Achieving OCD Relief: Consideration of TMS Earlier in the Treatment Continuum

COMMENTARY

Obsessive-compulsive disorder (OCD) is a chronic and debilitating condition that impacts over 2% of the global population.¹ Characterized by uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that the patient feels compelled to repeat over and over, OCD was previously ranked by the World Health Organization (WHO) to be one of the top 10 debilitating medical conditions associated with a decreased quality of life and loss of income.² It is now listed among other anxiety-based disorders, which together rank as the sixth leading cause of worldwide disability.

The economic burden on the US health care system for OCD treatments is estimated to be over $10.6 billion per year.³ Unfortunately, treatment options are limited and often do not work. Psychotherapy, including exposure response therapy (ERP), can be very helpful to manage OCD, but durability is limited. The reason for this is that OCD, like diabetes, is a chronic illness with constant daily implications and periodic worsening or relief.

As for medication, only 5 antidepressants have been approved by the US Food and Drug Administration (FDA) over the last 35 years to treat OCD, yet 40% to 60% of patients fail to achieve a response from them.⁴ Even worse, each of those medications requires 8 to 12 weeks to gauge treatment response and many patients have difficulty tolerating the higher doses needed to treat OCD. Other non-FDA-approved medications are also used off-label, including antipsychotic medications. According to a report by NOCD, insurance payers are spending about $104.2 million per year per 1 million members to achieve suboptimal outcomes in many cases.⁵ None of the medications have durability, which means they must be taken for life.

If you, a loved one, or a friend suffer from OCD, then you understand the pain caused by this condition. You know that it is often accompanied by depression and anxiety. You know how medications can cause significant adverse effects like sexual dysfunction, weight gain, metabolic issues, gastrointestinal issues, insomnia, and sedation—to name just a few. You also know how frustrating it is to not achieve relief—or watch someone continue to suffer with multiple failed medication trials.

This is why traditional transcranial magnetic stimulation (TMS), or the newer version, deep transcranial magnetic stimulation (deep TMS), should be recommended earlier rather than later in the OCD treatment continuum. Unlike depression, which is episodic, OCD is a chronic illness and takes an average of 14 to 17 years from the time OCD first appears for patients to receive appropriate treatment. Patients are needlessly suffering for months—or years—when there is an evidence-based treatment option that can help, especially for patients who are treatment resistant to initial medication and psychotherapy trials.

Deep TMS utilizes a magnetic field to regulate the neural activity of brain structures associated with OCD, specifically the anterior cingulate cortex and medial prefrontal cortex. A peer-reviewed multicenter clinical study found deep TMS to be a highly effective OCD treatment, with more than 1 in 3 patients with treatment-resistant OCD achieving a reduction of more than 30% in their OCD severity rating, greatly improving their quality of life.⁶ Apost-marketing studyof over 200 patients published in the Journal of Psychiatric Research found deep TMS to have an even greater effect in a real-life clinical practice setting.⁷ Nearly 60% of patients achieved a reduction in the OCD severity rating of more than 30%, and almost 90% of patients maintained their response for more than 1 year.⁸

Deep TMS is a noninvasive treatment that does not cause any systemic or long-lasting adverse effects. It does not require a significant recovery period, and the short treatments can easily be integrated into each patient’s day-to-day schedule.

Delaying TMS treatment until after multiple failed psychopharmacologic treatments, or for the most refractory of patients, is not in the best interest of patients, the mental health community, or for payers and our health care system in the management of OCD.

As insurance providers recognize the benefit of TMS treatment for depression, anxious depression, and now OCD, many are reducing the criteria for failed medication trials before they provide TMS coverage. Most recently, more commercial payers and all Medicare administrative contractors have been reducing the number of failed medication trials from 4 to 2 for depression. Insurance policies with OCD coverage require a failure of 2 medication trials.

There is hope for OCD patients with deep TMS treatment, and that hope needs to become a viable and widely accepted treatment for this condition. We need to stop the needless suffering and ensure that both providers and patients have access to the best treatment options possible to provide relief.

Dr Tendler is the Chief Medical Officer at BrainsWay, a global leader in advanced noninvasive neurostimulation treatments for mental health disorders. BrainsWay is boldly advancing neuroscience with its proprietary Deep Transcranial Magnetic Stimulation (Deep TMS™) platform technology to improve health and transform lives. BrainsWay is the first and only TMS company to obtain three FDA-cleared indications backed by pivotal clinical studies demonstrating clinically proven efficacy. Mr Blackman is the Director of Market Access at BrainsWay.

References

1. Obsessive-compulsive disorder (OCD). National Institute of Mental Health. Accessed April 6, 2023. https://www.nimh.nih.gov/health/statistics/obsessive-compulsive-disorder-ocd

2. OCD statistics around the world. BrainsWay. Accessed April 6, 2023. https://www.brainsway.com/knowledge-center/ocd-statistics-around-the-world/

3. Jalal B, Chamberlain SR, Robbins TW, Sahakian BJ. Obsessive–compulsive disorder—contamination fears, features, and treatment: novel smartphone therapies in light of global mental health and pandemics (COVID-19). CNS Spectr. 2022;27(2):136-144.

4. Roth Y, Barnea-Ygael N, Carmi L, et al. Deep transcranial magnetic stimulation for obsessive-compulsive disorder is efficacious even in patients who failed multiple medications and CBT. Psychiatry Res. 2020;290:113179.

5. Santa Barbara Actuaries. Insights into the cost of care for OCD: a national research study commissioned by NOCD and conducted by Santa Barbara Actuaries. NOCD. June 2021. Accessed April 6, 2023. https://f.hubspotusercontent40.net/hubfs/4566848/NOCD_SBA-Analysis_ebook-6.3.21-B.pdf

6. Swierkosz-Lenart K, Santos JFAD, Elowe J, et al. Therapies for obsessive-compulsive disorder: current state of the art and perspectives for approaching treatment-resistant patients. Front Psychiatry. 2023;14:1065812.

7. Roth Y, Tendler A, Arikan MK, et al. Real-world efficacy of deep TMS for obsessive-compulsive disorder: post-marketing data collected from twenty-two clinical sites. J Psychiatr Res. 2021;137:667-672.

8. Harmelech T, Tendler A, Arikan MK, et al. Long-term outcomes of a course of deep TMS for treatment-resistant OCD. Brain Stimul. 2022;15(1):226-228.