Have you ever wondered about using Deep Brain Stimulation, DBS, for kids dealing with Obsessive Compulsive Disorder, OCD? It's a hot topic among parents, but do we have enough evidence to back up this rather intense treatment? Let's dive in and take a closer look at deep brain stimulation.

Published On: 01/15/2023

Duration:  11 minutes, 49 seconds

Transcript:

JOSH FEDER: Welcome to the Carlat Psychiatry Podcast. This is another special episode from the Child Psychiatry team. I'm Dr. Josh Vader, the editor-in-chief of the Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice, second edition, 2023, and the other book, Prescribing Psychotropics.

MARA GOVERMAN: And I'm Mara Goverman. A licensed clinical social worker in Southern California with a private practice and an avid reader of the Carlat Psychiatry Report. Today we are looking at deep brain stimulation as influenced by Dr. John Raiss's article in our Carlat Child Psychiatry Report, October/November/December 2023 issue. To start, let's lay the groundwork for deep brain stimulation. Dr. Feder, could you share some insight into how this technique operates? 

JOSH FEDER: Sure, Deep Brain Stimulation, DBS, may be described as a high-tech fix for certain brain-related issues. Fix might be a generous word. Its mechanism involves modulating hyperactive brain networks by delivering controlled electrical stimulation to precise brain regions using an implanted pulse generator in the chest wall. Imagine this: tiny electrodes get implanted into specific spots in the brain tied to things like Parkinson's tremors or OCD symptoms. These electrodes link up to a gadget similar to a pacemaker snug under your skin around the chest. This gadget sends out steady electrical pulses calming down those brain areas that are acting up. Kind of like a pacemaker for the brain. When other treatments fall short or cause problems, DBS steps in. It's reversible so they can tweak or remove the device, but it's not a walk in the park. It involves surgery and needs careful monitoring to fine-tune the settings and get the best results with fewer side effects.

MARA GOVERMAN: Thanks for the helpful visual. While we're on the topic, we can also describe the other component to our discussion today. OCD, Obsessive Compulsive Disorder, is a mental health condition marked by recurring intrusive thoughts, obsessions, and repetitive behaviors or mental acts, compulsions. These obsessions can cause significant distress and anxiety, leading individuals to perform compulsions as a way to temporarily alleviate the anxiety a feared outcome. OCD can greatly impact daily life, relationships, and overall functioning, particularly when it occurs comorbidly with other conditions. It's considered a chronic condition, but treatments like therapy and medication can help manage symptoms effectively. One of these possible treatments being deep brain stimulation. Dr. Feder, it's common for parents to wonder about using deep brain stimulation, DBS, for their kids with obsessive-compulsive disorder, OCD. But people are curious if there is solid data backing up this pretty invasive treatment. What is your take? 

JOSH FEDER: DPS has a clear role in adults for tremor and Parkinson's disease, for essential tremor, and also for dystonia, and it's under investigation as a potential treatment for OCD in adults. This treatment is not a quick option. Optimizing its effects requires a gradual adjustment of stimulation levels over months, sometimes up to a year. The choice of specific brain targets for stimulation remains uncertain despite utilizing multiple sites. This procedure is not without risks. There can be surgical and hardware complications such as infection, brain hemorrhage, and device migration, meaning that the implant moves to the wrong place and device malfunction. That's when you implant the thing and it doesn't work at all or sends the wrong signal. Moreover, abrupt cessation of DBS may provoke severe escalations and psychiatric symptoms, including the obsessions and compulsions but also depression and anxiety, and even suicidal behavior. So while DBS is promising, it begs careful consideration due to its intricacies and potential ramifications, particularly when it comes to children experiencing severe intractable OCD.

MARA GOVERMAN: That is a really good point to touch on. Right now, using deep brain stimulation, DBS, outside research environments isn't the norm. For those under 18, it's typically a no-go, partly because long-term studies tracking young OCD patients found that most tend to improve over time without needing DBS. 

JOSH FEDER: Yes, even at adults, some big studies, a couple of randomized and blinded trials didn't find DBS effective for refractory major depression. But here's the twist, despite what the studies say, there's a buzz among consumers wanting to use DBS to help kids and teens dealing with OCD. It's interesting given the current guidelines and what we know from research. 

MARA GOVERMAN: I think it's crucial to look into this because it's tricky when the demand for a treatment isn't balanced out by considering the potential risks it carries.

JOSH FEDER: Yes, and Dr. Raisse's review provides a fascinating glimpse into how the general public perceives DBS in the context of adolescent OCD. They looked at a study that was industry-influenced, and it involved 260 individuals spanning ages 18 to 65. The participants were asked to share their opinions through a questionnaire regarding the use of DBS in adolescents coping with severe OCD. Of the participants, 106 had a history of OCD, 123 had a child with OCD, and 31 had both their own OCD history and a child with OCD. What is captivating about this study is that a substantial 63 percent of these respondents gave a nod to DBS, rating it quite positively on a Likert scale ranging from totally unacceptable to totally acceptable. It's intriguing to note that while only 15 percent found DBS unacceptable, the majority seemed open to the idea, highlighting a certain level of willingness to consider it as a potential treatment option. Digging deeper into their preferences, participants appeared more inclined to endorse DBS when considering scenarios involving a teenager experiencing suicidal thoughts. And that kind of makes sense. Assurance of substantial improvements in daily function and a significant reduction in symptoms. were key factors that swayed their opinions in favor of considering DBS. However, lurking concerns about safety aspects and potential harm to the brain or body seemed to be significant factors that made some people hesitant to fully endorse DBS. These apprehensions acted as stumbling blocks despite the potential benefits the treatment might offer. Interestingly, what didn't seem to play a significant role in shaping their views on DBS was their personal experience with DBS or the severity of their child's OCD symptoms. This suggests that while personal encounters with the condition might not directly influence perceptions of DBS, safety, and assurance of significant improvement weigh heavily in the decision-making process for individuals considering this treatment avenue for adolescent OCD. Mara, what do you think about the responses of these participants, and what do you think about treating OCD with DBS? 

MARA GOVERMAN: I believe that it's crucial to have an open and honest conversation with parents about avoiding intrusive treatments that lack sufficient evidence and may result in various side effects. Instead, let's work together and focus on exploring proven treatments that have a reliable track record. As a team, we can strive to conduct competent and comprehensive trials of these established treatments to ensure the best possible outcomes for their child. It's essential to carefully consider the risks and benefits. And make sure we're pursuing treatments that are based on solid foundation. 

JOSH FEDER: Well, that's right. And so in the rest of the issue where we have this particular research update, we go into OCD, including talking about exposure and response prevention therapy and how that works. It's really remarkable how effective that can be, and of course, we talk about the use of medications, typically SSRIs, and relatively higher doses to treat OCD as well, and these are often very effective. So, the way that I see it, DBS isn't sitting on our treatment algorithm now, and I don't think it's ready for prime time to sit on our treatment algorithm for OCD for children and adolescents any time in the near future.

MARA GOVERMAN: Most likely, DBS is not covered by insurance. It's very expensive, and we're not sure we have evidence-based research to confidently suggest that to our patients. So a second treatment plan is to provide psychoeducation. and evidence-based treatments that we do know work and perhaps are covered by insurance to help ensure quality results for our patients.

JOSH FEDER: The newsletter clinical update is available for subscribers to read in the Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get printed issues in the mail, for those who get printed issues in the mail, and email notifications when new issues are available on the website, both for the people who get the printed issues and for our online subscribers.

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MARA GOVERMAN: And everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry. 

JOSH FEDER: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don't receive industry funding. That helps us to bring you unbiased information that you can trust. 

MARA GOVERMAN: As always, thanks for listening and have a great day. 

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.