Clinical outcomes of deep brain stimulation for obsessive-compulsive disorder: Insight as a predictor of symptom changes.

AIM: Deep brain stimulation (DBS) is a safe and effective treatment option for people with refractory obsessive-compulsive disorder (OCD). Yet our understanding of predictors of response and prognostic factors remains rudimentary, and long-term comprehensive follow-ups are lacking. We aim to investigate the efficacy of DBS therapy for OCD patients, and predictors of clinical response. METHODS: Eight OCD participants underwent DBS stimulation of the nucleus accumbens (NAc) in an open-label longitudinal trial, duration of follow-up varied between 9 months and 7 years. Post-operative care involved comprehensive fine tuning of stimulation parameters and adjunct multidisciplinary therapy. RESULTS: Six participants achieved clinical response (35% improvement in obsessions and compulsions on the Yale Brown Obsessive Compulsive Scale (YBOCS)) within 6-9 weeks, response was maintained at last follow up. On average, the YBOCS improved by 45% at last follow up. Mixed linear modeling elucidated directionality of symptom changes: insight into symptoms strongly predicted (P = 0.008) changes in symptom severity during DBS therapy, likely driven by initial changes in depression and anxiety. Precise localization of DBS leads demonstrated that responders most often had their leads (and active contacts) placed dorsal compared to non-responders, relative to the Nac. CONCLUSION: The clinical efficacy of DBS for OCD is demonstrated, and mediators of changes in symptoms are proposed. The symptom improvements within this cohort should be seen within the context of the adjunct psychological and biopsychosocial care that implemented a shared decision-making approach, with flexible iterative DBS programming. Further research should explore the utility of insight as a clinical correlate of response. The trial was prospectively registered with the ANZCTR (ACTRN12612001142820).

Clinical recommendations for the care of people with treatment-refractory obsessive-compulsive disorder when undergoing deep brain stimulation.

Deep brain stimulation is an emerging therapy for treatment-refractory obsessive-compulsive disorder patients. Yet, accessibility is limited, treatment protocols are heterogeneous and there is no guideline or consensus on the best practices. Here, we combine evidence from scientific investigations, expert opinions and our clinical expertise to propose several clinical recommendations from the pre-operative, surgical and post-operative phases of deep brain stimulation care for treatment-refractory obsessive-compulsive disorder patients. A person-centered and biopsychosocial approach is adopted. Briefly, we discuss clinical characteristics associated with response, the use of improved educational materials, an evaluative consent process, comprehensive programming by an expert clinician, a more global assessment of treatment efficacy, multi-disciplinary adjunct psychotherapy and the importance of peer support programs. Furthermore, where gaps are identified, future research suggestions are made, including connectome surgical targeting, scientific evaluation of hardware models and health economic data. In addition, we encourage collaborative groups of data and knowledge sharing by way of a clinical registry and a peer group of programming clinicians. We aim to commence a discussion on the determinants of deep brain stimulation efficacy for treatment-refractory obsessive-compulsive disorder patients, a rare and severe patient group, and contribute to more standardized and evidence-based practices.

The challenges facing the public mental health sector: implications of the Victorian Psychiatry workforce project.

OBJECTIVES: This paper reviews the major findings of the Victorian Psychiatry Attraction, Recruitment and Retention Needs Analysis Project and considers some of the implications for the psychiatrist workforce working in public sector psychiatry. CONCLUSIONS: The report provides a snapshot of the issues that are impairing the ability of Victorian psychiatrists to comprehensively treat those in our community who have severe mental illness. As the report shows, the issues impacting the profession are multi-faceted and complex, yet surmountable.

Identity challenges and 'burden of normality' after DBS for severe OCD: a narrative case study.

BACKGROUND: Deep Brain Stimulation (DBS) is an emerging and potentially powerful biological treatment for severe Obsessive-Compulsive Disorder (OCD), but the wider impact of the intervention and the sometimes dramatic reduction in symptoms need greater attention in research and practice. The aim of this case study is to explore the subjective experience of preparing for and undergoing DBS as a treatment for severe and treatment-refractory OCD and the experience of the impact of the treatment. METHODS: This study of subjective experience before and after DBS is based on narrative analysis of two in-depth interviews conducted in November 2014 (1 year after DBS surgery) with a 30-year-old man and his father, utilizing Consolidated Criteria for Reporting Qualitative Studies (COREQ) criteria. RESULTS: The parallel stories show how OCD posed severe challenges to identity and social milestones, with profound positive and negative impact on the person and family. Yet symptom remission was accompanied by expanded horizons, but also by uncertainty and intense distress associated with the changed identity. DISCUSSION: The concept of 'burden of normality' is discussed, in light of a treatment experience with DBS for OCD that gives rise to a new array of life challenges and opportunities, with implications for clinical care. CONCLUSIONS: The concept of burden of normality has, thus far, not extended to evaluations of people who have had DBS for severe OCD and that of their lived experience and recovery trajectory thereafter. This concept highlights that there is work to be done on expectations of normal living and on the transitioning self-concept, in the post-surgical period.

MAOIs - does the evidence warrant their resurrection?

OBJECTIVE: The place of monoamine oxidase inhibitors (MAOIs) in psychiatry is reviewed, and the question posed as to whether they are now justifiably disregarded by prescribers. METHOD: Multiple databases (PubMed, Medline, Embase, Cochrane) were interrogated to provide an overview regarding the use, efficacy and toxicity of MAOIs. Data regarding funded use of these agents in New Zealand were obtained from PHARMAC. RESULTS: Evidence supports the use of MAOIs in major depressive disorder, certain anxiety disorders and, to lesser extent, bipolar depression. Older non-selective agents, such as phenelzine and tranylcypromine, have distinctive efficacy in 'atypical' and treatment-resistant depression, but at the cost of serious tolerability problems. Their relegation and perception by clinicians as 'last resort' medications - if considered at all - has occurred in the context of various concerns, notably dietary restrictions, potential adverse drug interactions and the usual requirement for divided doses. CONCLUSIONS: Sufficient evidence supports consideration of MAOIs in treatment-refractory and atypical depressive disorders, and in social anxiety disorder. Psychiatrists in training need to gain experience in using these agents.

Classification of eating disorders: comparison of relative prevalence rates using DSM-IV and DSM-5 criteria.

DSM-5 contains substantial changes to eating disorder diagnoses. We examined relative prevalence rates of DSM-IV and DSM-5 eating disorder diagnoses using Eating Disorder Examination-Questionnaire diagnostic algorithms in 117 community out-patients. DSM-5 criteria produced a reduction in combined 'other specified feeding or eating disorder' and 'unspecified feeding or eating disorder' from 46% to 29%, an increase in anorexia nervosa diagnoses from 35% to 47%, the same number of bulimia nervosa diagnoses and a 5% rate of binge eating disorder diagnoses.

How should we manage anxiety in patients with schizophrenia?

OBJECTIVE: We aim to provide a selective clinically focused review of the epidemiology, aetiology and management of comorbid anxiety in people with schizophrenia. METHOD: The following databases were reviewed: PubMed, Medline and Embase. RESULTS: Anxiety is highly prevalent throughout course of schizophrenia, but is often not identified or its clinical significance is under-appreciated. Also, there is a paucity of rigorous data to support specific treatment guidelines for people with schizophrenia and concurrent anxiety disorders. Psychological treatments such as cognitive behavioural therapy appear effective if targeted carefully, and preliminary data suggest that mindfulness approaches and progressive muscle relaxation may be beneficial. Pharmacological interventions need to be tailored to the individual and target specific symptom sets. There is a growing evidence base about the neurobiology of schizophrenia and concurrent anxiety symptoms or disorders which will hopefully enhance treatment options. CONCLUSIONS: Further research is required to guide treatment guidelines for anxiety in people with schizophrenia.

Treating OCD: what to do when first-line therapies fail.

OBJECTIVE: To provide a clinically-focused review of the biological treatment of treatment-resistant obsessive compulsive disorder (OCD). CONCLUSIONS: There is a paucity of research on how to manage OCD patients who fail to respond adequately to first line therapies. High-dose selective serotonin reuptake inhibitors (SSRIs) and clomipramine have good evidence-based data. Combinations of SSRIs have little support in clinical trials, but the combination of SSRIs and clomipramine can be helpful: careful clinical and cardiac monitoring is required. Certain adjunctive antipsychotics have a reasonable evidence base in OCD, but their use also needs to be weighed against the potential side effect burden. In patients with substantial generalised anxiety symptoms, clonazepam is worth considering. Of the other augmenting strategies, memantine and ondansetron appear useful in some cases, and are well tolerated. Topiramate might ameliorate compulsions to some degree, but it is less well tolerated. If all these strategies, along with expert psychological therapy, fail, careful consideration should be given to deep brain stimulation (DBS), which has an emerging evidence base and which can result in dramatic benefits for some individuals. For some patients, gamma radiosurgery might also still have a place.

Mentalization-based intervention to recurrent acute presentations and self-harm in a community mental health service setting.

OBJECTIVES: A proof-of-concept study over an 18-month period to determine whether a mentalization-based intervention (MBI) in a metropolitan community mental health service, when added to a recovery-based model of care, would be of clinical benefit to borderline personality disorder (BPD) consumers with a history of recurrent, deliberate self-harm. The feasibility of implementing the intervention, and factors that could improve its implementation, will be evaluated. METHODS: Three-monthly focus groups with participating community mental health service case managers (N = 8) assessed the implementation and the impact of an MBI added to a recovery model of care and the way the clinicians worked with consumers with BPD and recurrent, deliberate self-harm in this context. RESULTS: Qualitative analysis revealed compatibility of the MBI with a recovery-based case management approach for the above group of consumers, albeit with operational barriers. CONCLUSIONS: MBI with consumers with BPD appears to be compatible with recovery-focused psychiatric case management and was accepted by consumers. The case managers perceived that no harm was rendered in terms of deliberate self-harm and acute service utilization. The MBI led to a sense of improved therapeutic alliance in case managers working with consumers.

Deep Brain Stimulation for Obsessive-Compulsive Disorder: Optimal Stimulation Sites.

BACKGROUND: Deep brain stimulation (DBS) is a promising treatment option for treatment-refractory obsessive-compulsive disorder (OCD). Several stimulation targets have been used, mostly in and around the anterior limb of the internal capsule and ventral striatum. However, the precise target within this region remains a matter of debate. METHODS: Here, we retrospectively studied a multicenter cohort of 82 patients with OCD who underwent DBS of the ventral capsule/ventral striatum and mapped optimal stimulation sites in this region. RESULTS: DBS sweet-spot mapping performed on a discovery set of 58 patients revealed 2 optimal stimulation sites associated with improvements on the Yale-Brown Obsessive Compulsive Scale, one in the anterior limb of the internal capsule that overlapped with a previously identified OCD-DBS response tract and one in the region of the inferior thalamic peduncle and bed nucleus of the stria terminalis. Critically, the nucleus accumbens proper and anterior commissure were associated with beneficial but suboptimal clinical improvements. Moreover, overlap with the resulting sweet- and sour-spots significantly estimated variance in outcomes in an independent cohort of 22 patients from 2 additional DBS centers. Finally, beyond obsessive-compulsive symptoms, stimulation of the anterior site was associated with optimal outcomes for both depression and anxiety, while the posterior site was only associated with improvements in depression. CONCLUSIONS: Our results suggest how to refine targeting of DBS in OCD and may be helpful in guiding DBS programming in existing patients.

Schizophrenia and depression.

Depressive symptoms are common in people with schizophrenia and can be associated with suicidality, but are often either missed or dismissed by clinicians. General practitioners have a key role in initial assessment and subsequent monitoring of depressive symptoms, associated risks and physical health in patients with schizophrenia. Liaison with appropriate non-government organisations and public or private specialist mental health services can enhance GPs' management of depression in schizophrenia. Antidepressants, prescribed in tandem with antipsychotics, have a likely therapeutic role for persistent depressive symptoms in schizophrenia, but side effects can be troublesome. Although some of the atypical antipsychotics appear to have primary antidepressant effects, the utility of these agents alone in the setting of persistent depressive symptoms in schizophrenia has not been established.

The comparative efficacy of intramuscular antipsychotics for the management of acute agitation.

OBJECTIVE: To review the current role and comparative efficacy of short-acting intramuscular (IM) antipsychotics in the management of acute agitation, in current clinical practice. METHOD: The efficacy and tolerability of IM antipsychotics in the management of acute agitation in current clinical practice were reviewed in the Medline, PubMed, Cinahl Plus, Scopus-v.4 and PsycInfo databases. RESULTS: The comparative efficacy of the rapidly-acting IM atypical antipsychotics (olanzapine, ziprasidone and aripiprazole) is similar to that of the typical antipsychotic, haloperidol. IM olanzapine and ziprasidone were associated with fewer extrapyramidal side-effects and had similar cardiac tolerability to IM haloperidol. CONCLUSIONS: Further studies are required in the ongoing development of contemporary, evidence-based clinical guidelines in acute agitation, including head-to-head comparisons of currently utilized IM atypical antipsychotics, sequential treatment or combinations of medications.

Bridging the gap: does a specialist eating disorder service, aimed at developing a continuum of community care, make a difference?

OBJECTIVE: In 2010, the authors identified in a separate publication, Mind the evidence gap, the sparse evidence-base for the treatment of adult anorexia nervosa and barriers to accessing care. We report on the ensuing development, implementation and first 18-month results of a novel eating disorder service bridging the primary and specialist continuum of care in Victoria, Australia. METHOD: Using literature review, stakeholder, and consumer and carer consultation, a model for a community eating disorder service was developed and then implemented. All patients entering the service were then assessed at intake and, if they gave consent, at 12 month follow-up. RESULTS: From December 2010 to July 2012, 208 patients accessed The Body Image Eating Disorders Treatment and Recovery Service (BETRS). Fifty-three per cent had a diagnosis of anorexia nervosa and the mean number of co-morbid psychiatric diagnoses was two. Twenty-three per cent attended a day patient programme and showed a significant improvement in their body mass index. Measures of depression, anxiety and eating disorder symptomatology showed a concomitant, significant decrease. CONCLUSIONS: The development of BETRS has led to markedly improved access and effectiveness of specialist services in the region.

Phenomenological Changes Associated with Deep Brain Stimulation for Obsessive Compulsive Disorder: A Cognitive Appraisal Model of Recovery.

The current scientific enquiry of deep brain stimulation (DBS) does not capture the breadth of DBS-induced changes to an individual's life. Considering that DBS is applied in severe and complex cases, it is ethically and clinically necessary to consider the patient perspective and personally relevant outcomes. This lived experience investigation of people with obsessive compulsive disorder (OCD) undergoing DBS aims to provide a comprehensive evaluation of DBS-induced effects associated with OCD psychopathology. Six patients and six carers completed semi-structured open-ended interviews. A blended approach of interpretative phenomenological, inductive, and thematic analysis techniques was employed. Profound psychopathological changes were expressed; individuals felt more alive, had improved cognitive affective control, greater engagement in the world, and were able to manage their OCD. Through suppression of the condition, self-constructs were able to re-emerge and develop. A framework describing the progression of phenomenological changes, and a theoretical model describing changes in the cognitive appraisal of intrusions influencing recovery are proposed. This is the first identified qualitative investigation of DBS-induced changes in psychiatric patients and carers. Findings have implications for patient education and recovery models of OCD, and scientific understanding of DBS effects.

Patient feedback and psychosocial outcomes of deep brain stimulation in people with obsessive-compulsive disorder.

Severe and refractory psychiatric patients can experience complex and profound changes in symptomology, functioning and well-being from deep brain stimulation (DBS) therapy. Currently, the efficacy of DBS is assessed by clinician rated scales of primary symptoms, yet this does not capture the multitude of DBS mediated changes or represent the patient perspective. We aimed to elucidate the patient perspective in psychiatric DBS application by investigating 1) symptomatic, and 2) psychosocial changes, 3) therapeutic expectations and satisfaction, 4) decision-making capacity, and 5) clinical care recommendations from treatment refractory obsessive-compulsive disorder (OCD) DBS patients. Participants enrolled in an open label clinical trial of DBS therapy for OCD who had reached clinical response were invited to participate in a follow up survey. Participants completed a 1) feedback survey relating to goals, expectations, and satisfaction of therapy, and 2) self-report questionnaires on psychosocial functioning including quality of life, cognitive insight, locus of control, rumination, cognitive flexibility, impulsivity, affect, and well-being. Greatest change was reported for quality of life, rumination, affect and cognitive flexibility. Participants reported realistic expectations, high satisfaction, adequate pre-operative education and decision-making capacity; and advocated for greater access to DBS care and more widespread support services. This is the first identified investigation on psychiatric patient perspectives of functioning and therapeutic outcomes following DBS. Insights from the study have implications for informing psychoeducation, clinical practices, and neuroethical debates. We encourage a greater patient-centred and biopsychosocial approach in evaluating and managing OCD DBS patients, by considering personally meaningful goals and addressing symptomatic and psychosocial recovery.

Research Directions for Leveraging and Supporting the Lived Experience of Mental Illness within Psychology.

This paper explores the lived experience of mental illness within the field of psychology across higher education and the mental health workforce. There is a high prevalence of mental health issues among psychology students and practitioners, and it is critical not only to provide support for these populations, but also to acknowledge the value of leveraging their lived experience within their education and practice. There has been increased interest in and advocacy for the involvement of those with lived experience of mental illness within mental healthcare service provision to improve patient experiences and outcomes. However, there have been limited acknowledgement and research regarding the role of psychologists with personal lived experiences of mental illness, and how to leverage this experience. Further, there are challenges faced by both psychology students and practising psychologists with lived experience that act as barriers to leveraging their unique skills and experiences. Psychology students with lived experience face stigma, inadequate support, and incongruence between the course material and their personal experiences. Similarly, practising psychologists with lived experience encounter stigma and isolation, indicating the need for a culture change that promotes transparency and understanding. The paper calls for research in five key directions to provide evidence that can be used to support and leverage lived experience in psychology.

Determining the efficacy and tolerance of quetiapine extended release for the management of psychosis and accompanying acute behavioral disturbance in adult acute psychiatry.

BACKGROUND: This study was conducted to explore the efficacy and tolerability of quetiapine extended release (XR) to treat psychosis and accompanying acute behavioral disturbance in hospitalized psychiatric patients. METHODS: Patients with psychosis who displayed aggression were administered quetiapine XR (day 1 mean dose: 293.3 mg). Symptoms and side effects were assessed prospectively over an 8-day period. Symptoms were measured by the Overt Aggression Scale and Brief Psychiatric Rating Scale (BPRS), and side effects were measured using the Simpson-Angus Scale and Barnes Akathisia Rating Scale. RESULTS: Fifteen of 16 consenting patients completed the study. Aggression was significantly reduced by day 3. Psychopathology also was significantly reduced, with the greatest improvement in BPRS Thinking Disturbance subscale scores. No significant increase in movement side effects was seen by day 8. Seven participants were administered a concomitant sedating antipsychotic on an as-needed basis, particularly in the first 4 days of treatment; these participants displayed much greater aggression--but not psychopathology--at day 1, and it took longer for their aggression and psychopathology to improve compared with patients treated with quetiapine XR as the sole antipsychotic. CONCLUSIONS: Further research is needed before definitive recommendations can be made. However, current findings provide tentative support for quetiapine XR as a safe and effective medication for treating concurrent psychosis and behavioral disturbance, particularly in less severely aggressive patients.