PICO

Deep brain stimulation for

treatment resistant depression.

Clinical reality ?

Deep brain stimulation in the treatment of depression.

Acta Psychiatr Scand, 2011

Blomstedt P et al.

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

Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment-

Resistant Depression

Biological Psychiatry, 2008

Lozano, et al

Increased activity in the subcallosal cingulate gyrus

Pharmacotherapy

Transcranial magnetic stimulation

Electroconvulsive therapy

Altered activity of the SCG

Deep brain stimulation

Direct modulation of the SCG

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

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.

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

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

Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up

After 3 to 6 Years

Kennedy, et al.

Am J Psychiatry, 2011

1 unrelated death2 suicides2 lost to follow up3 devices removed

Argument in favour

Otherwise intractable depression

Remission rates around 30 %

Possible long term benefits

Arguments against

No clear target-area

Invasive procedure

Battery life

Open label assessment

Small N

Concurrent medication use

In conclusion

Experimental therapy

Clinical studies

Multidisciplinary teams