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Capsulotomy is an effective treatment for severe, refractory OCD, the results of a long-term follow-up study suggest, although it does carry a significant risk of adverse effects.

Capsulotomy is an effective treatment for severe, refractory obsessive-compulsive disorder (OCD), the results of a long-term follow-up study suggest, although the procedure does carry a significant risk of adverse effects. The findings appear in the Archives of General Psychiatry for August.

Twelve of the 25 patients in the study were considered to be treatment responders, including nine who were in remission from OCD at latest follow-up. However, based on the Execution, Apathy, and Disinhibition (EAD) scale designed by the researchers, clinically significant problems in these areas were seen in ten patients.

"Capsulotomy was reasonably effective," lead author Dr. Christian Ruck told Reuters Health, but "it had more frequent side effects than we anticipated."

According to Dr. Ruck, with the Karolinska Institute in Stockholm, prior research had suggested that capsulotomy was less risky. "One reason could be that previous studies underestimated the risk. Another reason could be that the surgery is performed slightly different in terms of size and precise location across different hospitals."
The patients, who were treated between 1988 and 2000 at one center, included nine who underwent bilateral gammacapsulotomy, 12 treated with bilateral thermocapsulotomy, and four treated with unilateral thermocapsulotomy.

On average, the Yale-Brown Obsessive Compulsive Rating Scale (Y-BOCS) score before surgery was 34. With treatment, the score fell to 18 (p < 0.001). The type of capsulotomy had no bearing on efficacy.

A treatment response, defined as a 35 per cent or greater reduction in the Y-BOCS score on long-term follow-up, was seen in 12 patients, including nine who were in remission (Y-BOCS less than 16). However, just three of the patients in remission had no adverse effects.

Of the ten patients with clinically relevant side effects (EAD score of at least three out of nine total), six had been treated with high doses of radiation or had undergone multiple surgeries. The average weight gain in the first year after treatment was 6 kg.

The take-home message for clinicians is that "capsulotomy may be an effective treatment for some severely ill OCD patients but it carries a significant risk," Dr. Ruck said.

MRI analysis suggested that treatment efficacy could be enhanced by reducing the lateral extension of the capsulotomy lesions. The results also suggest that the safety of the operation could be improved by reducing the medial and posterior extensions.

"The most important question now," Dr. Ruck concluded, "is whether the risk of this procedure can be limited by small changes in surgical method. We hope to be able to study this with brain imaging using patients from several centers."

Arch Gen Psychiatry 2008;65:914-922