Deep Brain Stimulation (DBS) For Obsessive Compulsive Disorder (OCD)
It's Not Exactly Brain Surgery, other than being literal brain surgery.
The Frontier Psychiatrists is a daily health-themed newsletter. Today, I'm doing a little bit of an overview about a treatment modality that I don't provide.
There are two noble prizes in Psychiatry, for interventions. The first was awarded to Julius Wagner-Jauregg, M.D., in 1927 for the development of malaria therapy for the treatment of neurosyphilis, or “general paresis of the insane.”
Yes, we gave people malaria as a treatment for insanity. It turns out that syphilis is caused by the parasite Treponema palladium, dies at a temperature of 104°F, and malaria, another parasitic infection, creates waxing and waning fevers, that get up to 105°F. And so, if you're able to infect somebody who happens to have neurosyphilis, those spirochetes in the brain, with malaria, the temperature will get so high that it's a biological treatment that kills the bugs that was making individuals insane. In the early part of the 20th century, when Warner-Jauregg developed this treatment modality, it actually emptied about 10% of the inpatient psychiatric volume at the time.
This was the first Nobel in Psychiatry. The second psychiatric treatment to win a Nobel prize was awarded to a neurosurgeon, Antonio Egas Moniz, about whom I've written previously. He was from Portugal, and the trans orbital phlebotomy was his second Nobel nomination but the first win. His earlier discovery is still used today: Moniz was responsible for cerebral angiography. These early neurosurgical interventions were based on extremely early data on neural circuits:
With the emergence of relatively crude models of the functional and structural neuroanatomy of mood and behavior regulation [e.g., Papez’ circuit (Papez 1937)], researchers hypothesized that abnormal mood and behavioral regulation derived from dysfunctional thalamo-cortical communication (Moniz 1937). Neurosurgical treatments thus shifted to disrupting the white matter tracts connecting these regions, culminating in the prefrontal leucotomy (Moniz 1937) which was later referred to as the prefrontal lobotomy.1
All of which is to say that interventional psychiatry has a much more distinguished track record than medication-centric Psychiatry, at least as far as the Nobel committee is concerned.
This brings us to today's topic: a 30,000 ft. overview of deep brain stimulation, DBS for short.
Before we move into the details, I'm gonna poke one of my neurosurgical colleagues for a minute. The following clip is from one of the finer British comedy shows, the Michell and Webb look, and, in this video, we meet a neurosurgeon, who's anxious to tell everyone else at the party what he does for a living.
Deep Brain Simulation is neurosurgery. As a reminder, everything we do in Psychiatry seems insane—on the part of the medical provider—until you remember that psychiatric illnesses can be really bad. Nobody would look sideways at a neurosurgeon, removing a tumor because we recognize that brain cancer is bad. People have neurosurgery to correct problems in their spine because we recognize that your spine being compressed is also bad. So, if you're wondering why anybody would want to drill into a brain to relieve a psychiatric problem, it's because the problem is terrible for some people. Many individuals have psychiatric illnesses that aren't very bad, and everybody has experiences that arise in the brain with varying levels of severity or impairment. It's easy to imagine that your bad mood and the pervasively and horrifically bad mood of somebody with depression are similar, but it's important to remember that they can be different, not just in degree but in kind. Similarly, just because you can get "really obsessive” about your sports car enthusiasm, or whatever it is, it doesn't follow that this is the same kind of experience that drives someone with OCD to suicide attempts.
Yes, as a reminder, obsessive-compulsive disorder, or OCD, has one of the highest rates of completed suicide—which people often don't think about. It’s on the order of 5000/100,000, which compares unfavorably to bipolar disorder at 200/100,000 and just being alive in America at 17/100,000.
Therefore, once you accept that a problem is a very bad problem, and deserves a serious, and durable solution. If that problem originates in the brain, it makes sense to think about the role of our neurological and neurosurgical colleagues.
The first review on Google scholar is coauthored by a medical school mentor, Jon Mink, M.D., as it turns out:
This approach was pioneered in movement disorders like Parkinson's disease. This disorder is thought to function through altering brain circuit function. Of note, while psychiatry has continued to futz around with the nonsense about brain chemistry despite ample evidence to the contrary—neurology (movement disorders specifically) and neurosurgery have moved well into the circuit based understanding of their disorders. Here is a diagram of the brain circuits thought to be involved in Parkinson’s disease2:
Here is what the procedure involves, if you are watching from the outside. A patient first gets what can be more than one brain scans. One of them is a magnetic residence imaging scan, or MRI, and the other is computed tomography or CT, which is an x-ray modality. These two scans are overlaid on top of each other. CT gives really clear imaging of bone, and blood, but not such great pictures of the brain itself. MRI can give very high resolution images of the brain, but does a less good job with bone. For very precise brain surgery like DBS, often an additional MRI sequences are obtained, including functional fMRI and magnetic resonance tractography, which follows the white matter track as they travel through the brain.
This allows detailed knowledge of both structure and function of the brain, which allows for a precisely calibrated and maximally safe approach.
Generally, the head is shaved. There are some debate on this topic, and I'm not a neurosurgeon, so I don't know all the details, but my understanding is that many surgeons prefer to reduce the risk of infection by getting rid of hair that could lead to infection.
A small incision is made in the skin of the scalp, and a small hole is drilled through the skull. Through this small hole in the skull, a probe is inserted in the brain, and, like a needle, gradually inserted through the soft brain till the tip is exactly in the right place. Around the tip are a number of electrodes, with precise spacing, that can generate pulses. The tip of this probe, when hooked up to an electrical stimulator, can convey a precise series of pulses into a specific part of the brain, that can stimulate a brain circuit from deep inside.
The surgery is sometimes done on one side, and sometimes bilaterally (as in OCD), in two separate surgical visits, depending on the problem the surgeon is trying to solve, along with the rest of the team.
These probes are then hooked up, under the skin, to a battery pack and stimulator in the upper chest, implanted like a pacemaker.
It's a pacemaker… for your brain.
Readers might be thinking, but don't they destroy some of my brain in the process? And the answer is, a little bit, yeah, and it turns out not to matter that much. The brain functions a lot more like a dance routine than a roof of a building. But I mean by that is if you put a hole in a roof, the roof doesn't really work as well to keep out the rain, and it's all gonna come through the hole, unless it's a very tiny hole, which in this case, it is. However, the brain is a lot more like a dance routine, and if you can imagine a bunch of dancers having to go through a routine on a stage, and then there is a floorboard that pops loose, and there's a hole in the stage of a couple inches square, the dance is gonna go on, because the dancers will adjust Their movements to avoid that hole. If the hole in the stage isn't very big, the dancers will just move around it.
The brain works a lot more like a dance routine then it does a piece of computer hardware, or a static roof, it's a dynamic system that's recalibrating it’s circuits in real time to address changes in the hardware, like that tiny injury from the insertion of an electrode.
Modern electrodes can do more than just stimulate—they can read neural activity as well. For example, closed-loop DBS systems simultaneously record and stimulate neural activity, allowing the stimulation to be adjusted according to disease-specific neural biomarkers.3
One could at this point wonder if, beyond Parkinson’s disease, essential tremor, and dystonia, psychiatric conditions—also originating in brain circuits, could be treated with DBS?
Helen Mayberg, M.D.4—a noted innovator in psychiatric DBS research—opens her 2011 review on the topic with Shakespeare quote:
Diseases desperate grown,
By desperate alliances are relieved,
Or not at all.
William Shakespeare, Hamlet, Act 4, Scene 3
Is she a Frontier Psychiatrist, or what?
In my opinion, the most progress has been made in the treatment of OCD. In this indication, DBS has the FDA status of a “humanitarian device exemption”—it’s not cleared, but the data is strong enough that it can be deployed outside of a clinical trial.
My colleague at MSSM, Dr. Figee, and colleagues authored a really excellent review, in which they highlight this meta-analysis data on OCD treated with DBS (from 2015).
From 16 studies, the average percentage of responders to DBS was 60.0% (95% CI¼ 49.0–69.0%), with response being defined as an OCD symptom decrease between at least 30–35% measured on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The mean reduction of Y-BOCS score after DBS was available for 66 patients and was estimated to be 45.1% (95% CI¼ 29.4–60.8%).5
And a more recent meta-analysis by Dufault (2025), et. al., (a paper still in pre-print) demonstrates robust effects in Treatment Resistant OCD6:
The authors summarize:
DBS reduced Y-BOCS scores by 18% or 7·3 points (p<0·01), while open trials showed 43% or 14·5 point improvement (p<0·01) at last follow-up. Improvements were significant within 12 months (39·7%, 13·7 points, p<0.01) and beyond 12 months (49·8%, 17·3 points, p<0.01). Secondary analysis revealed that DBS significantly alleviated anxiety (d=1·1) and depressive symptoms (d=1·0) and improved global functioning (mean difference 25·5). At last follow-up, 59·5% od participants were responders (≥35% Y-BOCS reduction), and 35·6% achieved remission (≤14 Y-BOCS). No predictors of response were identified. Not all DBS-targets were equally effective.
This is hopeful data for patients suffering from serious problems. In essential tremor, Parkinson’s disease, and more, this is a standard of care.
In psychiatry, maybe as our field embraces circuit-based explanations, it’s possible we will get more comfortable embracing durable circuit-based therapeutics like DBS? I’m headed to a consultation with one of my patients in the very near future. Stay tuned.
Holtzheimer PE, Mayberg HS. Deep brain stimulation for psychiatric disorders. Annu Rev Neurosci. 2011;34:289-307. doi: 10.1146/annurev-neuro-061010-113638. PMID: 21692660; PMCID: PMC4413475.
Miocinovic, S., Somayajula, S., Chitnis, S., & Vitek, J. L. (2013). History, applications, and mechanisms of deep brain stimulation. JAMA neurology, 70(2), 163-171.
Krauss, J. K., Lipsman, N., Aziz, T., Boutet, A., Brown, P., Chang, J. W., ... & Lozano, A. M. (2021). Technology of deep brain stimulation: current status and future directions. Nature Reviews Neurology, 17(2), 75-87.
Holtzheimer, P. E., & Mayberg, H. S. (2011). Deep brain stimulation for psychiatric disorders. Annual review of neuroscience, 34(1), 289-307.
Graat, I., Figee, M., & Denys, D. (2017). The application of deep brain stimulation in the treatment of psychiatric disorders. International Review of Psychiatry, 29(2), 178-190.
Dufault, S., Potvin, S., & Patry, S. Efficacy of Deep Brain Stimulation Anatomical Targets for Treatment-Resistant Obsessive-Compulsive Disorder: A Systematic Review and Meta-Analysis. Available at SSRN 5118871.