At what point do you consider referring for neuromodulatory treatments (TMS, deep brain stimulation) for treatment refractory-OCD?

This is a fantastic question! Although I do not use a standardized "protocol" to determine when to refer for TMS or DBS, I typically think about this in terms of (a) medication trials, (b) comorbidities, and (c) OCD severity.

Medication Trials

I would only consider TMS after trialing multiple serotone...

In my opinion, the biggest impediments to the widespread adoption of TMS tend to be cost (or insurance coverage) and time (the patient has to be willing and able to go for the treatment). While there is a theoretical low risk for seizures with the procedure, when it is performed properly, the genera...

After a year of chasing depression with meds, I tend to recommend TMS as an adjunct, not a substitute. In my experience, it has the benefit of requiring that the patient sleep at least 4 hours the night before, which can break patterns of insomnia. It also tends to smooth out convolutive thinking an...

The TMS OCD protocol can help, but the patient should stay on medication and must be engaged in ERP therapy while doing TMS treatment. TMS for OCD has never been recommended as a monotherapy.

I have seen decent positive effects in about 50% of cases (estimate), but I have never seen a full remission...