A Systematic Review of Clinical Practice Guidelines on the Use of Deep Brain Stimulation for Obsessive-Compulsive Disorder

Abstract

Aims

Deep brain stimulation (DBS), an invasive neurosurgical treatment where electrical stimuli are delivered in target brain areas, is an intervention that has traditionally been used for neurological movement disorders, but that has recently been considered for the management of psychiatric conditions, one of these being obsessive compulsive disorder (OCD). This review aimed to identify and assess clinical practice guidelines on the use of DBS for OCD, and, secondly, whether or not recommendations are tailored to individual patient characteristics, such as age, gender and comorbidities.

Methods

A systematic search of MEDLINE, EMBASE, APA Psych Info and Scopus was conducted, along with guideline development organisation websites, using all relevant synonyms of: “Guideline and DBS and OCD”. Studies were assessed by two independent reviewers, and discrepancies managed by a third reviewer. The protocol was registered with PROSPERO, following the PRISMA checklist. Included guidelines were appraised using the AGREE-II instrument.

Results

Nine guidelines were identified in total. Eight recommended DBS as a last-line option in the management of OCD, whilst the National Institute for Health and Care Excellence (NICE) recommended DBS should be used for research purposes only in OCD. Variability in the recommendations was also noted; indeed, only NICE undertook a cost-effectiveness analysis, and only the Congress of Neurological Surgeons (CNS) recommended target areas for electrode placement (i.e. subthalamic nucleus and nucleus accumbens). No guidelines clarified DBS settings, nor peri-operative optimisation measures. Patients’ preferences, age groups differences, ethnicity or comorbidities were not considered by any guideline. The guidelines’ quality ranged from moderate to high (50–92%), as per AGREE-II, with domains ‘scope and purpose’ and ‘editorial independence’ scoring the highest and ‘applicability’ and ‘stakeholder involvement’ the lowest across all guidelines.

Conclusion

Whilst eight guidelines supported the use of DBS for OCD as last-line therapy, a lack of cost-analysis, specific DBS settings, peri-operative procedures, and patients’ circumstances were analysed. Given the lack of randomised controlled trials in this field, more rigorous research is needed prior to wider DBS implementation.