PICO Deep brain stimulation for treatment resistant depression. Clinical reality ?
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Transcript of PICO Deep brain stimulation for treatment resistant depression. Clinical reality ?
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PICO
Deep brain stimulation for
treatment resistant depression.
Clinical reality ?
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Deep brain stimulation in the treatment of depression.
Acta Psychiatr Scand, 2011
Blomstedt P et al.
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Subcal.cing. gyrus (no 20)85% had ECTHDRS - 52% / 1
year35% remission
Capsula interna (no 15)100% had ECTHDRS -44% / 1 year40% remission
Nucleus accumbens (no 10)100% had ECTHDRS - 36% / 1
year30% remission
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Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment-
Resistant Depression
Biological Psychiatry, 2008
Lozano, et al
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Increased activity in the subcallosal cingulate gyrus
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Pharmacotherapy
Transcranial magnetic stimulation
Electroconvulsive therapy
Altered activity of the SCG
Deep brain stimulation
Direct modulation of the SCG
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Inclusion
Severe
Chronic
Treatment resistant
Failure to respond to a minimum of four different treatments
Antidepressant pharmacotherapy of sufficient dose and duration
Evidence-based psychotherapy
Electroconvulsive therapy
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Exclusion
comorbid Axis I psychiatric conditions,
Axis II cluster B diagnosis
suicidal behaviour within the past year
concurrent neurological or medical conditions that could interfere with
the treatment.
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Subjects (n = 20)
Male/female 9/11
Age at Enrollment (years) 47.4 ± 10.4
Age of Onset of MDD (years) 27.1 ± 8.3
Length of Current Episode (years) 6.9 ± 5.6
Number of Lifetime MDE (n) 3.9 ± 3.1
Received ECT (n) 17/20
Baseline HRSD-17 24.4 ± 3.5
3 patients received no ECT before DSTAll patients received medication during DST
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Adverse EffectNumber of
Patients
Wound Infection and Hardware removal 3
Reinsertion of DBS Hardware 1
Wound Infection Managed with Antibiotics Alone
1
Perioperative Seizure 1
Worsening Mood/Irritability 2
Perioperative Headache 4
Pain at Pulse Generator Site 1
No Adverse Effects 7
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Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up
After 3 to 6 Years
Kennedy, et al.
Am J Psychiatry, 2011
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1 unrelated death2 suicides2 lost to follow up3 devices removed
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Argument in favour
Otherwise intractable depression
Remission rates around 30 %
Possible long term benefits
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Arguments against
No clear target-area
Invasive procedure
Battery life
Open label assessment
Small N
Concurrent medication use
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In conclusion
Experimental therapy
Clinical studies
Multidisciplinary teams