by either intervention. Although still in the experimental stage, deep brain stimulation (DBS) offers many advantages over other physically-invasive procedures as a treatment for these psychiatric disorders. The purpose of this study is to systematically review reports on clinical trials of DBS for obsessive-compulsive disorder (OCD) and treatment-resistant depression (TRD). Locations for stimulation, success rates and effects of the stimulation on brain metabolism are noted when available. The first observation of the effects of DBS on OCD and TRD came in the course of using DBS to treat movement disorders. Reports of changes in OCD and depression during such studies are reviewed with particular attention to electrode locations and associated adverse events; although these reports were adventitious observations rather than planned. Subsequent studies have been guided by more precise theories of structures involved in DBS and OICD. This study suggests stimulation sites and prognostic indicators for DBS. We also briefly review tractography, a relatively new procedure that holds great promise for the further development of DBS. METHODS: Articles were retrieved from MEDLINE via PubMed. Relevant references in retrieved articles were followed up. We included all articles reporting on studies of patients selected for having OCD or TRD. Adequacy of the selected studies was evaluated by the Jadad scale. Evaluation criteria included: number of patients, use of recognized psychiatric rating scales, and use of brain blood flow measurements. Success rates classified as "improved" or "recovered" were recorded. Studies of DBS for movement disorders were included if they reported coincidental relief of depression or reduction in OCD. Most of the studies involved small numbers of subjects so individual studies were reviewed. RESULTS: While the number of cases was small, these were extremely treatment-resistant patients. While not everyone responded, about half the patients did show dramatic improvement. Associated adverse events were generally trivial in younger psychiatric patients but often severe in older movement disorder patients. The procedures differed from study to study, and the numbers of patients was usually too small to do meaningful statistics or make valid inferences as to who will respond to treatment. CONCLUSIONS: DBS is considered a promising technique for OCD and TRD. Outstanding questions about patient selection and electrode placement can probably be resolved by (a) larger studies, (b) genetic studies and (c) imaging studies (MRI, fMRI, PET, and tractography).

Project description:ImportanceTherapist-guided, internet-delivered cognitive behavioral therapy is an effective treatment option for children and adolescents with obsessive-compulsive disorder, but to our knowledge, its cost-effectiveness compared with traditional in-person treatment has not been established.ObjectiveTo evaluate the cost-effectiveness of guided internet-delivered cognitive behavioral therapy implemented within a stepped-care model compared with in-person cognitive behavioral therapy for young people with obsessive-compulsive disorder.Design, setting, and participantsThis economic evaluation of a randomized noninferiority trial conducted at 2 specialist obsessive-compulsive disorder clinics in Sweden enrolled 152 children and adolescents aged 8 to 17 years with obsessive-compulsive disorder, mainly through clinician referrals (110 [72%]). Recruitment began October 6, 2017, and ended May 24, 2019. Follow-up ended April 14, 2020.InterventionsParticipants were randomly assigned to receive either guided internet-delivered cognitive behavioral therapy or in-person cognitive behavioral therapy during a 16-week period. At the 3-month follow-up, nonresponders in both groups were offered additional in-person cognitive behavior therapy sessions.Main outcomes and measuresHealth outcomes were treatment response rates (primary outcome), remission rates, and quality-adjusted life-years. Cost data were collected before treatment, after treatment, at 3-month follow-up, and at 6-month follow-up (primary end point) and are presented in 2020 US dollars. The differences in incremental costs and health outcomes were compared between the groups and presented from the health care professional, health care sector, and societal perspectives.ResultsA total of 152 participants (94 girls [62%]; mean [SD] age, 13.4 [2.5] years) were randomized; 151 (99%) completed the trial. At the 6-month follow-up, 50 of 74 participants (68%) in the stepped-care group and 52 of 77 participants (68%) in the in-person cognitive behavioral therapy group were classified as treatment responders (odds ratio, 1.00 [95% CI, 0.51-1.98]; P = .99). Health economic analyses showed that the stepped-care group used fewer therapist resources than the in-person cognitive behavioral therapy group, resulting in a mean cost savings of $2104 (95% CI, $1202-$3006) per participant for the full study period of 10 months, corresponding to a relative savings of 39%. The cost savings remained largely comparable when taking wider health care sector and societal perspectives.Conclusions and relevanceThis study suggests that, for young people with obsessive-compulsive disorder, a low-cost digital intervention followed by in-person treatment for nonresponders was cost-effective compared with in-person cognitive behavior therapy alone.

Dataset Information

Effectiveness, Timing and Procedural Aspects of Cognitive Behavioral Therapy after Deep Brain Stimulation for Therapy-Resistant Obsessive Compulsive Disorder: A Systematic Review.

Publications

Effectiveness, Timing and Procedural Aspects of Cognitive Behavioral Therapy after Deep Brain Stimulation for Therapy-Resistant Obsessive Compulsive Disorder: A Systematic Review.

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