Part 2: Who Is the Optimal Candidate for Focused Ultrasound Treatment?

In part 2 of a conversation between Nir Lipsman, MD, PhD, and Peter Giacobbe, MS, MSc, the pair discussed the attributes of the optimal candidate for focused ultrasound to treat treatment resistant obsessive-compulsive disorder (OCD).

Lipsman said that, as a neurosurgeon, the question can not be answered in a vacuum. The Harquil Center for Neuromodulation offers multiple modalities under one roof.

"The reason that's important is because you want to avoid a hammer and nail phenomenon, where if you have a single tool, we may believe that everybody will benefit from that tool," Lipsman said.

He said it is best to have an open, transparent partnership between psychiatry and neurosurgery where every patient is discussed in monthly multidisciplinary rounds and is seen by multiple psychiatrists and neurosurgeons before making a decision on treatment.

"defining treatment resistance has been a challenge, and is a moving target of course, but every psychiatrist or surgeon working in this field believes that there is a point beyond which additional treatment may not be benefit that particular patient," Lipsman said.

He made the point that focused ultrasound is a lesional procedure and does not require the same upkeep as deep brain stimulation, meaning it might be well suited for a patient from a more remote community.

Giacobbe mentioned some wise words Lipsman had once said to him, that even though this is maximally invasive psychiatry, it is minimally invasive neurosurgery.
"From a surgical perspective, this is a procedure that has a low morbidity, low complication rate. Obviously, it is one of the most invasive things we do in psychiatry, perhaps the most invasive we do, but given that track record over many decades of neurosurgical intervention, that is very reassuring to people."
Giacobbe said the field is looking forward to the next generation of helmets.
"The current generation of helmets, we are not able to get to all the structures in the brain perhaps we would like, and with the next generation, and the next level biophysics that go along with that, we can target different structures and be able to have a nuanced approach," Giacobbe said.
He said on top of the next generation of helmets, the field has to start integrating biomarkers more consistently and track those to see to what degree it can help select targets of different presentations.

This is part 2 of a 2 part series. you can watch part 1 here.

Dr Nir Lipsman is a senior scientist at Sunnybrook Health Sciences in Toronto, Canada. He is currently the Director of Sunnybrook's Harquail Centre for Neuromodulation and Clinical Director of the Focused Ultrasound Centre of Excellence. Dr Peter Giacobbe is an associate scientist at Sunnybrook Health Sciences in Toronto, Canada. He is a staff psychiatrist at the University Health Network in Toronto, where he serves as the Head of the Electroconvulsive Therapy Service, co-Head of the rTMS service and Director of the Fellowship Program.