OCD: One of the Most Difficult Mental Health Disorders to Treat

Obsessive-Compulsive Disorder (OCD) is a disorder in which the person has a combination of obsessive thoughts associated with compulsive behaviors that temporarily relieve the obsessive thought. In someone with OCD, the OCD prompts them to think random thoughts have meaning.  Most everyone has random thoughts but someone with OCD the random thoughts become obsessions because of the meaning that becomes associated with the thoughts due to OCD.  OCD obsessions are lasting and unwanted thoughts that keep coming back.  The obsessions are often focused on a particular theme such as a fear of contamination, dirt, or germs, or having a fear of saying or doing the wrong things, or the need to have things organized in a certain way, or some OCD can be focused on aggressive or horrific thoughts, while some can have unwanted thoughts of a sexual nature or religious theme.

To be diagnosed as OCD these thoughts and compulsions need to be taking a toll on the person’s ability to function normally.  Typically spending an hour or more in a day on these obsessions and compulsions.  This necessitates the need for treatment.  The first line of treatment for OCD is therapy and medications.  The therapy that is most effective for OCD is Exposure Response Prevention (ERP).  This type of therapy challenges the person to be exposed to one of their triggering obsessions and then to resist doing the compulsion.  Initially one makes a hierarchal list of obsessive thoughts and associated compulsions and ranks these in descending order of the intensity of anxiety these provoke.  Then in therapy one works on the easiest one until that no longer is problematic.  Working oneself up the list.

Often times OCD is difficult to resist and the person feels little control over the compulsion to do what OCD is telling them to do in order to temporarily escape the obsessive thought.  For this reason, medications are often introduced to help lessen OCD’s “control” and help the person have more control over OCD.  The first line of treatment medication is an SSRI or serotonin based antidepressant, these and a tricyclic antidepressant called clomipramine (which also works on serotonin) are frequently effective in taking the edge off OCD.  Another approach is the supplement N-acetyl cysteine (NAC) which has been studied and shown to be effective in helping treat OCD.

One indication of the difficulty in getting adequate relief from OCD is the fact that in studies looking at medication treatments for OCD, the placebo arm does not typically show any response.  This is in contrast to studies looking at the effectiveness of medications for other mental health indications such as depression and anxiety where placebo effect can be significant.

Transcranial Magnetic Stimulation (TMS) is now FDA approved as a non-medication treatment option for OCD that has been unresponsive to medications and therapy.  At Brighter Day Psychiatry we have the Brainsway TMS machine and specifically the OCD helmet (or H7 helmet) which is specifically designed to target the area of the brain involved in OCD.  Although FDA approved, insurance coverage has been lagging.  Thus far only Cigna has a specific coverage policy for prior authorizing TMS treatments in individuals for whom medications and therapy have failed.  Other insurances may cover but the process is not as smooth and may require a single case agreement.  Typically, when Medicare covers these types of treatments then other insurance companies are quick to follow.

Brain scans of patients with OCD clearly show hyperactivity in the orbitofrontal cortices (OCC)/anterior cingulate cortices (ACC) when at rest or provoked to perform behaviors or emotions.  The study which led to FDA approval of TMS for OCD in 2019 was randomized, double-blind placebo controlled. This study and the pilot study which preceeded it were the first to show positive results from stimulation of the ACC and mPFC in the brain.  This study recruited 99 patients from 11 clinics and were divided into two groups a sham or a dTMS group.  The dTMS group received 6 weeks of daily dTMS with the Brainsway H7 coil.  Each treatment was administered after provoking OCD obsessive thoughts to activate the relevant brain areas.  Results showed that 38% of the active group had a >30% reduction in OCD symptoms and the sham group 11.1% had a >30% reduction in OCD.  By the end of the study 54% improved (20% reduction in OCD symptoms)  in the active group and 26.7% improved in the sham group.  The sham group had also received the provocation but no TMS stimulation.

If you or someone you love is struggling with OCD after treatment with medications and therapy it might be time to explore if TMS is right for you.  Contact us here at Brighter Day Psychiatry to find out whether you would be a good candidate for this treatment option.