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Malignant OCD patients require long-term medication, psychiatric care despite neurosurgery

02 Jul 2017

Malignant obsessive–compulsive disorder (OCD) has a poor long-term prognosis, a study suggests. Moreover, patients who undergo neurosurgical treatment with capsulotomy may require psychiatric treatment and psychotropic medication many years after the procedure.

To evaluate the long-term medical status of patients with severe obsessive–compulsive disorder (OCD) undergoing capsulotomy, researchers drew data from the national registers and identified 70 operated patients (mean age at surgery 39.8 years; 53 percent male) who were followed 13 to 43 years after surgery.

Hospitalization 5 years prior to and following surgery was investigated. Mortality data were derived from the Causes of Death Register, whereas psychotropic drug use was determined using the Prescribed Drug Register.

By the end of the study, 29 patients were dead (mean age at the time of death 68 years). There were two patients who had committed suicide and one had died of suspected suicide. Admission to a psychiatric ward in the 5 years preceding surgery and in the first 5 postoperative years was reported in 70 and 84 percent, respectively. About 75 percent overall were prescribed at least two psychotropic medications, often at high doses, the most common being antidepressants.

The present data show that malignant OCD has a poor long-term prognosis. Patients who are candidates for capsulotomy and their families should be informed that, while OCD symptoms may be improved with surgery, long-term freedom from medication and psychiatric care should not be expected.

In light of the findings, patients with severe, malignant OCD should be closely monitored and followed-up by a specialist OCD team to minimize morbidity and mortality, researchers said.

OCD is characterized by structural and functional alterations in cortico-striato-thalamic, limbic and parietal circuits. During capsulotomy, lesions are placed in the anterior limb of the internal capsules. Created using radiofrequency heating (thermocapsulotomy) or gamma radiation, the capsulotomy lesions involve fibres connecting the mediodorsal thalamus and the prefrontal cortex. [Am J Psychiatry 2014;171:340–9; Neuropsychopharmacology 2014;39:1547–57; Arch Gen Psychiatry 2010;67:701–11]

Neurosurgery has been performed as a last-resort treatment for patients with severe OCD who do not respond to traditional pharmacological or psychotherapeutic treatments. To date, the main indication of neurosurgery is for OCD, although procedures such as capsulotomy and cingulotomy have been used for a number of disorders in the past. [Am J Psychiatry 2014;171:340–9]

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