Gamma Ventral Capsulotomy for Obsessive-Compulsive Disorder: A Randomized Clinical Trial

JAMA Psychiatry (Impact Factor: 12.01). 07/2014; DOI: 10.1001/jamapsychiatry.2014.1193

ABSTRACT IMPORTANCE Select cases of intractable obsessive-compulsive disorder (OCD) have
undergone neurosurgical ablation for more than half a century. However, to our knowledge,
there have been no randomized clinical trials of such procedures for the treatment of any
psychiatric disorder.
OBJECTIVE To determine the efficacy and safety of a radiosurgery (gamma ventral
capsulotomy [GVC]) for intractable OCD.
DESIGN, SETTING, AND PARTICIPANTS In a double-blind, placebo-controlled, randomized
clinical trial, 16 patients with intractable OCD were randomized to active (n = 8) or sham
(n = 8) GVC. Blinding was maintained for 12 months. After unblinding, sham-group patients
were offered active GVC.
INTERVENTIONS Patients randomized to active GVC had 2 distinct isocenters on each side
irradiated at the ventral border of the anterior limb of the internal capsule. The patients
randomized to sham GVC received simulated radiosurgery using the same equipment.
MAIN OUTCOMES AND MEASURES Scores on the Yale-Brown Obsessive-Compulsive Scale
(Y-BOCS) and the Clinical Global Impression-Improvement (CGI-I) Scale. Response was
defined as a 35% or greater reduction in Y-BOCS severity and “improved” or “much improved”
CGI-I ratings.
RESULTS Three of 8 patients randomized to active treatment responded at 12 months, while
none of the 8 sham-GVC patients responded (absolute risk reduction, 0.375; 95% CI,
0.04-0.71). At 12 months, OCD symptom improvement was significantly higher in the
active-GVC group than in the sham group (Y-BOCS, P = .046; Dimensional Y-BOCS, P = .01).
At 54 months, 2 additional patients in the active group had become responders. Of the 4
sham-GVC patients who later received active GVC, 2 responded by post-GVC month 12. The
most serious adverse event was an asymptomatic radiation-induced cyst in 1 patient.
CONCLUSIONS AND RELEVANCE Gamma ventral capsulotomy benefitted patients with
otherwise intractable OCD and thus appears to be an alternative to deep-brain stimulation in
selected cases. Given the risks inherent in any psychiatric neurosurgery, such procedures
should be conducted at specialized centers.

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Available from: Carlos A de B Pereira, Aug 25, 2014
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