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Lapa JDS, Duarte JFS, Campos ACP, Davidson B, Nestor SM, Rabin JS, Giacobbe P, Lipsman N, Hamani C. Adverse Effects of Deep Brain Stimulation for Treatment-Resistant Depression: A Scoping Review. Neurosurgery 2024; 95:509-516. [PMID: 38511957 DOI: 10.1227/neu.0000000000002910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/24/2024] [Indexed: 03/22/2024] Open
Abstract
Deep brain stimulation (DBS) is an emerging therapy for treatment-resistant depression (TRD). Although adverse effects have been reported in early-phase and a few randomized clinical trials, little is known about its overall safety profile, which has been assumed to be similar to that of DBS for movement disorders. The objective of this study was to pool existing safety data on DBS for TRD. Following PRISMA guidelines, PubMed was searched for English articles describing adverse outcomes after DBS for TRD. Studies were included if they reported at least 5 patients with a minimal follow-up of 6 months. After abstract (n = 607) and full-article review (n = 127), 28 articles reporting on 353 patients met criteria for final inclusion. Follow-up of the studies retrieved ranged from 12 to 96 months. Hemorrhages occurred in 0.8% of patients and infections in 10.2%. The rate of completed suicide was 2.5%. Development or worsening of depressive symptoms, anxiety, and mania occurred in 18.4%, 9.1%, and 5.1%, respectively. There were some differences between targets, but between-study heterogeneity precluded statistical comparisons. In conclusion, DBS for TRD is associated with surgical and psychiatric adverse events. Hemorrhage and infection occur at rates within an accepted range for other DBS applications. The risk of suicide after DBS for TRD is 2.5% but may not represent a significant deviation from the natural history of TRD. Finally, risks of worsening depression, anxiety, and the incidence of mania should be acknowledged when considering DBS for TRD.
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Affiliation(s)
- Jorge D S Lapa
- Department of Medicine, Federal University of Sergipe, Aracaju , Sergipe , Brazil
- Department Neurosurgery, Hospital de Cirurgia, Aracaju , Sergipe , Brazil
| | - Joel F S Duarte
- Department Neurosurgery, Neurological Institute of Curitiba, Curitiba , Brazil
| | | | - Benjamin Davidson
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Sean M Nestor
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Jennifer S Rabin
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto , Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Clement Hamani
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
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Graat I, Franken S, van Rooijen G, de Koning P, Vulink N, de Kroo M, Denys D, Mocking R. Cognitive behavioral therapy in patients with deep brain stimulation for obsessive-compulsive disorder: a matched controlled study. Psychol Med 2023; 53:5861-5867. [PMID: 37795687 DOI: 10.1017/s0033291722003130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is effective for refractory obsessive-compulsive disorder (OCD). Post-operative cognitive behavioral therapy (CBT) may augment the effects of DBS, but previous results are conflicting. Here, we investigated whether CBT augments the effect of DBS for OCD. METHOD Patients with and without CBT following DBS of the ventral anterior limb of the internal capsule were included. First, we analyzed Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Hamilton Depression Rating Scale (HAM-D) scores before, during and after CBT in all patients with CBT. Second, we matched patients with and without CBT based on clinical baseline variables and initial response to DBS and compared the course of Y-BOCS and HAM-D scores over the same timeframe. RESULTS In total, 36 patients with and 16 patients without CBT were included. Average duration of CBT was 10.4 months (s.d. 6.4). In the 36 patients with CBT, Y-BOCS scores decreased on average by 3.8 points (14.8%) from start until end of CBT (p = 0.043). HAM-D scores did not decrease following CBT. Second, 10 patients with CBT were matched to 10 patients without CBT. In both groups, Y-BOCS scores decreased equally from start until end of CBT or over a similar timeframe (10% in CBT group v. 13.1% in no-CBT group, p = 0.741). CONCLUSIONS Obsessive-compulsive symptoms decreased over time in patients with and without post-operative CBT. Therefore, further improvement may be attributed to late effects of DBS itself. The present study emphasizes the need for prospective randomized controlled studies, examining the effects of CBT.
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Affiliation(s)
- Ilse Graat
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | | | | | | | | | | | - Roel Mocking
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
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Dandekar MP, Diaz AP, Rahman Z, Silva RH, Nahas Z, Aaronson S, Selvaraj S, Fenoy AJ, Sanches M, Soares JC, Riva-Posse P, Quevedo J. A narrative review on invasive brain stimulation for treatment-resistant depression. ACTA ACUST UNITED AC 2021; 44:317-330. [PMID: 34468549 PMCID: PMC9169472 DOI: 10.1590/1516-4446-2021-1874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/22/2021] [Indexed: 12/20/2022]
Abstract
While most patients with depression respond to pharmacotherapy and psychotherapy, about one-third will present treatment resistance to these interventions. For patients with treatment-resistant depression (TRD), invasive neurostimulation therapies such as vagus nerve stimulation, deep brain stimulation, and epidural cortical stimulation may be considered. We performed a narrative review of the published literature to identify papers discussing clinical studies with invasive neurostimulation therapies for TRD. After a database search and title and abstract screening, relevant English-language articles were analyzed. Vagus nerve stimulation, approved by the U.S. Food and Drug Administration as a TRD treatment, may take several months to show therapeutic benefits, and the average response rate varies from 15.2-83%. Deep brain stimulation studies have shown encouraging results, including rapid response rates (> 30%), despite conflicting findings from randomized controlled trials. Several brain regions, such as the subcallosal-cingulate gyrus, nucleus accumbens, ventral capsule/ventral striatum, anterior limb of the internal capsule, medial-forebrain bundle, lateral habenula, inferior-thalamic peduncle, and the bed-nucleus of the stria terminalis have been identified as key targets for TRD management. Epidural cortical stimulation, an invasive intervention with few reported cases, showed positive results (40-60% response), although more extensive trials are needed to confirm its potential in patients with TRD.
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Affiliation(s)
- Manoj P Dandekar
- Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana, India
| | - Alexandre P Diaz
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ziaur Rahman
- Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana, India
| | - Ritele H Silva
- Laboratório de Psiquiatria Translacional, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (UNESC), Criciúma, SC, Brazil
| | - Ziad Nahas
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Scott Aaronson
- Clinical Research Programs, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Sudhakar Selvaraj
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Albert J Fenoy
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Deep Brain Stimulation Program, Department of Neurosurgery, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Marsal Sanches
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Jair C Soares
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Joao Quevedo
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Laboratório de Psiquiatria Translacional, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (UNESC), Criciúma, SC, Brazil.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA.,Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, UTHealth, Houston, TX, USA
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Ramasubbu R, Golding S, Williams K, Mackie A, MacQueen G, Kiss ZHT. Recruitment Challenges for Studies of Deep Brain Stimulation for Treatment-Resistant Depression. Neuropsychiatr Dis Treat 2021; 17:765-775. [PMID: 33731996 PMCID: PMC7956889 DOI: 10.2147/ndt.s299913] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/13/2021] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Deep brain stimulation (DBS) is currently an investigational treatment for treatment-resistant depression (TRD). There is a need for more DBS trials to strengthen existing evidence of its efficacy for both regulatory and clinical reasons. Recruitment for DBS trials remains challenging due to unproven efficacy in sham-controlled DBS trials, invasive nature of the intervention and stringent eligibility criteria in patient selection. Here, we examined the referral patterns and reasons for exclusion of subjects in our DBS trial. METHODS Data were collected from all patients who expressed interest in participating in a DBS study involving subcallosal cingulate region from 2014 to 2016. Referral sources were categorized as either self-referral or professional referral. Evaluation for eligibility was performed in three stages; initial contact, brief telephone assessment, and in-person psychiatric evaluation. The reasons for exclusion were documented. Descriptive and inferential statistics were used for analysis. RESULTS Of the 225 patients who contacted us initially, 22 (9.2%) underwent DBS surgery. Self-referral was higher than the referral from professionals (72% versus 28%, P<0.0001). However, the acceptance rate for surgery was higher among the professional referrals than from self-referrals (40% versus 15%, P=0.03). The common reasons for exclusion were self-withdrawal (38.4%), residing out of province or country (26.1%) and psychiatric/medical comorbidity (21.7%). CONCLUSION These findings provide insight into DBS candidacy for future TRD trials. It suggests a need for comprehensive recruitment strategies including active engagement of patients and professionals throughout trials, and effective referral communication with education to optimize recruitment for future DBS trials.
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Affiliation(s)
- Rajamannar Ramasubbu
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada.,Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Sandra Golding
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
| | - Kimberly Williams
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Glenda MacQueen
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Zelma H T Kiss
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada.,Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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