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Vieira EV, Arantes PR, Hamani C, Iglesio R, Duarte KP, Teixeira MJ, Miguel EC, Lopes AC, Godinho F. Neurocircuitry of Deep Brain Stimulation for Obsessive-Compulsive Disorder as Revealed by Tractography: A Systematic Review. Front Psychiatry 2021; 12:680484. [PMID: 34276448 PMCID: PMC8280498 DOI: 10.3389/fpsyt.2021.680484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/04/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Deep brain stimulation (DBS) was proposed in 1999 to treat refractory obsessive-compulsive disorder (OCD). Despite the accumulated experience over more than two decades, 30-40% of patients fail to respond to this procedure. One potential reason to explain why some patients do not improve in the postoperative period is that DBS might not have engaged structural therapeutic networks that are crucial to a favorable outcome in non-responders. This article reviews magnetic resonance imaging diffusion studies (DTI-MRI), analyzing neural networks likely modulated by DBS in OCD patients and their corresponding clinical outcome. Methods: We used a systematic review process to search for studies published from 2005 to 2020 in six electronic databases. Search terms included obsessive-compulsive disorder, deep brain stimulation, diffusion-weighted imaging, diffusion tensor imaging, diffusion tractography, tractography, connectome, diffusion analyses, and white matter. No restriction was made concerning the surgical target, DTI-MRI technique and the method of data processing. Results: Eight studies published in the last 15 years were fully assessed. Most of them used 3 Tesla DTI-MRI, and different methods of data acquisition and processing. There was no consensus on potential structures and networks underlying DBS effects. Most studies stimulated the ventral anterior limb of the internal capsule (ALIC)/nucleus accumbens. However, the contribution of different white matter pathways that run through the ALIC for the effects of DBS remains elusive. Moreover, the improvement of cognitive and affective symptoms in OCD patients probably relies on electric modulation of distinct networks. Conclusion: Though, tractography is a valuable tool to understand neural circuits, the effects of modulating different fiber tracts in OCD are still unclear. Future advances on image acquisition and data processing and a larger number of studies are still required for the understanding of the role of tractography-based targeting and to clarify the importance of different tracts for the mechanisms of DBS.
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Affiliation(s)
- Eduardo Varjão Vieira
- Division of Neurosurgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Paula Ricci Arantes
- Department of Radiology, University of São Paulo Medical School, São Paulo, Brazil
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Harquail Centre for Neuromodulation, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Ricardo Iglesio
- Division of Neurosurgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Kleber Paiva Duarte
- Division of Neurosurgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Euripedes C Miguel
- Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Carlos Lopes
- Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Fabio Godinho
- Division of Neurosurgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil.,Functional Neurosurgery, Santa Marcelina Hospital, São Paulo, Brazil.,Center of Engineering, Modeling, and Applied Social Sciences, Federal University of ABC, Santo André, Brazil
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Abstract
Dementia poses important medical and societal challenges, and of all health risks people face in life, dementia is one of the most feared. Recent research indicates that up to about 40% of all cases of dementia might be preventable. A series of environmental, social, and medical risk-factors have been identified that should be targeted from midlife onwards when people are still cognitively healthy. At first glance, this seems not merely advisable, but even imperative. However, these new developments trigger a series of new ethical questions and concerns which have hardly been addressed to date. Pro-active ethical reflection, however, is crucial to ensure that the interests and well-being of those affected, ultimately all of us, are adequately respected. This is the goal of the current contribution. Against the background of a concrete case in primary dementia prevention, it provides a systematic overview of the current ethical literature and sketches an ethical research agenda. First, possible benefits of increased well-being must be balanced with the burdens of being engaged in particularly long-term interventions for which it is unclear whether they will ever pay out on a personal level. Second, while knowledge about one's options to maintain brain health might empower people, it might also undermine autonomy, put high social pressure on people, medicalize healthy adults, and stigmatize those who still develop dementia. Third, while synergistic effects might occur, the ideals of dementia prevention might also conflict with other health and non-health related values people hold in life.
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Affiliation(s)
- Dorothee Horstkötter
- MHeNS School for Mental Health and Neuroscience, Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands
| | - Kay Deckers
- Alzheimer Centre Limburg, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Sebastian Köhler
- Alzheimer Centre Limburg, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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Lepard JR, Walters BC. A Bibliometric Analysis of Neurosurgical Practice Guidelines. Neurosurgery 2020; 86:605-614. [PMID: 31264698 DOI: 10.1093/neuros/nyz240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 04/06/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the last 20 yr, the rate of neurosurgical guideline publication has increased. However, despite the higher volume and increasing emphasis on quality there remains no reliable means of measuring the overall impact of clinical practice guidelines (CPGs). OBJECTIVE To utilize citation analysis to evaluate the dispersion of neurosurgical CPGs. METHODS A list of neurosurgical guidelines was compiled by performing electronic searches using the Scopus (Elsevier, Amsterdam, Netherlands) and National Guideline Clearinghouse databases. The Scopus database was queried to obtain current publication and citation data for all included documents and categorized based upon recognized neurosurgical specialties. The h-index, R-index, h2-index, i10-index, and dissemination index (D-Index) were manually calculated for each subspecialty. RESULTS After applying screening criteria the search yielded 372 neurosurgical CPGs, which were included for bibliometric analysis. The overall calculated h-index for neurosurgery was 56. When broken down by subspecialty trauma/critical care had the highest value at 35, followed by spine and peripheral nerve at 30, cerebrovascular at 28, tumor at 16, pediatrics at 14, miscellaneous at 11, and functional/stereotactic/pain at 6. Cerebrovascular neurosurgery was noted to have the highest D-Index at 3.4. CONCLUSION A comprehensive framework is useful for guideline impact analysis. Bibliometric data provides a novel and adequate means of evaluating the successful dissemination of neurosurgical guidelines. There remains a paucity of data regarding implementation and clinical outcomes of individual guidelines.
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Affiliation(s)
- Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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54
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Davidson B, Hamani C, Meng Y, Baskaran A, Sharma S, Abrahao A, Richter MA, Levitt A, Giacobbe P, Lipsman N, Rabin JS. Examining cognitive change in magnetic resonance-guided focused ultrasound capsulotomy for psychiatric illness. Transl Psychiatry 2020; 10:397. [PMID: 33177508 PMCID: PMC7658970 DOI: 10.1038/s41398-020-01072-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/28/2020] [Accepted: 10/09/2020] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) anterior capsulotomy is a novel treatment option for patients with refractory obsessive compulsive disorder (OCD) or major depressive disorder (MDD). However, there is concern that lesional psychiatric surgery procedures may have adverse effects on cognition. In this study, we examined whether MRgFUS capsulotomy causes cognitive decline in patients with psychiatric illness. Ten patients with refractory OCD (n = 5) or MDD (n = 5) underwent MRgFUS capsulotomy. Cognitive functioning was measured at baseline as well as 6 months and 12 months postoperatively, with a battery of neuropsychological tests assessing domains of executive function, memory, and processing speed. Scores were analyzed at the individual-level, and changes ≥2 standard deviations were considered clinically significant. We also examined whether changes in clinical symptoms were associated with changes in cognitive performance. At baseline intellectual functioning was in the average to high-average range for the group. Following MRgFUS capsulotomy, there were no deteriorations in cognition that reached ≥2 standard deviations at 6 or 12 months. Eight out of ten patients demonstrated a ≥2 standard deviation improvement in at least one cognitive score at 6 or 12 months postoperatively. Improvements in clinical symptoms correlated significantly with self-reported improvements in frontal lobe function (p < 0.05), but not with objective measures of cognitive functioning. To summarize, MRgFUS capsulotomy did not result in cognitive decline in this cohort of patients with refractory OCD or MDD, suggesting that this procedure can be offered to patients with a very low risk of cognitive side effects.
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Affiliation(s)
- Benjamin Davidson
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
- Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Anusha Baskaran
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Sachie Sharma
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Agessandro Abrahao
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
| | - Margaret Anne Richter
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anthony Levitt
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Peter Giacobbe
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jennifer S Rabin
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
- Sunnybrook Research Institute, Toronto, ON, Canada.
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
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55
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Davidson B, Suresh H, Goubran M, Rabin JS, Meng Y, Mithani K, Pople CB, Giacobbe P, Hamani C, Lipsman N. Predicting response to psychiatric surgery: a systematic review of neuroimaging findings. J Psychiatry Neurosci 2020; 45:387-394. [PMID: 32293838 PMCID: PMC7595737 DOI: 10.1503/jpn.190208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Psychiatric surgery, including deep brain stimulation and stereotactic ablation, is an important treatment option in severe refractory psychiatric illness. Several large trials have demonstrated response rates of approximately 50%, underscoring the need to identify and select responders preoperatively. Recent advances in neuroimaging have brought this possibility into focus. We systematically reviewed the psychiatric surgery neuroimaging literature to assess the current state of evidence for preoperative imaging predictors of response. METHODS We performed this study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) frameworks, and preregistered it using PROSPERO. We systematically searched the Medline, Embase and Cochrane databases for studies reporting preoperative neuroimaging analyses correlated with clinical outcomes in patients who underwent psychiatric surgery. We recorded and synthesized the methodological details, imaging results and clinical correlations from these studies. RESULTS After removing duplicates, the search yielded 8388 unique articles, of which 7 met the inclusion criteria. The included articles were published between 2001 and 2018 and reported on the outcomes of 101 unique patients. Of the 6 studies that reported significant findings, all identified clusters of hypermetabolism, hyperconnectivity or increased size in the frontostriatal limbic circuitry. LIMITATIONS The included studies were few and highly varied, spanning 2 decades. CONCLUSION Although few studies have analyzed preoperative imaging for predictors of response to psychiatric surgery, we found consistency among the reported results: most studies implicated overactivity in the frontostriatal limbic network as being correlated with clinical response. Larger prospective studies are needed. REGISTRATION www.crd.york.ac.uk/prospero/display_record.php?RecordID=131151.
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Affiliation(s)
- Benjamin Davidson
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Hrishikesh Suresh
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Maged Goubran
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Jennifer S Rabin
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Ying Meng
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Karim Mithani
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Christopher B Pople
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Peter Giacobbe
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Clement Hamani
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
| | - Nir Lipsman
- From the Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (Davidson, Suresh, Hamani, Lipsman); and the Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada (Davidson, Goubran, Rabin, Meng, Mithani, Pople, Giacobbe, Hamani, Lipsman)
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Döbrössy MD, Ramanathan C, Ashouri Vajari D, Tong Y, Schlaepfer T, Coenen VA. Neuromodulation in Psychiatric disorders: Experimental and Clinical evidence for reward and motivation network Deep Brain Stimulation: Focus on the medial forebrain bundle. Eur J Neurosci 2020; 53:89-113. [PMID: 32931064 DOI: 10.1111/ejn.14975] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 12/28/2022]
Abstract
Deep brain stimulation (DBS) in psychiatric illnesses has been clinically tested over the past 20 years. The clinical application of DBS to the superolateral branch of the medial forebrain bundle in treatment-resistant depressed patients-one of several targets under investigation-has shown to be promising in a number of uncontrolled open label trials. However, there are remain numerous questions that need to be investigated to understand and optimize the clinical use of DBS in depression, including, for example, the relationship between the symptoms, the biological substrates/projections and the stimulation itself. In the context of precision and customized medicine, the current paper focuses on clinical and experimental research of medial forebrain bundle DBS in depression or in animal models of depression, demonstrating how clinical and scientific progress can work in tandem to test the therapeutic value and investigate the mechanisms of this experimental treatment. As one of the hypotheses is that depression engenders changes in the reward and motivational networks, the review looks at how stimulation of the medial forebrain bundle impacts the dopaminergic system.
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Affiliation(s)
- Máté D Döbrössy
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany.,Center for Basics in Neuromodulation, Freiburg University, Freiburg, Germany
| | - Chockalingam Ramanathan
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany
| | - Danesh Ashouri Vajari
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - Yixin Tong
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany
| | - Thomas Schlaepfer
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Interventional Biological Psychiatry, University Hospital Freiburg, Freiburg, Germany
| | - Volker A Coenen
- Laboratory of Stereotaxy and Interventional Neurosciences, Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany.,Center for Basics in Neuromodulation, Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg, Germany
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57
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Emotions Modulate Subthalamic Nucleus Activity: New Evidence in Obsessive-Compulsive Disorder and Parkinson's Disease Patients. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 6:556-567. [PMID: 33060034 DOI: 10.1016/j.bpsc.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Subthalamic nucleus (STN) deep brain stimulation alleviates obsessive-compulsive disorder (OCD) symptoms, suggesting that this basal ganglia structure may play a key role in integrating limbic and motor information. We explored the modulation of STN neural activity by visual emotional information under different motor demands. METHODS We compared STN local field potentials acquired in 7 patients with OCD and 15 patients with Parkinson's disease off and on levodopa while patients categorized pictures as unpleasant, pleasant, or neutral and pressed a button for 1 of these 3 categories depending on the instruction. RESULTS During image presentation, theta power increased for unpleasant compared with neutral images in both patients with OCD and patients with Parkinson's disease. Only in patients with OCD was theta power also increased in pleasant compared with neutral trials. During the button press in patients with OCD, no modification of STN activity was seen on average, but theta power increased when the image triggering the motor response was unpleasant. Conversely, in patients with Parkinson's disease, a beta decrease was observed during the button press unrelated to the valence of the stimulus. Finally, in patients with OCD, a significant positive relationship was observed between the amplitude of the emotionally related theta response and symptom severity (measured using the Yale-Brown Obsessive Compulsive Scale). CONCLUSIONS We highlighted modulations of STN theta band activity related to emotions that were specific to OCD and correlated with OCD symptom severity. STN theta-induced activity might therefore underlie dysfunction of the limbic STN and its related network leading to OCD pathophysiology.
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Hescham S, Liu H, Jahanshahi A, Temel Y. Deep brain stimulation and cognition: Translational aspects. Neurobiol Learn Mem 2020; 174:107283. [PMID: 32739395 DOI: 10.1016/j.nlm.2020.107283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/10/2020] [Accepted: 07/26/2020] [Indexed: 11/19/2022]
Abstract
Many neurological patients suffer from memory loss. To date, pharmacological treatments for memory disorders have limited and short-lasting effects. Therefore, researchers are investigating novel therapies such as deep brain stimulation (DBS) to alleviate memory impairments. Up to now stimulation of the fornix, nucleus basalis of Meynert and entorhinal cortex have been found to enhance memory performance. Here, we provide an overview of the different DBS targets and mechanisms within the memory circuit, which could be relevant for enhancing memory in patients. Future studies are warranted, accelerating the efforts to further unravel mechanisms of action of DBS in memory-related disorders and develop stimulation protocols based on these mechanisms.
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Affiliation(s)
- Sarah Hescham
- Department of Neurosurgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands; European Graduate School of Neuroscience (EURON), Maastricht University, Maastricht, the Netherlands.
| | - Huajie Liu
- Department of Neurosurgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands; European Graduate School of Neuroscience (EURON), Maastricht University, Maastricht, the Netherlands
| | - Ali Jahanshahi
- Department of Neurosurgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands; European Graduate School of Neuroscience (EURON), Maastricht University, Maastricht, the Netherlands
| | - Yasin Temel
- Department of Neurosurgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands; European Graduate School of Neuroscience (EURON), Maastricht University, Maastricht, the Netherlands
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59
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Peker S, Samanci MY, Yilmaz M, Sengoz M, Ulku N, Ogel K. Efficacy and Safety of Gamma Ventral Capsulotomy for Treatment-Resistant Obsessive-Compulsive Disorder: A Single-Center Experience. World Neurosurg 2020; 141:e941-e952. [PMID: 32565377 DOI: 10.1016/j.wneu.2020.06.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is a chronic disease with a lifetime prevalence of 3% and is associated with severe impairment in familial and socio-occupational functioning. Gamma ventral capsulotomy (GVC) is a treatment choice in carefully chosen patients, with few published reports. In this study, we aimed to report the efficacy and safety of GVC in 21 patients with treatment-resistant OCD. METHODS This is a retrospective single-center study. Twenty-one patients meeting the selection criteria were included. Patients were considered responders if there were ≥35% reduction in post-GVC Yale-Brown Obsessive Compulsive Scale scores and considered in remission if scores were ≤8. The mean and median clinical follow-up durations were 60.7 and 56 months, respectively (range, 38-149 months). RESULTS The mean baseline Yale-Brown Obsessive Compulsive Scale score of 35.7 (n = 21) decreased to 15.3 (n = 20) at 36 months follow-up evaluation (P < 0.0001). Fifteen patients (75%) achieved a full response. Of those patients, 7 (35%) were considered to be in remission. There were no partial responders, and 5 patients (25%) were classified as nonresponders. The pre-GVC mean Beck Depression Inventory-II score of 35.1 (n = 21) decreased to 13.8 (n = 20) at 36 months follow-up evaluation (P < 0.0001). Three patients (14.3%) had a transient post-GVC headache that resolved within a week, and 2 patients (9.5%) had persistent headaches that responded to 2-week oral corticosteroid treatment. A brain cyst developed after GVC in 2 patients (10%). No clinically notable abnormalities were seen on neurologic examination at any follow-up. CONCLUSIONS Gamma ventral capsulotomy is a reasonable treatment method in select patients with treatment-resistant OCD.
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Affiliation(s)
- Selçuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Istanbul, Turkey.
| | | | - Meltem Yilmaz
- Department of Medical Biotechnology, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Meric Sengoz
- Department of Radiation Oncology, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Nazan Ulku
- Department of Psychology, Acıbadem Kozyatağı Hospital, Istanbul, Turkey
| | - Kültegin Ogel
- Department of Psychiatry, Health Sciences Institute, Istanbul Bilgi University, Istanbul, Turkey
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60
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Luyten L. The Bed Nucleus of the Stria Terminalis: Translational Deep Brain Stimulation to Reduce Anxiety. Neuroscientist 2020; 26:278-284. [PMID: 31971488 DOI: 10.1177/1073858419898381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent clinical evidence has put forward a new region of interest for the treatment of psychiatric disorders. Deep brain stimulation in the bed nucleus of the stria terminalis (BST) significantly attenuates symptoms in patients suffering from severe, treatment-resistant obsessive-compulsive disorder (OCD). The BST is not typically implicated in OCD neuropsychopathology but is certainly not an unknown in the field of emotional learning and memory. Substantial evidence supports its involvement in anxiety responses, particularly to ambiguous threats. This seems consistent with the intolerance of uncertainty and tendency to overestimate danger, which fuel obsessions and compulsions in many patients with OCD. Translational research in rodents can help to obtain a deeper understanding of the effects of high-frequency electrical stimulation in the BST on anxiety, which may be valuable to improve treatment for psychiatric patients.
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Affiliation(s)
- Laura Luyten
- Faculty of Psychology and Educational Sciences, Centre for Psychology of Learning and Experimental Psychopathology, KU Leuven, Leuven, Belgium.,Leuven Brain Institute, Leuven, Belgium
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Abstract
The clinical use of deep brain stimulation (DBS) is among the most important advances in the clinical neurosciences in the past two decades. As a surgical tool, DBS can directly measure pathological brain activity and can deliver adjustable stimulation for therapeutic effect in neurological and psychiatric disorders correlated with dysfunctional circuitry. The development of DBS has opened new opportunities to access and interrogate malfunctioning brain circuits and to test the therapeutic potential of regulating the output of these circuits in a broad range of disorders. Despite the success and rapid adoption of DBS, crucial questions remain, including which brain areas should be targeted and in which patients. This Review considers how DBS has facilitated advances in our understanding of how circuit malfunction can lead to brain disorders and outlines the key unmet challenges and future directions in the DBS field. Determining the next steps in DBS science will help to define the future role of this technology in the development of novel therapeutics for the most challenging disorders affecting the human brain.
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Cabrera LY, Courchesne C, Kiss ZHT, Illes J. Clinical Perspectives on Psychiatric Neurosurgery. Stereotact Funct Neurosurg 2020; 97:391-398. [PMID: 31955163 DOI: 10.1159/000505080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/22/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical interventions such as stereotactic radiosurgery and magnetic resonance-guided focused ultrasound, and neuromodulatory interventions such as deep brain stimulation (DBS) and vagal nerve stimulation, are under investigation to remediate psychiatric conditions resistant to conventional therapies involving drugs and psychological supports. OBJECTIVE Given the complicated history of psychiatric neurosurgery and its renaissance today, we sought to examine current perceptions and predictions about the field among practicing functional neurosurgeons. METHODS We designed a 51-question online survey comprising Likert-type, multiple-choice, and rank-order questions and distributed it to members of the American Society for Stereotactic and Functional Neurosurgery (ASSFN). Descriptive and inferential statistical analyses were performed on the data. RESULTS We received 38 completed surveys. Half (n = 19) of responders reported devoting at least a portion of their clinical practice to psychiatric neurosurgery, utilizing DBS and treating obsessive compulsive disorder (OCD) most frequently overall. Respondents indicated that psychiatric neurosurgery is more medically effective (OR 0, p = 0.03242, two-sided Fisher's exact test) and has clearer clinical indications for the treatment of OCD than for the treatment of depression (OR 0.09775, p = 0.005137, two-sided Fisher's exact test). Seventy-one percent of all respondents (n = 27) supported the clinical utility of ablative surgery in modern neuropsychiatric practice, 87% (n = 33) agreed that ablative procedures constitute a valid treatment alternative to DBS for some patients, and 61% (n = 23) agreed that ablative surgery may be an acceptable treatment option for patients who are unlikely to comply with postoperative care. CONCLUSIONS This up-to-date account of practices, perceptions, and predictions about psychiatric neurosurgery contributes to the knowledge about evolving attitudes over time and informs priorities for education and further surgical innovation on the psychiatric neurosurgery landscape.
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Affiliation(s)
- Laura Yenisa Cabrera
- Center for Ethics & Humanities in the Life Sciences, Department of Translational Neuroscience, Michigan State University, East Lansing, Michigan, USA,
| | - Caitlin Courchesne
- Neuroethics Canada, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zelma H T Kiss
- Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Judy Illes
- Neuroethics Canada, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Cabrera LY, Boyce HMK, McKenzie R, Bluhm R. Conflicts of interest and industry professional relationships in psychiatric neurosurgery: a comparative literature review. Neurosurg Focus 2019; 45:E20. [PMID: 30064327 DOI: 10.3171/2018.4.focus17399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The research required to establish that psychiatric treatments are effective often depends on collaboration between academic clinical researchers and industry. Some of the goals of clinical practice and those of commercial developers of psychiatric therapies overlap, such as developing safe and effective treatments. However, there might also be incompatible goals; physicians aim to provide the best care they can to their patients, whereas the medical industry ultimately aims to develop therapies that are commercially successful. In some cases, however, clinical research may be aiming both at improved patient care and commercial success. It is in these cases that a conflict of interest (COI) arises. The goal of this study was to identify differences and commonalities regarding COIs between 2 kinds of somatic psychiatric interventions: pharmacological and neurosurgical. METHODS The authors conducted a study focused on professional concerns regarding pharmacological and neurosurgical psychiatric interventions. They used medical and bioethics journal articles as an indicator of professionals' concerns and carried out a thematic content analysis of peer-reviewed articles published between 1960 and 2015, using PubMed and Google Scholar. RESULTS One hundred thirty-seven relevant articles were identified, of which 86 papers focused primarily on psychopharmacology and 51 on neurosurgery. The intervention most discussed in the psychiatric neurosurgery data set was deep brain stimulation (n = 42). While there were no significant differences at the level of categories, pharmacological and neurosurgical interventions differ in the underlying themes discussed. Two issues widely discussed in the articles on pharmaceutical interventions, but largely neglected in the neurosurgery articles, were medical professional issues and industry involvement. CONCLUSIONS COIs are a neglected issue in the discussion of ethics concerns regarding medical devices in psychiatry. Yet as these interventions become more common, it is important to address them in part through learning from the discussion regarding COIs in the pharmaceutical industry and by developing approaches to address those aspects of COIs that are unique to the medical device industry.
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Affiliation(s)
- Laura Y Cabrera
- 1Center for Ethics and Humanities in the Life Sciences and Department of Translational Science & Molecular Medicine, Michigan State University, East Lansing
| | - Hayden M K Boyce
- 2Spectrum Health Medical Group, Department of Neurosciences, Grand Rapids.,3College of Human Medicine West Michigan, Michigan State University, Grand Rapids
| | - Rachel McKenzie
- 4Lyman Briggs College, Michigan State University, East Lansing; and
| | - Robyn Bluhm
- 4Lyman Briggs College, Michigan State University, East Lansing; and.,5Department of Philosophy, Michigan State University, East Lansing, Michigan
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Abstract
Neuroethics research and scholarship intersect with dynamic academic disciplines in science, engineering, and the humanities. On the occasion of the 15th anniversary of the formation of the International Neuroethics Society, we identify current and future topics for neuroethics and discuss the many social and political challenges that emerge from the converging dynamics of neurotechnologies and artificial intelligence. We also highlight the need for a global, transdisciplinary, and integrated community of researchers to address the challenges that are precipitated by this rapid sociotechnological transformation.
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65
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Doshi PK, Hegde A, Desai A. Nucleus Accumbens Deep Brain Stimulation for Obsessive-Compulsive Disorder and Aggression in an Autistic Patient: A Case Report and Hypothesis of the Role of Nucleus Accumbens in Autism and Comorbid Symptoms. World Neurosurg 2019; 125:387-391. [PMID: 30797934 DOI: 10.1016/j.wneu.2019.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autism spectrum disorder represents a set of developmental disorders characterized by lack of social interaction and verbal and nonverbal communication in the first 3 years of life. It is also associated with several comorbidities, including epilepsy, aggression, self-mutilating behavior, and obsessive-compulsive behavior. In some cases, obsessive-compulsive disorder (OCD) develops. The nucleus accumbens (NAc) plays a key role in reward circuitry and is involved in the control of OCD and aggression. CASE DESCRIPTION A 42-year-old woman with autism was offered NAc deep brain stimulation for her comorbidities of OCD and aggression. The NAc was targeted using standard stereotactic methods, and postoperative scans confirmed the position of the active electrode to be within the NAc. The patient experienced significant symptom relief. At 1-year follow-up, the Yale-Brown Obsessive Compulsive Scale score for OCD, excluding items 1-5 of the scale, improved from 19 to 5. Hamilton Depression Scale and Hamilton Anxiety Scale scores similarly improved from 20 to 15 and from 30 to 18, respectively. Social Communication Questionnaire Current version for autism score improved from 26 to 16. Subscores for reciprocal social interactionimproved from 13 to 8; for communication improved from 5 to 4; and for restricted, repetitive, and stereotyped patterns of behavior improved from 6 to 3. CONCLUSIONS This case report illustrated the role of the NAc in OCD and aggression in an autistic patient. We discussed the role of the NAc as a target to explain the outcome of this case.
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Affiliation(s)
- Paresh K Doshi
- Department of Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, India.
| | - Anaita Hegde
- Department of Pediatrics, Jaslok Hospital and Research Centre, Mumbai, India
| | - Amit Desai
- Department of Psychiatry, Jaslok Hospital and Research Centre, Mumbai, India
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Miguel EC, Lopes AC, McLaughlin NCR, Norén G, Gentil AF, Hamani C, Shavitt RG, Batistuzzo MC, Vattimo EFQ, Canteras M, De Salles A, Gorgulho A, Salvajoli JV, Fonoff ET, Paddick I, Hoexter MQ, Lindquist C, Haber SN, Greenberg BD, Sheth SA. Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder. Mol Psychiatry 2019; 24:218-240. [PMID: 29743581 PMCID: PMC6698394 DOI: 10.1038/s41380-018-0054-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/26/2018] [Accepted: 03/06/2018] [Indexed: 11/08/2022]
Abstract
For more than half a century, stereotactic neurosurgical procedures have been available to treat patients with severe, debilitating symptoms of obsessive-compulsive disorder (OCD) that have proven refractory to extensive, appropriate pharmacological, and psychological treatment. Although reliable predictors of outcome remain elusive, the establishment of narrower selection criteria for neurosurgical candidacy, together with a better understanding of the functional neuroanatomy implicated in OCD, has resulted in improved clinical efficacy for an array of ablative and non-ablative intervention techniques targeting the cingulum, internal capsule, and other limbic regions. It was against this backdrop that gamma knife capsulotomy (GKC) for OCD was developed. In this paper, we review the history of this stereotactic radiosurgical procedure, from its inception to recent advances. We perform a systematic review of the existing literature and also provide a narrative account of the evolution of the procedure, detailing how the procedure has changed over time, and has been shaped by forces of evidence and innovation. As the procedure has evolved and adverse events have decreased considerably, favorable response rates have remained attainable for approximately one-half to two-thirds of individuals treated at experienced centers. A reduction in obsessive-compulsive symptom severity may result not only from direct modulation of OCD neural pathways but also from enhanced efficacy of pharmacological and psychological therapies working in a synergistic fashion with GKC. Possible complications include frontal lobe edema and even the rare formation of delayed radionecrotic cysts. These adverse events have become much less common with new radiation dose and targeting strategies. Detailed neuropsychological assessments from recent studies suggest that cognitive function is not impaired, and in some domains may even improve following treatment. We conclude this review with discussions covering topics essential for further progress of this therapy, including suggestions for future trial design given the unique features of GKC therapy, considerations for optimizing stereotactic targeting and dose planning using biophysical models, and the use of advanced imaging techniques to understand circuitry and predict response. GKC, and in particular its modern variant, gamma ventral capsulotomy, continues to be a reliable treatment option for selected cases of otherwise highly refractory OCD.
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Affiliation(s)
- Euripedes C Miguel
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil.
| | - Antonio C Lopes
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Nicole C R McLaughlin
- Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA
| | - Georg Norén
- Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA
| | - André F Gentil
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Harquail Centre for Neuromodulation, University of Toronto, Toronto, Ontario, Canada
| | - Roseli G Shavitt
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Marcelo C Batistuzzo
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Edoardo F Q Vattimo
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Miguel Canteras
- Discipline of Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Erich Talamoni Fonoff
- Department of Neurology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Marcelo Q Hoexter
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Suzanne N Haber
- University of Rochester School of Medicine, Rochester, New York, USA
- McLean Hospital, Harvard University, Boston, USA
| | - Benjamin D Greenberg
- Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA
| | - Sameer A Sheth
- Discipline of Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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67
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Zhang C, Deng Z, Pan Y, Zhang J, Zeljic K, Jin H, van der Stelt O, Gong H, Zhan S, Li D, Sun B. Pallidal deep brain stimulation combined with capsulotomy for Tourette's syndrome with psychiatric comorbidity. J Neurosurg 2019; 131:1788-1796. [PMID: 30611137 DOI: 10.3171/2018.8.jns181339] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/09/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE A current challenge is finding an effective and safe treatment for severely disabled patients with Tourette's syndrome (TS) and comorbid psychiatric disorders, in whom conventional treatments have failed. The authors aimed to evaluate the utility of globus pallidus internus deep brain stimulation (GPi-DBS) combined with bilateral anterior capsulotomy in treating these clinically challenging patients. METHODS The authors conducted a retrospective review of the clinical history and outcomes of 10 severely disabled patients with treatment-refractory TS and a psychiatric comorbidity, who had undergone GPi-DBS combined with bilateral anterior capsulotomy in their hospital. At the time of surgery, patients presented mainly with obsessive-compulsive disorder and affective disorders. Clinical outcome assessments of tic and psychiatric symptoms, as well as of general adaptive functioning and quality of life, were performed at the time of surgery and at 6, 12, and between 24 and 96 months postsurgery. RESULTS After surgery, all patients showed significant progressive improvements in tic and psychiatric symptoms, along with improvements in general adaptive functioning and quality of life. Tic alleviation reached 64% at 12 months and 77% at the last follow-up on the Yale Global Tic Severity Scale. At the final follow-up, patients had functionally recovered and displayed no or only mild tic and psychiatric symptoms. All patients tolerated treatment reasonably well, with no serious side effects. CONCLUSIONS GPi-DBS combined with bilateral anterior capsulotomy seems to offer major clinical benefits to severely disabled patients with otherwise treatment-refractory TS and psychiatric comorbidities.
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Affiliation(s)
- Chencheng Zhang
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Zhengdao Deng
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Yixin Pan
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Jing Zhang
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Kristina Zeljic
- 2Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences
- 3University of Chinese Academy of Sciences
| | - Haiyan Jin
- 4Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Hengfen Gong
- 6Department of Psychiatry, Pudong Mental Health Center, Shanghai, China
| | - Shikun Zhan
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Dianyou Li
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Bomin Sun
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
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68
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Cabrera LY, Brandt M, McKenzie R, Bluhm R. Online comments about psychiatric neurosurgery and psychopharmacological interventions: Public perceptions and concerns. Soc Sci Med 2019; 220:184-192. [DOI: 10.1016/j.socscimed.2018.11.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/08/2018] [Accepted: 11/10/2018] [Indexed: 01/15/2023]
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Senova S, Clair AH, Palfi S, Yelnik J, Domenech P, Mallet L. Deep Brain Stimulation for Refractory Obsessive-Compulsive Disorder: Towards an Individualized Approach. Front Psychiatry 2019; 10:905. [PMID: 31920754 PMCID: PMC6923766 DOI: 10.3389/fpsyt.2019.00905] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022] Open
Abstract
Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder featuring repetitive intrusive thoughts and behaviors associated with a significant handicap. Of patients, 20% are refractory to medication and cognitive behavioral therapy. Refractory OCD is associated with suicidal behavior and significant degradation of social and professional functioning, with high health costs. Deep brain stimulation (DBS) has been proposed as a reversible and controllable method to treat refractory patients, with meta-analyses showing 60% response rate following DBS, whatever the target: anterior limb of the internal capsule (ALIC), ventral capsule/ventral striatum (VC/VS), nucleus accumbens (NAcc), anteromedial subthalamic nucleus (amSTN), or inferior thalamic peduncle (ITP). But how do we choose the "best" target? Functional neuroimaging studies have shown that ALIC-DBS requires the modulation of the fiber tract within the ventral ALIC via the ventral striatum, bordering the bed nucleus of the stria terminalis and connecting the medial prefrontal cortex with the thalamus to be successful. VC/VS effective sites of stimulation were found within the VC and primarily connected to the medial orbitofrontal cortex (OFC) dorsomedial thalamus, amygdala, and the habenula. NAcc-DBS has been found to reduce OCD symptoms by decreasing excessive fronto-striatal connectivity between NAcc and the lateral and medial prefrontal cortex. The amSTN effective stimulation sites are located at the inferior medial border of the STN, primarily connected to lateral OFC, dorsal anterior cingulate, and dorsolateral prefrontal cortex. Finally, ITP-DBS recruits a bidirectional fiber pathway between the OFC and the thalamus. Thus, these functional connectivity studies show that the various DBS targets lie within the same diseased neural network. They share similar efficacy profiles on OCD symptoms as estimated on the Y-BOCS, the amSTN being the target supported by the strongest evidence in the literature. VC/VS-DBS, amSTN-DBS, and ALIC-DBS were also found to improve mood, behavioral adaptability and potentially both, respectively. Because OCD is such a heterogeneous disease with many different symptom dimensions, the ultimate aim should be to find the most appropriate DBS target for a given refractory patient. This quest will benefit from further investigation and understanding of the individual functional connectivity of OCD patients.
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Affiliation(s)
- Suhan Senova
- AP-HP, Groupe Hospitalier Henri-Mondor, DHU PePsy, Neurosurgery, Psychiatry and Addictology departments, Créteil, France.,Université Paris Est Creteil, Faculté de Médecine, Créteil, France.,IMRB UPEC/INSERM U 955 Team 14, Créteil, France
| | - Anne-Hélène Clair
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Institut du Cerveau et de la Moelle épinière, Paris, France
| | - Stéphane Palfi
- AP-HP, Groupe Hospitalier Henri-Mondor, DHU PePsy, Neurosurgery, Psychiatry and Addictology departments, Créteil, France.,Université Paris Est Creteil, Faculté de Médecine, Créteil, France.,IMRB UPEC/INSERM U 955 Team 14, Créteil, France
| | - Jérôme Yelnik
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Institut du Cerveau et de la Moelle épinière, Paris, France
| | - Philippe Domenech
- AP-HP, Groupe Hospitalier Henri-Mondor, DHU PePsy, Neurosurgery, Psychiatry and Addictology departments, Créteil, France.,Université Paris Est Creteil, Faculté de Médecine, Créteil, France.,Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Institut du Cerveau et de la Moelle épinière, Paris, France
| | - Luc Mallet
- AP-HP, Groupe Hospitalier Henri-Mondor, DHU PePsy, Neurosurgery, Psychiatry and Addictology departments, Créteil, France.,Université Paris Est Creteil, Faculté de Médecine, Créteil, France.,Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Institut du Cerveau et de la Moelle épinière, Paris, France.,Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, Geneva, Switzerland
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70
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Doshi PK, Arumugham SS, Bhide A, Vaishya S, Desai A, Singh OP, Math SB, Gautam S, Satyanarayana Rao TS, Mohandas E, Srinivas D, Avasthi A, Grover S, Reddy YCJ. Indian guidelines on neurosurgical interventions in psychiatric disorders. Indian J Psychiatry 2019; 61:13-21. [PMID: 30745649 PMCID: PMC6341921 DOI: 10.4103/psychiatry.indianjpsychiatry_536_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Neurosurgery for psychiatric disorders (NPD) has been practiced for >80 years. However, the interests have waxed and waned, from 1000s of surgeries in 1940-1950s to handful of surgery in 60-80s. This changed with the application of deep brain stimulation surgery, a surgery, considered to be "reversible" there has been a resurgence in interest. The Indian society for stereotactic and functional neurosurgery (ISSFN) and the world society for stereotactic and functional neurosurgery took the note of the past experiences and decided to form the guidelines for NPD. In 2011, an international task force was formed to develop the guidelines, which got published in 2013. In 2018, eminent psychiatrists from India, functional neurosurgeon representing The Neuromodulation Society and ISSFN came-together to deliberate on the current status, need, and legal aspects of NPD. In May 2018, Mental Health Act also came in to force in India, which had laid down the requirements to be fulfilled for NPD. In light of this after taking inputs from all stakeholders and review of the literature, the group has proposed the guidelines for NPD that can help to steer these surgery and its progress in India.
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Affiliation(s)
- Paresh K Doshi
- Department of Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, Maharastra, India
| | - Shyam S Arumugham
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Ajit Bhide
- Department of Psychiatry, St. Martha's Hospital, Bengaluru, Karnataka, India
| | - Sandeep Vaishya
- Consultant Neurosurgeon, Department of Neurosurgery, Fortis Hospital, Gurgaon, Haryana, India
| | - Amit Desai
- Department of Psychiatry, Jaslok Hospital and Research Centre, Mumbai, Maharastra, India
| | - Om Prakash Singh
- Department of Psychiatry, Nilratan Sirchar Medical College, Kolkata, West Bengal, India
| | - Suresh B Math
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Shiv Gautam
- Consultant Psychiatrist, Gautam Hospital and Research Centre, Civil Lines, Jaipur, Rajasthan, India
| | - T S Satyanarayana Rao
- Department of Psychiatry, J.S.S Medical College and Hospital, J.S.S University, Mysore, Karnataka, India
| | - E Mohandas
- Consultant Psychiatrist, Sun Medical and Research Centre, Trichur, Kerala, India
| | - Dwarkanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Ajit Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Y C Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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71
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Balachander S, Arumugham SS, Srinivas D. Ablative neurosurgery and deep brain stimulation for obsessive-compulsive disorder. Indian J Psychiatry 2019; 61:S77-S84. [PMID: 30745680 PMCID: PMC6343416 DOI: 10.4103/psychiatry.indianjpsychiatry_523_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. We review the recent literature on contemporary surgical options for OCD, focusing on clinical aspects such as patient selection, presurgical assessment, and safety and effectiveness of these procedures. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.
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Affiliation(s)
- Srinivas Balachander
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Shyam Sundar Arumugham
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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72
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Tastevin M, Spatola G, Régis J, Lançon C, Richieri R. Deep brain stimulation in the treatment of obsessive-compulsive disorder: current perspectives. Neuropsychiatr Dis Treat 2019; 15:1259-1272. [PMID: 31190832 PMCID: PMC6526924 DOI: 10.2147/ndt.s178207] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/23/2019] [Indexed: 12/18/2022] Open
Abstract
Deep brain stimulation (DBS) is a neuro-psychosurgical technique widely accepted in movement disorders, such as Parkinson's disease. Since 1999, DBS has been explored for severe, chronic and treatment-refractory psychiatric diseases. Our review focuses on DBS in obsessive-compulsive disorder (OCD), considered as a last treatment resort by most of learned societies in psychiatry. Two main stimulation areas have been studied: the striatal region and the subthalamic nucleus. But, most of the trials are open-labeled, and the rare controlled ones have failed to highlight the most efficient target. The recent perspectives are otherwise encouraging. Indeed, clinicians are currently considering other promising targets. A case series of 2 patients reported a decrease in OCD symptoms after DBS in the medial forebrain bundle and an open-label study is exploring bilateral habenula stimulation. New response criteria are also investigating such as quality of life, or subjective and lived-experience. Moreover, first papers about cost-effectiveness which is an important criterion in decision making, have been published. The effectiveness of tractography-assisted DBS or micro-assisted DBS is studying with the aim to improve targeting precision. In addition, a trial involving rechargeable pacemakers is undergoing because this mechanism could be efficient and have a positive impact on cost-effectiveness. A recent trial has discussed the possibility of using combined cognitive behavioral therapy (CBT) and DBS as an augmentation strategy. Finally, based on RDoc Research, the latest hypotheses about the understanding of cortico-striato-thalamo-cortical circuits could offer new directions including clinical predictors and biomarkers to perform adaptive closed-loop systems in the next future.
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Affiliation(s)
- Maud Tastevin
- Department of Psychiatry, Addictions and Psychiatry for Children, Public Assistance Marseille Hospitals, 13005 Marseille, France
| | - Giorgio Spatola
- Department of Functional and Stereotactic Neurosurgery, Public Assistance Marseille Hospitals, 13005 Marseille, France.,Institut de Neurosciences des Systèmes, Aix Marseille University, Inserm UMR1106, France
| | - Jean Régis
- Department of Functional and Stereotactic Neurosurgery, Public Assistance Marseille Hospitals, 13005 Marseille, France.,Institut de Neurosciences des Systèmes, Aix Marseille University, Inserm UMR1106, France
| | - Christophe Lançon
- Department of Psychiatry, Addictions and Psychiatry for Children, Public Assistance Marseille Hospitals, 13005 Marseille, France
| | - Raphaëlle Richieri
- Department of Psychiatry, Addictions and Psychiatry for Children, Public Assistance Marseille Hospitals, 13005 Marseille, France.,Faculté des Sciences de Saint Jérôme, Aix Marseille University, Institut Fresnel - UMR 7249, Marseille, France
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73
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Sauvaget A, Poulet E, Mantovani A, Bulteau S, Damier P, Moutaud B, Paternoster M, de Bartolomeis A, DʼUrso G. The Psychiatric Neuromodulation Unit: Implementation and Management. J ECT 2018; 34:211-219. [PMID: 29944606 DOI: 10.1097/yct.0000000000000513] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The proven effectiveness of neuromodulation and stimulation techniques for the management of psychiatric disorders has brought strongly needed innovation in psychiatry, given the high prevalence and high costs of treatment resistance. Although evidence-based guidelines in neuromodulation have been implemented to improve the clinical efficacy, safety, and research procedures, practical suggestions on how to design a psychiatric neuromodulation unit (PNU) are not available in the scientific literature. In this contribution, we have combined the results of a literature search with the suggestions of clinical psychiatrists, managers, and bioethicists who have had firsthand experience in building a PNU. Eleven key issues concerning the implementation and management of a PNU were identified: general context, team composition, environment, basic technical equipment, clinical versus research activities, target clinical population, education and training, interdisciplinarity, ethical aspects, regulatory and reimbursement issues, fund-raising, and partnership development. Moreover, a business plan comprising pragmatic solutions and recommendations for designing an efficient PNU was laid out.
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Affiliation(s)
| | | | | | | | - Philippe Damier
- CHU de Nantes, CIC0004, Nantes & Université de Nantes, UFR Médecine, Nantes
| | - Baptiste Moutaud
- CNRS, Cermes3, Research Center on Sciences, Health, Mental Health and Society, Paris, France
| | | | - Andrea de Bartolomeis
- Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Giordano DʼUrso
- Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
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74
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Iturrate I, Pereira M, Millán JDR. Closed-loop electrical neurostimulation: Challenges and opportunities. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2018. [DOI: 10.1016/j.cobme.2018.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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75
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Sugiyama K, Nozaki T, Asakawa T, Sameshima T, Koizumi S, Hiramatsu H, Namba H. Deep Brain Stimulation for Intractable Obsessive-compulsive Disorder: The International and Japanese Situation/Scenario. Neurol Med Chir (Tokyo) 2018; 58:369-376. [PMID: 30089754 PMCID: PMC6156130 DOI: 10.2176/nmc.st.2018-0115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Deep brain stimulation (DBS) is used to treat symptoms by modulating the cortico-striato-thalamo-cortical (CSTC) loop in the central nervous system (CNS), and attempts to research loop circuit disorders have been globally initiated among the intractable neurological and psychiatric disorders. DBS treatment has been evaluated for all these newly found CNS loop circuit disorders. In 2011, neurosurgical treatments for psychiatric disorders were renamed from “psychosurgery” to “neurosurgery for psychiatric disorders (NPD)” by the World Society for Stereotactic and Functional Neurosurgery (WSSFN). Moreover, in 2014, “Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders” was published by the WSSFN to address the differences in correspondence of stereotactic NPD. Globally, two multicenter prospective randomized control trials regarding DBS of the subcallosal cingulated gyrus and ventral anterior internal capsule/ventral striatum for intractable depression have been terminated after futility analysis. However, DBS for intractable obsessive-compulsive disorder (OCD), unlike for intractable depression, is showing steady development. In Japan, NPDs have not been performed since 1975 following the adoption of “Resolution of total denial for psychosurgery” by the Japanese Society of Psychiatry and Neurology. Nevertheless, a trend to adopt new neuro-modulation techniques for psychiatric disorders, including DBS, are emerging. We have created a clinical research protocol for the use of DBS in intractable OCD, which has been approved by the ethical committee of Hamamatsu University School of Medicine, with the hope of commencing DBS treatment for intractable OCD patients in the near future.
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Affiliation(s)
- Kenji Sugiyama
- Department of Neurosurgery, Hamamatsu University School of Medicine
| | - Takao Nozaki
- Department of Neurosurgery, Hamamatsu University School of Medicine
| | - Tetsuya Asakawa
- Department of Neurosurgery, Hamamatsu University School of Medicine
| | | | | | - Hisaya Hiramatsu
- Department of Neurosurgery, Hamamatsu University School of Medicine
| | - Hiroki Namba
- Department of Neurosurgery, Hamamatsu University School of Medicine
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76
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Schwabe K, Krauss JK. What rodent models of deep brain stimulation can teach us about the neural circuit regulation of prepulse inhibition in neuropsychiatric disorders. Schizophr Res 2018; 198:45-51. [PMID: 28663025 DOI: 10.1016/j.schres.2017.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/16/2017] [Accepted: 06/19/2017] [Indexed: 11/29/2022]
Abstract
Deep brain stimulation (DBS) is routinely used for treatment of movement disorders and it is also under investigation for neuropsychiatric disorders with deficient sensorimotor gating, such as schizophrenia, Tourette's syndrome and obsessive compulsive disorder. Electrical stimulation induces excitation and inhibition both at the stimulation site and at projection sites, thus modulating synchrony and oscillatory behavior of neuronal networks. We first provide background information on DBS in neuropsychiatric disorders accompanied by deficient sensorimotor gating. We then introduce prepulse inhibition (PPI) as a measure for sensorimotor gating in these disorders. Thereafter, we report on the use of DBS in rat models with deficient PPI induced by pharmacologic, genetic and neurodevelopmental manipulation. These models offer the opportunity to define the neuronal circuit regulation that is of relevance to PPI and its deficits in neuropsychiatric disorders with disturbed sensorimotor gating. Finally, we report on the use of the PPI paradigm in human patients operated for DBS on/off stimulation, which may further elucidate the neuronal network involved in regulation of PPI.
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Affiliation(s)
- Kerstin Schwabe
- Department of Neurosurgery, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
| | - Joachim K Krauss
- Department of Neurosurgery, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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77
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Stahl D, Cabrera L, Gibb T. Should DBS for Psychiatric Disorders be Considered a Form of Psychosurgery? Ethical and Legal Considerations. SCIENCE AND ENGINEERING ETHICS 2018; 24:1119-1142. [PMID: 28653164 DOI: 10.1007/s11948-017-9934-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/17/2017] [Indexed: 05/13/2023]
Abstract
Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community's interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS-though a much more precise and refined treatment than its predecessors-is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS.
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Affiliation(s)
- Devan Stahl
- Michigan State Univeristy, College of Human Medicine, East Fee Hall, 965 Fee Rd, RmC213, East Lansing, MI, 48824, USA.
| | - Laura Cabrera
- Michigan State University, College of Human Medicine, East Fee Hall, 965 Fee Rd, RmC211, East Lansing, MI, 48824, USA
| | - Tyler Gibb
- Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA
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78
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Pugh J, Pycroft L, Sandberg A, Aziz T, Savulescu J. Brainjacking in deep brain stimulation and autonomy. ETHICS AND INFORMATION TECHNOLOGY 2018; 20:219-232. [PMID: 30595661 PMCID: PMC6290799 DOI: 10.1007/s10676-018-9466-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
'Brainjacking' refers to the exercise of unauthorized control of another's electronic brain implant. Whilst the possibility of hacking a Brain-Computer Interface (BCI) has already been proven in both experimental and real-life settings, there is reason to believe that it will soon be possible to interfere with the software settings of the Implanted Pulse Generators (IPGs) that play a central role in Deep Brain Stimulation (DBS) systems. Whilst brainjacking raises ethical concerns pertaining to privacy and physical or psychological harm, we claim that the possibility of brainjacking DBS raises particularly profound concerns about individual autonomy, since the possibility of hacking such devices raises the prospect of third parties exerting influence over the neural circuits underpinning the subject's cognitive, emotional and motivational states. However, although it seems natural to assume that brainjacking represents a profound threat to individual autonomy, we suggest that the implications of brainjacking for individual autonomy are complicated by the fact that technologies targeted by brainjacking often serve to enhance certain aspects of the user's autonomy. The difficulty of ascertaining the implications of brainjacking DBS for individual autonomy is exacerbated by the varied understandings of autonomy in the neuroethical and philosophical literature. In this paper, we seek to bring some conceptual clarity to this area by mapping out some of the prominent views concerning the different dimension of autonomous agency, and the implications of brainjacking DBS for each dimension. Drawing on three hypothetical case studies, we show that there could plausibly be some circumstances in which brainjacking could potentially be carried out in ways that could serve to enhance certain dimensions of the target's autonomy. Our analysis raises further questions about the power, scope, and necessity of obtaining prior consent in seeking to protect patient autonomy when directly interfering with their neural states, in particular in the context of self-regulating closed-loop stimulation devices.
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Affiliation(s)
- Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Laurie Pycroft
- Oxford Functional Neurosurgery, University of Oxford, Oxford, UK
| | - Anders Sandberg
- Future of Humanity Institute, University of Oxford, Oxford, UK
| | - Tipu Aziz
- Oxford Functional Neurosurgery, University of Oxford, Oxford, UK
| | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
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79
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Gault JM, Davis R, Cascella NG, Saks ER, Corripio-Collado I, Anderson WS, Olincy A, Thompson JA, Pomarol-Clotet E, Sawa A, Daskalakis ZJ, Lipsman N, Abosch A. Approaches to neuromodulation for schizophrenia. J Neurol Neurosurg Psychiatry 2018; 89:777-787. [PMID: 29242310 DOI: 10.1136/jnnp-2017-316946] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/09/2017] [Accepted: 10/29/2017] [Indexed: 11/03/2022]
Abstract
Based on the success of deep brain stimulation (DBS) for treating movement disorders, there is growing interest in using DBS to treat schizophrenia (SZ). We review the unmet needs of patients with SZ and the scientific rationale behind the DBS targets proposed in the literature in order to guide future development of DBS to treat this vulnerable patient population. SZ remains a devastating disorder despite treatment. Relapse, untreated psychosis, intolerable side effects and the lack of effective treatment for negative and cognitive symptoms contribute to poor outcome. Novel therapeutic interventions are needed to treat SZ and DBS is emerging as a potential intervention. Convergent genetic, pharmacological and neuroimaging evidence implicating neuropathology associated with psychosis is consistent with SZ being a circuit disorder amenable to striatal modulation with DBS. Many of the DBS targets proposed in the literature may modulate striatal dysregulation. Additional targets are considered for treating tardive dyskinesia and negative and cognitive symptoms. A need is identified for the concurrent development of neurophysiological biomarkers relevant to SZ pathology in order to inform DBS targeting. Finally, we discuss the current clinical trials of DBS for SZ, and their ethical considerations. We conclude that patients with severe symptoms despite treatment must have the capacity to consent for a DBS clinical trial in which risks can be estimated, but benefit is not known. In addition, psychiatric populations should have access to the potential benefits of neurosurgical advances.
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Affiliation(s)
- Judith M Gault
- Department of Neurosurgery, University of Colorado at Denver Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Rachel Davis
- Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Nicola G Cascella
- Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elyn R Saks
- University of Southern California Law School, Los Angeles, California, USA
| | - Iluminada Corripio-Collado
- Psychiatric Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ann Olincy
- Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado at Denver Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edith Pomarol-Clotet
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
| | - Akira Sawa
- Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zafiris J Daskalakis
- Centre for Addiction and Mental Health Collaborative Program in Neuroscience, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado at Denver Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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80
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Zanello M, Duriez P, Pallud J, Roux A, Sharshar T, Gorwood P, Devaux B. Letter: Long-Term Follow-up Study of MRI-Guided Bilateral Anterior Capsulotomy in Patients With Refractory Anorexia Nervosa. Neurosurgery 2018; 83:E39-E40. [PMID: 29912370 DOI: 10.1093/neuros/nyy123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Marc Zanello
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
| | - Philibert Duriez
- Paris Descartes University Paris, France.,CMME (Groupe Hospitalier Sainte-Anne) Paris Descartes University Paris, France
| | - Johan Pallud
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
| | - Alexandre Roux
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
| | - Tarek Sharshar
- Paris Descartes University Paris, France.,Anaesthesia and Intensive Care Unit Sainte-Anne Hospital Paris, France
| | - Philip Gorwood
- Paris Descartes University Paris, France.,CMME (Groupe Hospitalier Sainte-Anne) Paris Descartes University Paris, France
| | - Bertrand Devaux
- Department of Neurosurgery Sainte-Anne Hospital Paris, France.,Paris Descartes University Paris, France
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81
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Abstract
Deep brain stimulation (DBS) has been offered to patients suffering of severe and resistant neuropsychiatric disorders like Obsessive Compulsive Disorder (OCD), Gilles de la Tourette Syndrome (TS) and Major Depression (MDD). Modulation of several targets within the cortico-striato-thalamo-cortical circuits can lead to a decrease of symptom severity in those patients. This review focuses on the recent clinical outcomes in DBS in psychiatric disorders. Studies on OCD and TS are now focusing on the long-term effects of DBS, with encouraging results regarding not only the decrease of symptoms, but also quality of life. They also highlighted efficient adjuvant techniques, like cognitive and behavioural therapy and support programs, to enhance an often-partial response to DBS. The application of DBS for MDD is more recent and, despite encouraging initial open-label studies, two large randomised studies have failed to demonstrate an efficacy of DBS in MDD according to evidence-based medicine criteria. Last years, DBS was also tested in other resistant psychiatric disorders, as anorexia nervosa and addiction, with encouraging preliminary results. However, today, no target – whatever the disease – can meet the criteria for clinical efficacy as recently defined by an international committee for neurosurgery for psychiatric disorders. Consequently, DBS in psychiatric disorders still needs to proceed within the frame of clinical trials.
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Affiliation(s)
- Anne-Hélène Clair
- Sorbonne University, UPMC Paris 06 University, INSERM, CNRS, Institut du Cerveau et de la Moelle épinière, Paris, France
| | - William Haynes
- Sorbonne University, UPMC Paris 06 University, INSERM, CNRS, Institut du Cerveau et de la Moelle épinière, Paris, France.,Neurosurgery department, University Hospital of Montpellier, Montpellier, France
| | - Luc Mallet
- Sorbonne University, UPMC Paris 06 University, INSERM, CNRS, Institut du Cerveau et de la Moelle épinière, Paris, France.,Psychiatry and Addictology Department - Neurosurgery Department, Personalized Neurology & Psychiatry University Department, University Hospitals Henri Mondor - Albert Chenevier, Créteil, France
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82
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Park RJ, Scaife JC, Aziz TZ. Study Protocol: Using Deep-Brain Stimulation, Multimodal Neuroimaging and Neuroethics to Understand and Treat Severe Enduring Anorexia Nervosa. Front Psychiatry 2018; 9:24. [PMID: 29681866 PMCID: PMC5898619 DOI: 10.3389/fpsyt.2018.00024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/22/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Research suggests that altered eating and the pursuit of thinness in anorexia nervosa (AN) are, in part, a consequence of aberrant reward circuitry. The neural circuits involved in reward processing and compulsivity overlap significantly, and this has been suggested as a transdiagnostic factor underpinning obsessive compulsive disorder, addictions and eating disorders. The nucleus accumbens (NAcc) is central to both reward processing and compulsivity. In previous studies, deep-brain stimulation (DBS) to the NAcc has been shown to result in neural and symptomatic improvement in both obsessive compulsive disorder and addictions. Moreover, in rats, DBS to the NAcc medial shell increases food intake. We hypothesise that this treatment may be of benefit in severe and enduring anorexia nervosa (SE-AN), but first, feasibility and ethical standards need to be established. The aims of this study are as follows: (1) to provide feasibility and preliminary efficacy data on DBS to the NAcc as a treatment for SE-AN; (2) to assess any subsequent neural changes and (3) to develop a neuroethical gold standard to guide applications of this treatment. METHOD This is a longitudinal study of six individuals with SE-AN of >7 years. It includes an integrated neuroethical sub-study. DBS will be applied to the NAcc and we will track the mechanisms underpinning AN using magnetoelectroencephalography, neuropsychological and behavioural measures. Serial measures will be taken on each intensively studied patient, pre- and post-DBS system insertion. This will allow elucidation of the processes involved in symptomatic change over a 15-month period, which includes a double-blind crossover phase of stimulator on/off. DISCUSSION Novel, empirical treatments for SE-AN are urgently required due to high morbidity and mortality costs. If feasible and effective, DBS to the NAcc could be game-changing in the management of this condition. A neuroethical gold standard is crucial to optimally underpin such treatment development. CLINICAL TRIAL REGISTRATION The study is ongoing and registered with www.ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT01924598, 22 July, 2013. It has full ethical and HRA approval (Project ID 128658).
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Affiliation(s)
- Rebecca J. Park
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Jessica C. Scaife
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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83
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Cabrera LY, Bittlinger M, Lou H, Müller S, Illes J. The re-emergence of psychiatric neurosurgery: insights from a cross-national study of newspaper and magazine coverage. Acta Neurochir (Wien) 2018; 160:625-635. [PMID: 29264778 DOI: 10.1007/s00701-017-3428-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/06/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Surgical approaches to treat psychiatric disorders have made a comeback. News media plays an essential role in exposing the public to trends in health care such as the re-emergence of therapeutic interventions in psychiatric neurosurgery that were set aside for decades, and in shaping attitudes and acceptance to them. METHOD We conducted an analysis of media articles covering all types of psychiatric neurosurgery published in Canada, USA, Germany, and Spain between the years 1960 and 2015. We applied both quantitative and qualitative methods to elucidate patterns of reporting for conditions, themes and tone, across geographic regions, time, and for type of intervention. RESULTS Coverage of psychiatric neurosurgery has surged since 2001 and is largely consistent across the countries examined. It focuses on depression and deep brain stimulation, and is explicit about historical context. The tone of coverage becomes more positive for Canada, USA and Spain over time; the tone of coverage from Germany remains cautious. Identity and privacy are among the few ethical and philosophical issues raised, notably in the German press. CONCLUSIONS The focused and optimistic attention to contemporary psychiatric neurosurgery in the media, but inattention to ethical issues, places an extra burden on functional neurosurgeons, psychiatrists, and other frontline health professionals to attend to queries from patients and policy makers about the full range of relevant emergent and emerging interventions and the mental health issues to which they may beneficially apply.
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Affiliation(s)
- Laura Y Cabrera
- Center for Ethics & Humanities in the Life Sciences, Department of Translational Science and Molecular Medicine, Michigan State University, East Fee Hall, 965 Fee Road, Rm C211, East Lansing, MI, 48824, USA
| | - Merlin Bittlinger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, CCM, Division of Mind and Brain Research, Berlin, Germany
| | - Hayami Lou
- Neuroethics Canada, The University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC, V6T 2B5, Canada
| | - Sabine Müller
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, CCM, Division of Mind and Brain Research, Berlin, Germany
| | - Judy Illes
- Neuroethics Canada, The University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC, V6T 2B5, Canada.
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84
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Naesström M, Blomstedt P, Hariz M, Bodlund O. Deep brain stimulation for obsessive-compulsive disorder: Knowledge and concerns among psychiatrists, psychotherapists and patients. Surg Neurol Int 2017; 8:298. [PMID: 29285414 PMCID: PMC5735431 DOI: 10.4103/sni.sni_19_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/15/2017] [Indexed: 11/04/2022] Open
Abstract
Background: Deep brain stimulation (DBS) is under investigation for severe obsessive-compulsive disorder (OCD) resistant to other therapies. The number of implants worldwide is slowly increasing. Therefore, it is of importance to explore knowledge and concerns of this novel treatment among patients and their psychiatric healthcare contacts. This information is relevant for scientific professionals working with clinical studies for DBS for this indication. Especially, for future study designs and the creation of information targeting healthcare professionals and patients. The aim of this study was to explore the knowledge and concerns toward DBS among patients with OCD, psychiatrists, and cognitive behavioral therapists. Methods: The study was conducted through web-based surveys for the aimed target groups –psychiatrist, patients, and cognitive behavioral therapists. The surveys contained questions regarding previous knowledge of DBS, source of knowledge, attitudes, and concerns towards the therapy. Results: The main source of information was from scientific sources among psychiatrists and psychotherapists. The patient's main source of information was the media. Common concerns among the groups included complications from surgery, anesthesia, stimulation side effects, and the novelty of the treatment. Specific concerns for the groups included; personality changes mentioned by patients and psychotherapists, and ethical concerns among psychiatrists. Conclusion: There are challenges for DBS in OCD as identified by the participants of this study; source and quality of information, efficacy, potential adverse effects, and eligibility. In all of which the current evidence base still is limited. A broad research agenda is needed for studies going forward.
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Affiliation(s)
| | - Patric Blomstedt
- Unit of Deep Brain Stimulation, Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden
| | - Marwan Hariz
- Unit of Deep Brain Stimulation, Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden.,Unit of Functional Neurosurgery, UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Owe Bodlund
- Department of Clinical Sciences/Psychiatry, Umeå University, Sweden
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85
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Bell E, Leger P, Sankar T, Racine E. Deep Brain Stimulation as Clinical Innovation: An Ethical and Organizational Framework to Sustain Deliberations About Psychiatric Deep Brain Stimulation. Neurosurgery 2017; 79:3-10. [PMID: 26909704 DOI: 10.1227/neu.0000000000001207] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
UNLABELLED Deep brain stimulation (DBS) for psychiatric disorders needs to be investigated in proper research trials. However, there are rare circumstances in which DBS could be offered to psychiatric patients as a form of surgical innovation, therefore potentially blurring the lines between these research trials and health care. In this article, we discuss the conditions under which surgical innovation may be accepted as a practice falling at the frontiers of standard clinical care and research per se. However, recognizing this distinction does not settle all ethical issues. Our article offers ethical guideposts to allow clinicians, surgical teams, institutions, and institutional review boards to deliberate about some of the fundamental issues that should be considered before surgical innovation with psychiatric DBS is undertaken. We provide key guiding questions to sustain this deliberation. Then we review the normative and empirical literature that exists to guide reflection about the ethics of surgical innovation and psychiatric DBS with respect to general ethical questions pertinent to psychiatric DBS, multidisciplinary team perspectives in psychiatric DBS, mechanisms for oversight in psychiatric DBS, and capacity and consent in psychiatric DBS. The considerations presented here are to recognize the very specific nature of surgical innovation and to ensure that surgical innovation in the context of psychiatric DBS remains a limited, special category of activity that does not replace appropriate surgical research or become the standard of care based on limited evidence. ABBREVIATIONS DBS, deep brain stimulationIRB, institutional review boardOCD, obsessive-compulsive disorder.
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Affiliation(s)
- Emily Bell
- *Neuroethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), Montréal, Quebec, Canada; ‡Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada; §Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada; ¶Departments of Neurology and Neurosurgery, Experimental Medicine & Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
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86
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Zhang C, Chen Y, Tian S, Wang T, Xie Y, Jin H, Lin G, Gong H, Zeljic K, Sun B, Yang T, Zhan S. Effects of Anterior Capsulotomy on Decision Making in Patients with Refractory Obsessive-Compulsive Disorder. Front Psychol 2017; 8:1814. [PMID: 29089909 PMCID: PMC5651033 DOI: 10.3389/fpsyg.2017.01814] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/29/2017] [Indexed: 12/05/2022] Open
Abstract
Despite various lines of evidence implicating impaired decision-making ability in individuals with obsessive–compulsive disorder (OCD), neuropsychological investigation has generated inconsistent findings. Although the cortico-striato-thalamo-cortical (CSTC) circuitry has been suggested, the involvement of the cortex has not yet been fully demonstrated. Moreover, it is unknown whether surgical intervention on the CSTC circuitry results in a predicted improvement of decision-making ability of OCD. Here we present a study of decision making based on the Iowa Gambling Task (IGT) to investigate decision making in a large sample of individuals with treatment-resistant OCD with and without anterior capsulotomy (AC). Task performance was evaluated in healthy subjects, individuals with OCD that had not undergone surgery, and postsurgical OCD patients with AC. The latter group was further divided into a short-term postsurgical group and a long-term postsurgical group. We found that the OCD patients without surgery performed significantly worse than the healthy controls on the IGT. There were no significant differences in decision-making between the presurgical OCD patients and those at the short-term postsurgical follow-up. Decision-making ability of the long-term postsurgical OCD patients was improved to the level comparable to that of healthy controls. All clinical symptoms (OCD, depression, and anxiety) assessed by psychiatric rating scales were significantly alleviated post-surgically, but exhibited no correlation with their IGT task performance. Our findings provide strong evidence that OCD is linked to impairments in decision-making ability; that impaired CSTC circuitry function is directly involved in the manifestation of OCD; and that AC related improvements in cognitive functions are caused by long-term plasticity in the brain circuitry.
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Affiliation(s)
- Chencheng Zhang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yilin Chen
- Institute of Neuroscience, Key Laboratory of Primate Neurobiology, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Shuaiwei Tian
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yile Xie
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiyan Jin
- Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guozhen Lin
- Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hengfen Gong
- Department of Psychiatry, Pudong District Mental Health Center, Shanghai, China
| | - Kristina Zeljic
- Institute of Neuroscience, Key Laboratory of Primate Neurobiology, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| | - Bomin Sun
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianming Yang
- Institute of Neuroscience, Key Laboratory of Primate Neurobiology, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| | - Shikun Zhan
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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87
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Zhang C, Li D, Jin H, Zeljic K, Sun B. Target-specific deep brain stimulation of the ventral capsule/ventral striatum for the treatment of neuropsychiatric disease. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:402. [PMID: 29152502 DOI: 10.21037/atm.2017.07.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Deep brain stimulation (DBS) is a well-established therapy for Parkinson's disease and other movement disorders. An accumulating body of evidence supports the extension of DBS application for the treatment of refractory psychiatric disorders. The ventral capsule/ventral striatum (VC/VS) is the most common anatomical target for obsessive-compulsive disorder (OCD), addiction, and depression. However, no specific electrode is available for the clinical targeting of these areas for DBS. According to the anatomical features of the VC/VS, a novel electrode was developed for simultaneous and independently programmed stimulation of the nucleus accumbens (NAc) and the anterior limb of the internal capsule (ALIC). This VC/VS-specific electrode has the potential to enhance stimulus intensity, provide independent and flexible target stimulation.
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Affiliation(s)
- Chencheng Zhang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dianyou Li
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Haiyan Jin
- Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Kristina Zeljic
- Institute of Neuroscience, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai 200031, China
| | - Bomin Sun
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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88
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Nanda P, Banks GP, Pathak YJ, Sheth SA. Connectivity-based parcellation of the anterior limb of the internal capsule. Hum Brain Mapp 2017; 38:6107-6117. [PMID: 28913860 PMCID: PMC6206867 DOI: 10.1002/hbm.23815] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/21/2017] [Accepted: 09/07/2017] [Indexed: 01/05/2023] Open
Abstract
The anterior limb of the internal capsule (ALIC) is an important locus of frontal-subcortical fiber tracts involved in cognitive and limbic feedback loops. However, the structural organization of its component fiber tracts remains unclear. Therefore, although the ALIC is a promising target for various neurosurgical procedures for psychiatric disorders, more precise understanding of its organization is required to optimize target localization. Using diffusion tensor imaging (DTI) collected on healthy subjects by the Human Connectome Project (HCP), we generated parcellations of the ALIC by dividing it according to structural connectivity to various frontal regions. We then compared individuals' parcellations to evaluate the ALIC's structural consistency. All 40 included subjects demonstrated a posterior-superior to anterior-inferior axis of tract organization in the ALIC. Nonetheless, subdivisions of the ALIC were found to vary substantially, as voxels in the average parcellation were accurately assigned for a mean of only 66.2% of subjects. There were, however, some loci of consistency, most notably in the region maximally connected to orbitofrontal cortex. These findings clarify the highly variable organization of the ALIC and may represent a tool for patient-specific targeting of neuromodulation. Hum Brain Mapp 38:6107-6117, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Pranav Nanda
- Department of Neurological SurgeryColumbia University Medical CenterNew YorkNew York
| | - Garrett P. Banks
- Department of Neurological SurgeryColumbia University Medical CenterNew YorkNew York
| | - Yagna J. Pathak
- Department of Neurological SurgeryColumbia University Medical CenterNew YorkNew York
| | - Sameer A. Sheth
- Department of Neurological SurgeryColumbia University Medical CenterNew YorkNew York
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89
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Caruso JP, Sheehan JP. Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy. Neurosurg Focus 2017; 43:E6. [DOI: 10.3171/2017.6.focus17257] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
At the peak of his career, Walter J. Freeman II was a celebrated physician and scientist. He served as the first chairman of the Department of Neurology at George Washington University and was a tireless advocate of surgical treatment for mental illness. His eccentric appearance, engaging personality during interviews, and theatrical demonstrations of his surgical techniques gained him substantial popularity with local and national media, and he performed more than 3000 prefrontal and transorbital lobotomies between 1930 and 1960. However, poor patient outcomes, unfavorable portrayals of the lobotomy in literature and film, and increased regulatory scrutiny contributed to the lobotomy’s decline in popularity. The development of antipsychotic medications eventually relegated the lobotomy to rare circumstances, and Freeman’s reputation deteriorated. Today, despite significant advancements in technique, oversight, and ethical scrutiny, neurosurgical treatment of mental illness still carries a degree of social stigma.This review presents a historical account of Walter Freeman’s life and career, and the popularization of the lobotomy in the US. Additionally, the authors pay special attention to the influence of popular literature and film on the public’s perception of psychosurgery. Aided by an understanding of this pivotal period in medical history, neurosurgeons are poised to confront the ethical and sociological questions facing psychosurgery as it continues to evolve.
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Affiliation(s)
| | - Jason P. Sheehan
- Departments of 1Neurological Surgery and
- 2Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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90
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Liu W, Li D, Sun F, Zhang X, Wang T, Zhan S, Pan Y, Huang P, Jin H, Li Y, Sun B. Long-Term Follow-up Study of MRI-Guided Bilateral Anterior Capsulotomy in Patients With Refractory Anorexia Nervosa. Neurosurgery 2017; 83:86-92. [DOI: 10.1093/neuros/nyx366] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/09/2017] [Indexed: 02/05/2023] Open
Abstract
Abstract
BACKGROUND
Anorexia nervosa (AN) is one of the most challenging psychiatric disorders to treat. The poor clinical outcomes warrant novel treatments for AN, especially in severe and persistent cases.
OBJECTIVE
To explore the feasibility of magnetic resonance imaging-guided bilateral anterior capsulotomy in the treatment of refractory AN.
METHODS
Seventy-four patients diagnosed with refractory AN who underwent capsulotomy completed this 3-yr follow-up study. Outcomes included body mass index (BMI) and results from a series of psychiatric scales (for obsessive, depressive, and anxious symptoms) that were implemented at baseline (presurgery), and 1 mo, 1 yr, and 3 yr after surgery.
RESULTS
Compared to presurgical levels, BMI increased significantly at 1-yr and 3-yr follow-ups. Compared to presurgery scores, psychiatric scale scores were significantly improved at 1-mo postsurgery, and continued to remain low at the 1-yr and 3-yr follow-ups. In addition, Mini-Mental State Examination (MMSE) scores were in the normal range during the long-term follow-up. The most common short-term side effects included urinary incontinence (n = 7), sleep disorders (n = 8), and fatigue (n = 6). Long-term complications included disinhibition (n = 6), memory loss (n = 3), and lethargy (n = 4). No patient in this study experienced death or disability.
CONCLUSION
Capsulotomy enabled patients with refractory AN to normalize their weight, especially those in life-threatening conditions. While it appears to be an acceptable life-saving treatment, it is indicated only when fulfilling strict criteria given its complications and irreversibility.
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Affiliation(s)
- Wei Liu
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Dianyou Li
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Fafa Sun
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoxiao Zhang
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Shikun Zhan
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Yixin Pan
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Peng Huang
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
| | - Haiyan Jin
- Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School, of Medicine, Shanghai, China
| | - Yongchao Li
- Department of Psychiatry, Shanghai YangPu District Mental Health Center, Shanghai, China
| | - Bomin Sun
- Department of Stereotactic and Functional Neurosurgery, Ruijin Hospital, Shanghai, Jiao Tong University School of Medicine, Shanghai, China
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91
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Beeker T, Schlaepfer TE, Coenen VA. Autonomy in Depressive Patients Undergoing DBS-Treatment: Informed Consent, Freedom of Will and DBS' Potential to Restore It. Front Integr Neurosci 2017; 11:11. [PMID: 28642690 PMCID: PMC5462943 DOI: 10.3389/fnint.2017.00011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 05/22/2017] [Indexed: 12/17/2022] Open
Abstract
According to the World Health Organization, depression is one of the most common and most disabling psychiatric disorders, affecting at any given time approximately 325 million people worldwide. As there is strong evidence that depressive disorders are associated with a dynamic dysregulation of neural circuits involved in emotional processing, recently several attempts have been made to intervene directly in these circuits via deep brain stimulation (DBS) in patients with treatment-resistant major depressive disorder (MDD). Given the promising results of most of these studies, the rising medical interest in this new treatment correlates with a growing sensitivity to ethical questions. One of the most crucial concerns is that DBS might interfere with patients' ability to make autonomous decisions. Thus, the goal of this article is to evaluate the impact DBS presumably has on the capacity to decide and act autonomously in patients with MDD in the light of the autonomy-undermining effects depression has itself. Following the chronological order of the procedure, special attention will first be paid to depression's effects on patients' capacity to make use of their free will in giving valid Informed Consent. We suggest that while the majority of patients with MDD appear capable of autonomous choices, as it is required for Informed Consent, they might still be unable to effectively act according to their own will whenever acting includes significant personal effort. In reducing disabling depressive symptoms like anhedonia and decrease of energy, DBS for treatment resistant MDD thus rather seems to be an opportunity to substantially increase autonomy than a threat to it.
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Affiliation(s)
- Timo Beeker
- Department of Psychiatry and Psychotherapy, Medical School Brandenburg Theodor FontaneRüdersdorf, Germany
| | - Thomas E. Schlaepfer
- Department of Interventional Biological Psychiatry, Freiburg University Medical CenterFreiburg, Germany
- Medical Faculty, Freiburg UniversityFreiburg, Germany
| | - Volker A. Coenen
- Medical Faculty, Freiburg UniversityFreiburg, Germany
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical CenterFreiburg, Germany
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92
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Raymaekers S, Vansteelandt K, Luyten L, Bervoets C, Demyttenaere K, Gabriëls L, Nuttin B. Long-term electrical stimulation of bed nucleus of stria terminalis for obsessive-compulsive disorder. Mol Psychiatry 2017; 22:931-934. [PMID: 27480493 DOI: 10.1038/mp.2016.124] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/15/2016] [Accepted: 06/17/2016] [Indexed: 12/21/2022]
Abstract
We previously reported that bilateral electrical stimulation in the anterior limb of the internal capsule/bed nucleus of the stria terminalis (IC/BST) effectively reduces symptoms in severe treatment-resistant obsessive-compulsive disorder (OCD) patients. Here we used a linear mixed model to investigate the evolution of symptomatic and functional status of our patients (n=24) and examined if baseline variables could predict this evolution. Data were collected during routine, clinical psychiatric visits. Our analysis showed a long-term, sustained effect of electrical stimulation in the IC/BST. After a fast initial decline of OCD symptoms, these symptoms remain relatively stable. In addition, we found a strong ON/OFF effect of stimulation (e.g., due to battery depletion). Our data also show that it is not the surgical procedure but rather the electrical stimulation that drives the improvement in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores. The Beck Depression Inventory (BDI) at baseline was the only predictor significantly related to the evolution of the Y-BOCS. A higher BDI at baseline seemed to be related to a smaller decrease of the Y-BOCS over time. In conclusion, electrical stimulation in the IC/BST has a fast and sustained effect on OCD and comorbid symptoms and functional status of patients.
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Affiliation(s)
- S Raymaekers
- KU Leuven Research Group Psychiatry, Leuven, Belgium.,Z.ORG UPC KU Leuven, Leuven, Belgium
| | - K Vansteelandt
- KU Leuven Research Group Psychiatry, Leuven, Belgium.,Z.ORG UPC KU Leuven, Leuven, Belgium
| | - L Luyten
- KU Leuven Research Group Psychology of Learning and Experimental Psychopathology, Leuven, Belgium.,KU Leuven Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium
| | | | - K Demyttenaere
- KU Leuven Research Group Psychiatry, Leuven, Belgium.,Z.ORG UPC KU Leuven, Leuven, Belgium
| | | | - B Nuttin
- KU Leuven Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium.,UZ Leuven Department of Neurosurgery, Leuven, Belgium
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93
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Lipsman N, Woodside DB, Lozano AM. Ethical surgical placebo-controlled trials of deep brain stimulation for treatment-resistant anorexia nervosa - Authors' reply. Lancet Psychiatry 2017; 4:442. [PMID: 28554428 DOI: 10.1016/s2215-0366(17)30201-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/21/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Nir Lipsman
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - D Blake Woodside
- Department of Psychiatry, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network, Toronto, ON M5T 2S8, Canada.
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94
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Pepper J, Meliak L, Akram H, Hyam J, Milabo C, Candelario J, Foltynie T, Limousin P, Curtis C, Hariz M, Zrinzo L. Changing of the guard: reducing infection when replacing neural pacemakers. J Neurosurg 2017; 126:1165-1172. [DOI: 10.3171/2016.4.jns152934] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Infection of deep brain stimulation (DBS) hardware has a significant impact on patient morbidity. Previous experience suggests that infection rates appear to be higher after implantable pulse generator (IPG) replacement surgery than after the de novo DBS procedure. In this study the authors examine the effect of a change in practice during DBS IPG replacements at their institution.
METHODS
Starting in January 2012, patient screening for methicillin-resistant Staphylococcus aureus (MRSA) and, and where necessary, eradication was performed prior to elective DBS IPG change. Moreover, topical vancomycin was placed in the IPG pocket during surgery. The authors then prospectively examined the infection rate in patients undergoing DBS IPG replacement at their center over a 3-year period with at least 9 months of follow-up.
RESULTS
The total incidence of infection in this prospective consecutive series of 101 IPG replacement procedures was 0%, with a mean follow-up duration of 24 ± 11 months. This was significantly lower than the authors' previously published historical control group, prior to implementing the change in practice, where the infection rate for IPG replacement was 8.5% (8/94 procedures; p = 0.003).
CONCLUSIONS
This study suggests that a change in clinical practice can significantly lower infection rates in patients undergoing DBS IPG replacement. These simple measures can minimize unnecessary surgery, loss of benefit from chronic stimulation, and costly hardware replacement, further improving the cost efficacy of DBS therapies.
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Affiliation(s)
- Joshua Pepper
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Lara Meliak
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Harith Akram
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Jonathan Hyam
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
- 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Catherine Milabo
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Joseph Candelario
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Thomas Foltynie
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Patricia Limousin
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
| | - Carmel Curtis
- 3Department of Clinical Microbiology, University College London Hospital, London, United Kingdom; and
| | - Marwan Hariz
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
- 4Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Ludvic Zrinzo
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square, London
- 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London
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95
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Park RJ, Singh I, Pike AC, Tan JOA. Deep Brain Stimulation in Anorexia Nervosa: Hope for the Hopeless or Exploitation of the Vulnerable? The Oxford Neuroethics Gold Standard Framework. Front Psychiatry 2017; 8:44. [PMID: 28373849 PMCID: PMC5357647 DOI: 10.3389/fpsyt.2017.00044] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/03/2017] [Indexed: 01/13/2023] Open
Abstract
Neurosurgical interventions for psychiatric disorders have a long and troubled history (1, 2) but have become much more refined in the last few decades due to the rapid development of neuroimaging and robotic technologies (2). These advances have enabled the design of less invasive techniques, which are more focused, such as deep brain stimulation (DBS) (3). DBS involves electrode insertion into specific neural targets implicated in pathological behavior, which are then repeatedly stimulated at adjustable frequencies. DBS has been used for Parkinson's disease and movement disorders since the 1960s (4-6) and over the last decade has been applied to treatment-refractory psychiatric disorders, with some evidence of benefit in obsessive-compulsive disorder (OCD), major depressive disorder, and addictions (7). Recent consensus guidelines on best practice in psychiatric neurosurgery (8) stress, however, that DBS for psychiatric disorders remains at an experimental and exploratory stage. The ethics of DBS-in particular for psychiatric conditions-is debated (1, 8-10). Much of this discourse surrounds the philosophical implications of competence, authenticity, personality, or identity change following neurosurgical interventions, but there is a paucity of applied guidance on neuroethical best practice in psychiatric DBS, and health-care professionals have expressed that they require more (11). This paper aims to redress this balance by providing a practical, applied neuroethical gold standard framework to guide research ethics committees, researchers, and institutional sponsors. We will describe this as applied to our protocol for a particular research trial of DBS in severe and enduring anorexia nervosa (SE-AN) (https://clinicaltrials.gov/ct2/show/NCT01924598, unique identifier NCT01924598), but believe it may have wider application to DBS in other psychiatric disorders.
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Affiliation(s)
- Rebecca J. Park
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ilina Singh
- Neuroscience Ethics and Society Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Alexandra C. Pike
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
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96
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Fins JJ, Kubu CS, Mayberg HS, Merkel R, Nuttin B, Schlaepfer TE. Being open minded about neuromodulation trials: Finding success in our “failures”. Brain Stimul 2017; 10:181-186. [DOI: 10.1016/j.brs.2016.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 11/09/2016] [Accepted: 12/20/2016] [Indexed: 11/28/2022] Open
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97
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Park SC, Lee JK, Kim CH, Hong JP, Lee DH. Gamma-knife subcaudate tractotomy for treatment-resistant depression and target characteristics: a case report and review. Acta Neurochir (Wien) 2017; 159:113-120. [PMID: 27900544 DOI: 10.1007/s00701-016-3001-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 10/18/2016] [Indexed: 01/01/2023]
Abstract
Stereotactic subcaudate tractotomy has previously been suggested to be an effective treatment for depression. This is the first study to report the use of gamma-knife subcaudate tractotomy for treatment-resistant depression. A 49-year-old woman with major depressive disorder had been treated for 30 years, with nine suicide attempts during that time. The right and left target maximum diameter was 11 mm within 50 % isodose lines. The target was located more posteriorly and inferiorly than the subgenual cingulate target typically used for deep-brain stimulation. The maximum radiation dose was 130 Gy. During the 4 months after surgery, the patient improved gradually from 23 to 4 according to the Hamilton Rating Scale for Depression and antidepressant medication was discontinued. Target-sized focal lesions were identified and no edema was seen postoperatively. No aggravation or neurologic deficit occurred during the 2.5 years of follow-up. Gamma-knife subcaudate tractotomy for depression is a minimally invasive technique. Investigations of the effectiveness and safety profile in a larger group are warranted.
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Affiliation(s)
- Seong-Cheol Park
- Department of Neurosurgery, Asan Medical Center, 88, Olympic Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Korea
| | - Jung Kyo Lee
- Department of Neurosurgery, Asan Medical Center, 88, Olympic Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Korea.
- College of Medicine, University of Ulsan, 88, Olympic Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Korea.
| | - Chan-Hyung Kim
- Department of Psychiatry, Severance Hospital, Yonsei University, Seoul, Korea
| | - Jin Pyo Hong
- College of Medicine, University of Ulsan, 88, Olympic Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Korea
- Department of Psychiatry, Asan Medical Center, Seoul, Korea
| | - Do Hee Lee
- Department of Neurosurgery, Asan Medical Center, 88, Olympic Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Korea
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98
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Neumaier F, Paterno M, Alpdogan S, Tevoufouet EE, Schneider T, Hescheler J, Albanna W. Surgical Approaches in Psychiatry: A Survey of the World Literature on Psychosurgery. World Neurosurg 2017; 97:603-634.e8. [DOI: 10.1016/j.wneu.2016.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 09/29/2016] [Accepted: 10/01/2016] [Indexed: 12/11/2022]
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99
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Luyten L, Hendrickx S, Raymaekers S, Gabriëls L, Nuttin B. Electrical stimulation in the bed nucleus of the stria terminalis alleviates severe obsessive-compulsive disorder. Mol Psychiatry 2016; 21:1272-80. [PMID: 26303665 DOI: 10.1038/mp.2015.124] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/11/2015] [Accepted: 06/25/2015] [Indexed: 12/22/2022]
Abstract
In 1998, we proposed deep brain stimulation as a last-resort treatment option for patients suffering from severe, treatment-resistant obsessive-compulsive disorder (OCD). Here, 24 OCD patients were included in a long-term follow-up study to evaluate the effects of electrical stimulation in the anterior limbs of the internal capsule (ALIC) and bed nucleus of the stria terminalis (BST). We find that electrical stimulation in the ALIC/BST area is safe and significantly decreases obsessions, compulsions, and associated anxiety and depressive symptoms, and improves global functioning in a blinded crossover trial (n=17), after 4 years (n=18), and at last follow-up (up to 171 months, n=24). Moreover, our data indicate that BST may be a better stimulation target compared with ALIC to alleviate OCD symptoms. We conclude that electrical stimulation in BST is a promising therapeutic option for otherwise treatment-resistant OCD patients.
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Affiliation(s)
- L Luyten
- KU Leuven Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium.,KU Leuven Research Group Psychology of Learning and Experimental Psychopathology, Leuven, Belgium
| | - S Hendrickx
- KU Leuven Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium
| | - S Raymaekers
- KU Leuven Research Group Psychiatry, Leuven, Belgium
| | - L Gabriëls
- UPC-KU Leuven University Center for OCD, Leuven, Belgium
| | - B Nuttin
- KU Leuven Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium.,UZ Leuven Department of Neurosurgery, Leuven, Belgium
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100
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van den Heuvel OA, van Wingen G, Soriano-Mas C, Alonso P, Chamberlain SR, Nakamae T, Denys D, Goudriaan AE, Veltman DJ. Brain circuitry of compulsivity. Eur Neuropsychopharmacol 2016; 26:810-27. [PMID: 26711687 DOI: 10.1016/j.euroneuro.2015.12.005] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 08/28/2015] [Accepted: 12/01/2015] [Indexed: 01/27/2023]
Abstract
Compulsivity is associated with alterations in the structure and the function of parallel and interacting brain circuits involved in emotional processing (involving both the reward and the fear circuits), cognitive control, and motor functioning. These brain circuits develop during the pre-natal period and early childhood under strong genetic and environmental influences. In this review we bring together literature on cognitive, emotional, and behavioral processes in compulsivity, based mainly on studies in patients with obsessive-compulsive disorder and addiction. Disease symptoms normally change over time. Goal-directed behaviors, in response to reward or anxiety, often become more habitual over time. During the course of compulsive disorders the mental processes and repetitive behaviors themselves contribute to the neuroplastic changes in the involved circuits, mainly in case of chronicity. On the other hand, successful treatment is able to normalize altered circuit functioning or to induce compensatory mechanisms. We conclude that insight in the neurobiological characteristics of the individual symptom profile and disease course, including the potential targets for neuroplasticity is an unmet need to advance the field.
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Affiliation(s)
- Odile A van den Heuvel
- Department of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands; Department of Anatomy & Neurosciences, VUmc, Amsterdam, The Netherlands; The Obsessive-Compulsive Disorder Team, Haukeland University Hospital, Bergen, Norway.
| | - Guido van Wingen
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Carles Soriano-Mas
- OCD Clinical and Research Unit, Department of Psychiatry, Bellvitge University Hospital; Bellvitge Biomedical Research Institute (IDIBELL), and CIBERSAM (Centro de Investigación en Red de Salud Mental), Carlos III Health Institute, Barcelona, Spain; Department of Psychobiology and Methodology in Health Sciences, Universitat Autònoma de Barcelona, Spain
| | - Pino Alonso
- OCD Clinical and Research Unit, Department of Psychiatry, Bellvitge University Hospital; Bellvitge Biomedical Research Institute (IDIBELL), and CIBERSAM (Centro de Investigación en Red de Salud Mental), Carlos III Health Institute, Barcelona, Spain; Department of Clinical Sciences, Bellvitge Campus, University of Barcelona, Spain
| | - Samuel R Chamberlain
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom; Cambridge and Peterborough NHS Foundation Trust (CPFT), Cambridge, United Kingdom
| | - Takashi Nakamae
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anna E Goudriaan
- Academic Medical Center, Department of Psychiatry, Amsterdam Institute for Addiction Research, University of Amsterdam, Amsterdam, The Netherlands; Arkin Mental Health and Jellinek Addiction Treatment, Amsterdam, The Netherlands
| | - Dick J Veltman
- Department of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands
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