New Hope, for OCD, Is Insurance Covered*, Thanks to This Very Persuasive Newsletter
Evernorth Behavioral Health, as of September 15th, covers dTMS for OCD, and I am completely serious and not at all kidding that it is all thanks to this very newsletter and no one else.
TL;DR the title is making fun of me. But Evernorth, formerly CIGNA, now covers dTMS for OCD!
To be clear, I didn’t do it. It’s been a heroic team effort that took industry1, professional society committees2, payers,3 doctors4, patients5, researchers,6 and even journalists7, all working together. I had a tiny part in the story. Yes, it’s a joke about me being a big narcissist. Yes, I understand people think that.8 No, I don’t believe it to be accurate—I was worried so I asked my psychiatrist to check several times.9 No, I don’t take it as an insult! NPD is a real and serious illness, about which I have contributed scholarly work! Yes, there is some truth to me being a little… confident. I’m a good enough physician.10 This part was supposed to be short!11 C’mon, meta-commentary in my head, let’s stop stalling and write this piece about obsessing already…12
Welcome to Our Keeping up With the News Column for This Week!
In the August 2nd, 2022 article I wrote addressing prior-authorization denial for theoretically experimental and unproven treatments, I made a strident argument which is:13 It is unethical to continue to request more data after FDA clearance for feigned dubiousness about efficacy. The specific treatment I’m referring to here (deep TMS)14 involves brain stimulation15 that is non-invasive16 and causes no permanent changes in brains, and is still the most effective biological treatment17 for obsessive compulsive disorder.
TMS works by creating pulsing, strong magnetic fields that can cause neurons in your brain to fire in a new pattern. This new rhythm of firing interrupts the repetitive thought neural circuit18—this circuit tortures people with obsessions.
We should define what we mean by OCD, for all of my dear readers:
But I’m Messy! I Can’t Have OCD!
OCD, it’s not just hand washing. It’s awful. People can not-stop-thinking-about-it. This is more than just “being contaminated and washing your hands.” It’s thoughts like: “what if I killed someone? What if I am a secret serial killer?” Or even “I might rape that child…what if I’m a pedophile?!”—psychopath serial killers or pedophiles don’t worry about those things. They are, in a way, free of doubt. They may have other problems, but they know for sure who they murdered and that they are sexually attracted to kids. They are not in doubt. OCDBrain is, in the worry and doubt checking game, like most people are when they check their phones:
Imagine if every time you checked your phone it wasn’t to see if you missed a text…
It was to make sure you hadn’t murdered someone. That’s crazy. Of course you didn’t. BING. Let me check one more time. Phew. I guess I di—BING—maybe one more che—BING—I could go back home to double ch—BING. 8, 10, 22, all Hours of the day. Every day. All day. Nearly all the—BING—time. BING. BING. Wait, did I miss a message? I’ll just casually ch—BING.
And, perhaps, the most horrifying version of this is for people with “Harm OCD”, where sufferers become obsessed with suicide. Or, with the worry that they might complete suicide. Horrible images barge into your head, unbidden:
“Hang yourself, there is rope, do it, hang yourself hang yourself hang hang HANG.”
“If you’re not careful enough…”
“How can you be so sure you won’t stab yourself in the neck with that pen? Maybe you should just go to the hospital, just in case you might?”
Even if you didn’t personally want to die at all, and you like your life otherwise, these sorts of thoughts-you-can’t-shake-for-hours are profoundly disturbing. The “compulsive” symptoms are not the real story of OCD. Other people can see them, so they get a spotlight. They are a way to reduce the distress of thinking about awful things, if only for a few seconds. This is what coping looks like when you brain has a horror show on repeat. Obsessions, they are the core. People regularly suffer for years and have no idea this is not what other people are also doing in their heads too. They can be in their 60s before they timidly admit “I know it sounds crazy BUT…” to their psychiatrist. And maybe that is a year into treatment. Or more. Or never. Who wants to admit to thinking about hurting children? Thought crimes aren’t real… except to people with OCDbrain, quietly condemning themselves for their evil, criminal, secret psychopath thoughts.
No wonder 14% of people with OCD will attempt suicide at least once. Death-to-suicide rates in OCD are shown to range from 0.7% to 1.4% .
This compares horrifically to other illness in terms of suicide risk (we measure these in “per 100,000”). The base rate in the population, per the World Health Organization is 10.7/100,000.
OCD, in these terms, has a completed suicide rate of 700-1,400/100,000.
To compare, in depression, it’s 214/100,000. Borderline Personality Disorder is a leader, at around 5,000/100,000, and schizophrenia at between 5000-14000/100,000. In bipolar disorder, in a 20 year follow up by Jamison and Goodwin19, it was 9,800/100,000. Eating disorders are higher still.
Yes, you read that correctly. OCD is more lethal in amount of death due to suicide than Major Depression. It’s also more common, and they both suck. But still. It’s almost an order of magnitude more lethal. (Reference here, in body text, because this is such a major claim: The Epidemiology of Suicide by Silke Bachmann, Int J Environ Res Public Health. 2018 Jul; 15(7): 1425.)