OCD Treatment: ERP, Medication and Deep TMS

Obsessive-compulsive disorder affects roughly 1 to 2 percent of adults, according to NIMH, and the average patient waits years between the onset of symptoms and effective treatment. That delay is partly stigma and partly a treatment landscape where the approaches that work are specific, and the approaches that are commonly offered are not. General talk therapy does not treat OCD. Low-dose SSRIs for six weeks do not treat OCD. Three things do, and this article is about those three.

What OCD is, briefly

OCD is defined by obsessions, which are intrusive, unwanted thoughts, images or urges that cause distress, and compulsions, which are repetitive behaviors or mental acts performed to reduce that distress or prevent a feared outcome. The content varies widely: contamination and washing, doubt and checking, symmetry and ordering, taboo thoughts about harm, sex or religion with mental rituals, and relationship or health-focused variants. The structure is always the same. An obsession produces anxiety, a compulsion relieves it briefly, and the relief reinforces the cycle.

Diagnosis is clinical, by interview, often with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to measure severity and track treatment. Scores of 16 and above are generally considered clinically significant; 24 and above is severe. A good evaluation also screens for the conditions that commonly accompany OCD, including depression, tic disorders, body dysmorphic disorder and hoarding, and distinguishes OCD from generalized anxiety and from obsessive-compulsive personality traits, which are different.

Exposure and response prevention

Exposure and response prevention, or ERP, is the psychotherapy for OCD. It is a form of cognitive behavioral therapy in which the patient, with the therapist, deliberately confronts the triggers of obsessions in a graded way and refrains from performing the compulsion. Over repeated exposures the anxiety habituates and the brain learns that the feared outcome does not occur, or that uncertainty is tolerable. The International OCD Foundation and every major treatment guideline place ERP as the first-line psychological treatment, with response rates in trials around 50 to 60 percent and larger effect sizes than general CBT.

ERP is demanding. A standard course is 12 to 20 sessions, often weekly, with between-session homework that is the actual mechanism of change. Intensive formats compress this into daily sessions over a few weeks and work well for severe cases. The most common reason ERP fails is that it was not actually ERP: a therapist without specific training offers supportive therapy or generic anxiety management instead. When looking for a therapist, ask directly whether they practice exposure and response prevention for OCD and how many OCD patients they have treated.

Stedfast Psychiatry provides and refers for ERP, and for patients whose therapist is outside the practice we coordinate medication management with their ERP work.

Medication

SSRIs are the first-line medication for OCD, and four carry FDA approval for it: fluoxetine, fluvoxamine, paroxetine and sertraline. Escitalopram and citalopram are used off-label with similar evidence. The tricyclic clomipramine, which has strong serotonergic activity, was the original OCD medication and remains effective, with more side effects.

Two things distinguish OCD prescribing from depression prescribing, and getting them wrong is the second most common reason treatment fails. First, dose. OCD typically requires doses at or above the top of the depression range: fluoxetine 60 to 80 mg, sertraline 200 mg, fluvoxamine 300 mg, escitalopram 20 to 40 mg. A patient on sertraline 50 mg has not had an adequate OCD trial. Second, time. Response in OCD is slower than in depression, with meaningful improvement often not appearing until 8 to 12 weeks at the target dose. An adequate trial is at least 12 weeks at a maximal tolerated dose.

Roughly 40 to 60 percent of patients respond to an adequate SSRI trial, with response usually defined as a 25 to 35 percent reduction in Y-BOCS score. Full remission on medication alone is less common, which is why combining with ERP is the standard recommendation for moderate to severe OCD. For patients who do not respond to two adequate SSRI trials, augmentation with a low-dose antipsychotic such as aripiprazole or risperidone has the best evidence, particularly when tics are present. Switching to clomipramine, or combining it cautiously with an SSRI, is another established step.

Deep TMS for OCD

In 2018 the FDA cleared the BrainsWay Deep TMS system with the H7 coil for treatment of obsessive-compulsive disorder, making it the first and, as of this writing, the only TMS device with an OCD clearance. The H7 coil is designed to stimulate the medial prefrontal cortex and anterior cingulate cortex, regions implicated in OCD's abnormal circuitry, more deeply than standard figure-eight coils reach.

The pivotal multicenter trial, published in the American Journal of Psychiatry in 2019, enrolled patients with OCD who had not responded adequately to at least one SSRI and, in most cases, to psychotherapy. Treatment was five sessions a week for six weeks, 29 sessions in total. Each session began with a brief, individualized symptom provocation, in which the patient was exposed to an OCD trigger to activate the relevant circuit before stimulation. At six weeks, 38 percent of patients receiving active treatment met the response criterion of at least a 30 percent reduction in Y-BOCS, versus 11 percent with sham stimulation. The benefit persisted at one-month follow-up. Later real-world data from multiple clinics reported response rates somewhat higher than the trial, as is common once treatment moves out of a rigid protocol.

Deep TMS for OCD is well tolerated. The most common side effect is scalp discomfort or headache during or after sessions, which fades over the first week. There is no sedation, no cognitive impairment and no systemic effect. The main exclusions are a seizure disorder and ferromagnetic metal in or near the head. Patients continue their medication and ERP during the course.

We offer Deep TMS for OCD at our Palm Beach Gardens office. Insurance coverage for the OCD indication is less uniform than for depression; some commercial plans cover it with prior authorization after documented SSRI and ERP failures, and others do not yet have a policy. Our staff verify coverage before scheduling, and self-pay pricing is available.

How the three fit together

For mild to moderate OCD, ERP alone is a reasonable start, particularly for patients who prefer to avoid medication. For moderate to severe OCD, or when ERP is not accessible, an SSRI at OCD dosing is started, ideally with ERP alongside. The combination outperforms either alone in trials and in practice.

If after an adequate trial of ERP and at least one or two adequate SSRI trials the Y-BOCS remains in the clinically significant range, Deep TMS enters the conversation. It is not a replacement for ERP and medication but an addition to them, and patients who have struggled to engage with ERP often find it easier after TMS reduces the baseline intensity of obsessions. Antipsychotic augmentation and clomipramine remain options alongside or instead of TMS, depending on the patient. For the small number of patients with severe, disabling OCD unresponsive to everything, deep brain stimulation is approved under a humanitarian device exemption at specialized centers.

What adequate treatment looks like

If you have been treated for OCD and are still suffering, ask yourself these questions. Was the therapy actually ERP, with exposures and homework? Was the SSRI dose at the top of the range? Was it continued for at least 12 weeks at that dose? Was the Y-BOCS or a similar measure used to track change? If the answer to any of these is no, you have not yet had adequate treatment, and the odds of improvement with proper treatment are good. If the answer to all of them is yes, you are a candidate for the next steps, and Deep TMS is one of them.

Stedfast Psychiatry evaluates and treats OCD at all 13 offices in Florida and South Carolina and by telehealth, with Deep TMS for OCD at Palm Beach Gardens. The self-pay new-patient visit is $185; most insurance and Medicare are accepted.

Related reading

• What Is TMS Therapy? A Plain-English Guide6 min
• Deep TMS vs NeuroStar: What the Difference Means for You6 min
• Does TMS Work? What the Evidence Shows7 min
• How Much Does TMS Cost With and Without Insurance?6 min
• Anxiety or ADHD? How to Tell the Difference5 min

This article is educational and does not replace evaluation by a licensed clinician. If you are in crisis, call or text 988.