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Pham MT, Campbell TA, Dorfman N, Torgerson L, Kostick-Quenet K, Blumenthal-Barby J, Storch EA, Lázaro-Muñoz G. Clinician Perspectives on Levels of Evidence and Oversight for Deep Brain Stimulation for Treatment-Resistant Childhood OCD. J Obsessive Compuls Relat Disord 2023; 39:100830. [PMID: 37781644 PMCID: PMC10538479 DOI: 10.1016/j.jocrd.2023.100830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Approximately 10-20% of children with obsessive-compulsive disorder (OCD) have treatment-resistant presentations, and there is likely interest in developing interventions for this patient group, which may include deep brain stimulation (DBS). The World Society for Stereotactic and Functional Neurosurgery has argued that at least two successful randomized controlled trials should be available before DBS treatment for a psychiatric disorder is considered "established." The FDA approved DBS for adults with treatment-resistant OCD under a humanitarian device exemption (HDE) in 2009, which requires that a device be used to manage or treat a condition impacting 8,000 or fewer patients annually in the United States. DBS is currently offered to children ages 7 and older with treatment-resistant dystonia under an HDE. Ethical and empirical work are needed to evaluate whether and under what conditions it might be appropriate to offer DBS for treatment-resistant childhood OCD. To address this gap, we report qualitative data from semi-structured interviews with 25 clinicians with expertise in this area. First, we report clinician perspectives on acceptable levels of evidence to offer DBS in this patient population. Second, we describe their perspectives on institutional policies or protocols that might be needed to effectively provide care for this patient population.
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Affiliation(s)
- Michelle T Pham
- Center for Bioethics and Social Justice, College of Human Medicine, Michigan State University, East Fee Hall 965 Wilson Road Rm A-126, East Lansing, MI 48824, United States
| | - Tiffany A Campbell
- Center for Bioethics, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, United States
| | - Natalie Dorfman
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Jennifer Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 326D, Houston, TX, 77030, United States
| | - Eric A Storch
- Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd Suite E4.100, Houston, TX, 77030, United States
| | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, United States
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
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Porwal MH, Karra H, Sharma U, Bhatti D. Deep brain stimulation for refractory obsessive-compulsive disorder: A review and analysis of the FDA MAUDE database. Surg Neurol Int 2022; 13:399. [PMID: 36128133 PMCID: PMC9479641 DOI: 10.25259/sni_613_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Deep brain stimulation (DBS) is used as a treatment option for patients diagnosed with a form of obsessive-compulsive disorder (OCD) that is highly resistant to conventional treatment methods. In 2009, DBS was granted a humanitarian device exemption-approval by the Food and Drug Administration after promising preliminary data. Monitoring of long-term safety data through post market surveillance of adverse events has not yet been conducted for DBS in OCD patients. This study aims to address this critical knowledge gap. Methods: All patient- and device-related (PR; DR) reports from January 1, 2012, to December 31, 2021, were downloaded and compiled from the manufacturer and user facility device experience (MAUDE) database pertaining to DBS for OCD using the product class name “Deep Brain Stimulator For OCD.” Data in this study were examined using descriptive statistics to evaluate for frequency of reporting. Results: The most frequently reported PR adverse event categories included psychiatric (40%), neurological (19%), other (14%), decreased therapeutic response (10%), and infections (10%). The most frequent DR reports were high impedance (14%), energy output problem (7%), battery problem (7%), malposition of device (7%), and improper/incorrect procedure or method (7%). Conclusion: The PR and DR adverse events in our study align with the previous findings of adverse events. They also further solidify that DBS for refractory OCD may be a viable option for the right patient population. However, further studies are essential given the limitations of the MAUDE database.
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Affiliation(s)
- Mokshal H. Porwal
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - Hamsitha Karra
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - Umesh Sharma
- Department of Neurology, Orlando Regional Medical Center,
| | - Danish Bhatti
- Department of Neurology, University of Central Florida College of Medicine, Orlando, Florida, United States
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Professional attitudes toward the use of neuromodulatory technologies in Mexico: Insight for neuroethical considerations of cultural diversity. CNS Spectr 2022; 27:255-257. [PMID: 33298232 DOI: 10.1017/s1092852920002151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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4
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Stevens I, Gilbert F. International Regulatory Standards for the Qualitative Measurement of Deep Brain Stimulation in Clinical Research. J Empir Res Hum Res Ethics 2022; 17:228-241. [DOI: 10.1177/15562646221094922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Deep brain stimulation (DBS) has progressed to become a promising treatment modality for neurologic and psychiatric disorders like epilepsy and major depressive disorder due to its growing personalization. Despite evidence pointing to the benefits of DBS if tested on these personalized qualitative metrics, rather than randomized-control trial quantitative standards, the evaluation of these novel devices appears to be based on the latter. This study surveyed the presence of this trend in the national regulatory guidelines of the prominent DBS researching countries. It was found that two governing bodies, in the European Union and Australia, acknowledged the option for qualitative measures. These findings support further development of national regulatory guidelines, so the neuroscientific community developing these neurotechnologies can better understand the impact their treatments have on patients.
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Affiliation(s)
- I. Stevens
- School of Humanities, University of Tasmania, Hobart, Tasmania, Australia
| | - F. Gilbert
- School of Humanities, University of Tasmania, Hobart, Tasmania, Australia
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Pressing ethical issues in considering pediatric deep brain stimulation for obsessive-compulsive disorder. Brain Stimul 2021; 14:1566-1572. [PMID: 34700055 DOI: 10.1016/j.brs.2021.10.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/09/2021] [Accepted: 10/22/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Refractory obsessive-compulsive disorder (OCD) among adults is the first psychiatric indication of deep brain stimulation (DBS) to receive an FDA Humanitarian Device Exemption (HDE). Given the HDE approval and encouraging evidence that has since emerged, exploration of DBS for OCD may expand to adolescents in the future. More than 100,000 adolescents in the U.S. suffer from refractory OCD, and there is already a precedent for the transition of DBS in adults to children in the case of dystonia. However, the risk-benefit analysis of pediatric DBS for OCD may be more complex and raise different ethical questions compared to pediatric DBS for dystonia. OBJECTIVE This study aimed to gain insight into pressing ethical issues related to using DBS in adolescents with OCD. METHODS Semi-structured interviews were conducted with clinicians (n = 25) caring for pediatric patients with refractory OCD. Interview transcripts were coded with MAXQDA 2018 software and analyzed using thematic content analysis to identify emergent themes. RESULTS Five central themes were identified in clinician responses, three of which were exacerbated in the pediatric DBS setting. Clinicians expressed concerns related to conditions of decision-making including adolescents' capacity to assent (80%), the lack of evidence about the outcomes and potential unknown effects of using DBS in adolescents with OCD (68%), and the importance of exhausting other treatment options before considering DBS (20%). CONCLUSIONS Strategies to address clinician concerns include implementation of validated decision support tools and further research into the outcomes of pediatric DBS for OCD to establish clear guidelines for patient selection.
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Kane PB, Bittlinger M, Kimmelman J. Individualized therapy trials: navigating patient care, research goals and ethics. Nat Med 2021; 27:1679-1686. [PMID: 34642487 DOI: 10.1038/s41591-021-01519-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
'Individualized therapy' trials (sometimes called n-of-1 trials) use patients as their own controls to evaluate treatments. Here we divide such trials into three categories: multi-crossover trials aimed at individual patient management, multi-crossover trial series and pre-post trials. These trials all customize interventions for patients; however, the latter two categories also aim to inform medical practice and thus embody tensions between the goals of care and research that are typical of other types of clinical trials. In this Perspective, we discuss four domains where such tensions play out-clinical equipoise, informed consent, reporting and funding, and we provide recommendations for addressing each.
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Affiliation(s)
- Patrick Bodilly Kane
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Merlin Bittlinger
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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Cabrera LY, Nowak GR, McCright AM, Achtyes E, Bluhm R. Last Resort Interventions?: A Qualitative Study of Psychiatrists' Experience with and Views on Psychiatric Electroceutical Interventions. Psychiatr Q 2021; 92:419-430. [PMID: 32789719 PMCID: PMC7881051 DOI: 10.1007/s11126-020-09819-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Psychiatrists play an important role in providing access to psychiatric electrical interventions (PEIs) such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). As such, their views on these procedures likely influence whether they refer or provide these types of treatments for their clinically depressed patients. Despite this, scholars have too infrequently examined psychiatrists' views about specific PEIs and have not yet examined their views across different PEIs. To gain insight into psychiatrists' views about PEIs, we conducted a qualitative study based on semi-structured interviews with 16 psychiatrists in Michigan. The majority of psychiatrists had a positive attitude towards PEIs in general. One-third reported cautionary attitudes towards PEIs; they did not reject the interventions but were skeptical of their effectiveness or felt they needed further development. The majority of psychiatrists consider ECT and TMS to be viable therapies that they would discuss with their patients after several failed medication trials. There was a lack of knowledge about surgical PEIs, such as deep brain stimulation. This study provides insights into how psychiatrists perceive PEIs. While broadly positive attitudes exist, this research highlights certain challenges, particularly lack of knowledge and ambiguity about the use of PEIs.
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Affiliation(s)
- L Y Cabrera
- Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Fee Hall, 965 Wilson Road, Rm C211, East Lansing, MI, 48824, USA.
- Department of Translational Neuroscience, Michigan State University, East Lansing, MI, USA.
| | - G R Nowak
- Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Fee Hall, 965 Wilson Road, Rm C211, East Lansing, MI, 48824, USA
- Department of Sociology, Michigan State University, East Lansing, MI, USA
| | - A M McCright
- Department of Sociology, Michigan State University, East Lansing, MI, USA
| | - E Achtyes
- Division of Psychiatry and Behavioral Medicine, Michigan State University, Grand Rapids, MI, USA
- Pine Rest Christian Mental Health Services, Grand Rapids, MI, USA
| | - R Bluhm
- Lyman Briggs College and Dept. of Philosophy, Michigan State University, East Lansing, MI, USA
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Cabrera LY, Courchesne C, Bittlinger M, Müller S, Martinez R, Racine E, Illes J. Authentic Self and Last Resort: International Perceptions of Psychiatric Neurosurgery. Cult Med Psychiatry 2021; 45:141-161. [PMID: 32562138 DOI: 10.1007/s11013-020-09679-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Psychiatric neurosurgery has resurfaced over the past two decades for the treatment of severe mental health disorders, with improved precision and safety over older interventions alongside the development of novel ones. Little is known, however, about current public opinions, expectations, hopes, and concerns over this evolution in neurotechnology, particularly given the controversial history of psychosurgery. To fill this knowledge gap, we conducted a study with eight focus groups in Vancouver and Montreal (Canada; n = 14), Berlin (Germany; n = 22), and Madrid (Spain; n = 12). Focus group texts were transcribed and analyzed using qualitative content analysis in the language local to each city, guided by the theoretical framework of pragmatic neuroethics. Findings indicate that participants across all cities hold concerns about the last resort nature of psychiatric neurosurgery and the potential impact on the authentic self of patients who undergo these procedures. The views captured serve to advance discussion on the appropriate timing for psychiatric neurosurgery, promote sound health policy for the allocation of this resource, and foster scientific literacy about advances for mental health internationally.
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Affiliation(s)
- L Y Cabrera
- Center for Ethics & Humanities in the Life Sciences, Department of Translational Neuroscience, Michigan State University, East Fee Hall, 965 Wilson Road, Rm C211, East Lansing, MI, 48824, USA.
| | - C Courchesne
- The University of British Columbia, Vancouver, Canada
| | - M Bittlinger
- Division of Mind and Brain Research, Department of Psychiatry and Psychotherapy, CCM, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - S Müller
- Division of Mind and Brain Research, Department of Psychiatry and Psychotherapy, CCM, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - R Martinez
- Functional Neurosurgery and Radiosurgery Unit, Ruber International Hospital, Madrid, Spain
| | - E Racine
- Institut de Recherches Cliniques de Montréal (IRCM), Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montreal, Canada.,Department of Neurology and Neurosurgery and Biomedical Ethics Unit, McGill University, Montreal, Canada
| | - J Illes
- Department of Medicine, The University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC, V6T 2B5, Canada.
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Deep brain stimulation for refractory obsessive-compulsive disorder (OCD): emerging or established therapy? Mol Psychiatry 2021; 26:60-65. [PMID: 33144712 PMCID: PMC7815503 DOI: 10.1038/s41380-020-00933-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/22/2020] [Indexed: 11/08/2022]
Abstract
A consensus has yet to emerge whether deep brain stimulation (DBS) for treatment-refractory obsessive-compulsive disorder (OCD) can be considered an established therapy. In 2014, the World Society for Stereotactic and Functional Neurosurgery (WSSFN) published consensus guidelines stating that a therapy becomes established when "at least two blinded randomized controlled clinical trials from two different groups of researchers are published, both reporting an acceptable risk-benefit ratio, at least comparable with other existing therapies. The clinical trials should be on the same brain area for the same psychiatric indication." The authors have now compiled the available evidence to make a clear statement on whether DBS for OCD is established therapy. Two blinded randomized controlled trials have been published, one with level I evidence (Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score improved 37% during stimulation on), the other with level II evidence (25% improvement). A clinical cohort study (N = 70) showed 40% Y-BOCS score improvement during DBS, and a prospective international multi-center study 42% improvement (N = 30). The WSSFN states that electrical stimulation for otherwise treatment refractory OCD using a multipolar electrode implanted in the ventral anterior capsule region (including bed nucleus of stria terminalis and nucleus accumbens) remains investigational. It represents an emerging, but not yet established therapy. A multidisciplinary team involving psychiatrists and neurosurgeons is a prerequisite for such therapy, and the future of surgical treatment of psychiatric patients remains in the realm of the psychiatrist.
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10
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McCradden MD, Anderson JA, Zlotnik Shaul R. Accountability in the Machine Learning Pipeline: The Critical Role of Research Ethics Oversight. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:40-42. [PMID: 33103980 DOI: 10.1080/15265161.2020.1820111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Lai Y, Wang T, Zhang C, Lin G, Voon V, Chang J, Sun B. Effectiveness and safety of neuroablation for severe and treatment-resistant obsessive-compulsive disorder: a systematic review and meta-analysis. J Psychiatry Neurosci 2020; 45:356-369. [PMID: 32549057 PMCID: PMC7850151 DOI: 10.1503/jpn.190079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/05/2019] [Accepted: 01/16/2020] [Indexed: 11/01/2022] Open
Abstract
Background Several neuroablative procedures are available for severe and treatment-resistant obsessive-compulsive disorder (OCD), but limited knowledge about their relative clinical advantages and disadvantages poses obstacles for treatment decision-making. Methods We searched PubMed, Embase, Scopus, Web of Knowledge and the Cochrane Library for reports up to February 2019. We reviewed the literature on the effectiveness (assessed using the Yale-Brown Obsessive Compulsive Scale [Y-BOCS]) and safety of various neuroablative interventions for severe and treatment-resistant OCD. Results We included 23 studies involving 487 patients in the systematic review; 21 studies with 459 patients entered meta-analysis. Overall, neuroablation achieved a response rate (proportion of patients with ≥ 35% reduction in Y-BOCS) of 55%. Most of the adverse events (88.4%) were mild and transient. The top 3 adverse events were headache (14.9%), cognitive deficits (9.1%) and behaviour problems (8.1%). Severe or permanent adverse events included personality changes (2.3%) and brain edema or brain cyst (1.5%). The response rates associated with capsulotomy, limbic leucotomy and cingulotomy were 59% (95% confidence interval [CI] 54-65), 47% (95% CI 23-72) and 36% (95% CI 23-50), respectively. Interventions with different coverages of the dorsal part of the internal capsule were associated with different adverse-event profiles but were unlikely to modify clinical effectiveness. Limitations The level of evidence of most included studies was relatively low. Conclusion Ablative surgeries are safe and effective for a large proportion of patients with severe and treatment-resistant OCD. Among the available procedures, capsulotomy seemed to be the most effective. Further research is needed to improve clinical effectiveness and minimize risks.
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Affiliation(s)
- Yijie Lai
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Tao Wang
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Chencheng Zhang
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Guozhen Lin
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Valerie Voon
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Jinwoo Chang
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Bomin Sun
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
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Israely S, Leisman G. Can neuromodulation techniques optimally exploit cerebello-thalamo-cortical circuit properties to enhance motor learning post-stroke? Rev Neurosci 2020; 30:821-837. [PMID: 31194694 DOI: 10.1515/revneuro-2019-0008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023]
Abstract
Individuals post-stroke sustain motor deficits years after the stroke. Despite recent advancements in the applications of non-invasive brain stimulation techniques and Deep Brain Stimulation in humans, there is a lack of evidence supporting their use for rehabilitation after brain lesions. Non-invasive brain stimulation is already in use for treating motor deficits in individuals with Parkinson's disease and post-stroke. Deep Brain Stimulation has become an established treatment for individuals with movement disorders, such as Parkinson's disease, essential tremor, epilepsy, cerebral palsy and dystonia. It has also been utilized for the treatment of Tourette's syndrome, Alzheimer's disease and neuropsychiatric conditions such as obsessive-compulsive disorder, major depression and anorexia nervosa. There exists growing scientific knowledge from animal studies supporting the use of Deep Brain Stimulation to enhance motor recovery after brain damage. Nevertheless, these results are currently not applicable to humans. This review details the current literature supporting the use of these techniques to enhance motor recovery, both from human and animal studies, aiming to encourage development in this domain.
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Affiliation(s)
- Sharon Israely
- Department of Medical Neurobiology, IMRIC and ELSC, The Hebrew University, Hadassah Medical School, Jerusalem 9112102, Israel
| | - Gerry Leisman
- Department of Physiotherapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.,Universidad de Ciencias Médicas Instituto de Neurología y Neurocirugía, Neurofisiología Clinica, Havana, Cuba
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13
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Gaber T, Brown M. Recent advances in neuromodulation for spinal cord injuries. PROGRESS IN NEUROLOGY AND PSYCHIATRY 2020. [DOI: 10.1002/pnp.554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tarek Gaber
- Dr Gaber is a Consultant in Rehabilitation Medicine at Wrightington, Wigan and Leigh NHS Trust
| | - Mary Brown
- Dr Brown is Consultant in Rehabilitation Medicine at Salford Royal NHS Trust
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14
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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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15
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Desmoulin-Canselier S. Patient's lived experience with DBS between medical research and care: some legal implications. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:375-386. [PMID: 30074133 DOI: 10.1007/s11019-018-9859-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the past 50 years, an ethical-legal boundary has been drawn between treatment and research. It is based on the reasoning that the two activities pursue different purposes. Treatment is aimed at achieving optimal therapeutic benefits for the individual patient, whereas the goal of scientific research is to increase knowledge, in the public interest. From this viewpoint, the patient's experience should be clearly distinguished from that of a participant in a clinical trial. On this premise, two parallel and mutually exclusive regimes have been established. Yet in the case of deep brain stimulation (DBS), this presentation is a poor fit, for both the patient's lived experience and medical practice and research. The frictions may be explained by the specificities of the treatment (including surgery and medical devices) and of the pathologies concerned (chronic and evolutive), and by the characteristics of the medical team implementing the treatment. These particularities challenge the dominant frame of reference in medical bioethics and cause difficulties for the current legal framework in fulfilling its dual role: to protect patients while supporting the development of innovative treatments. The dominant model is still the clinical trial for medication safety and legal requirements of drug market regulation. However, DBS forces us to reflect on a medical device that is permanently implanted in the brain by highly specialized multi-disciplinary neurosurgical teams, for the treatment of chronic evolutive diseases. These devices demand fine-tuning on a case-by-case basis and there is still a lot to discover about why DBS is effective (or not). As a result, the wall between treatment and research is osmotic: many discoveries are made incidentally, in the course of treatment. The following study begins with these observations, and suggests that we review legal provisions (especially in French and United States law) so that they are better adapted to the first-person needs and experience of the patient undergoing brain stimulation.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- CNRS/Université de Nantes UMR 6297 Droit et Changement Social, Faculté de Droit et de sciences politiques, Université de Nantes, Chemin de la Censive du Tertre, Nantes, France.
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Huys D, Kohl S, Baldermann JC, Timmermann L, Sturm V, Visser-Vandewalle V, Kuhn J. Open-label trial of anterior limb of internal capsule-nucleus accumbens deep brain stimulation for obsessive-compulsive disorder: insights gained. J Neurol Neurosurg Psychiatry 2019; 90:805-812. [PMID: 30770458 DOI: 10.1136/jnnp-2018-318996] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND For more than 15 years, deep brain stimulation (DBS) has served as a last-resort treatment for severe treatment-resistant obsessive-compulsive disorder (OCD). METHODS From 2010 to 2016, 20 patients with OCD (10 men/10 women) were included in a single-centre trial with a naturalistic open-label design over 1 year to evaluate the effects of DBS in the anterior limb of the internal capsule and nucleus accumbens region (ALIC-NAcc) on OCD symptoms, executive functions, and personality traits. RESULTS ALIC-NAcc-DBS significantly decreased OCD symptoms (mean Yale-Brown Obsessive Compulsive Scale reduction 33%, 40% full responders) and improves global functioning without loss of efficacy over 1 year. No significant changes were found in depressive or anxiety symptoms. Our study did not show any effect of ALIC-NAcc-DBS on personality traits or executive functions, and no potential outcome predictors were identified in a post hoc analysis. Other than several individual minor adverse events, ALIC-NAcc-DBS has been shown to be safe, but 35% of patients reported a sudden increase in anxiety and anhedonia after acute cessation of stimulation. CONCLUSIONS We conclude that ALIC-NAcc-DBS is a well-tolerated and promising last-resort treatment option for OCD. The cause of variability in the outcome remains unclear, and the aspect of reversibility must be examined critically. The present data from one of the largest samples of patients with OCD treated with DBS thus far support the results of previous studies with smaller samples.
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Affiliation(s)
- Daniel Huys
- Department of Psychiatry and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Sina Kohl
- Department of Psychiatry and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Juan Carlos Baldermann
- Department of Psychiatry and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Lars Timmermann
- Department of Neurology, University Hospital Giessen and Marburg, Campus Marburg, Marburg, Germany
| | - Volker Sturm
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Veerle Visser-Vandewalle
- Department of Psychiatry and Psychotherapy, University Hospital of Cologne, Cologne, Germany.,Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University Hospital of Cologne, Cologne, Germany.,Johanniter Hospital Oberhausen, Department of Psychiatry, Psychotherapy and Psychosomatics, Oberhausen, Germany
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Desmoulin-Canselier S, Moutaud B. Animal Models and Animal Experimentation in the Development of Deep Brain Stimulation: From a Specific Controversy to a Multidimensional Debate. Front Neuroanat 2019; 13:51. [PMID: 31191261 PMCID: PMC6548025 DOI: 10.3389/fnana.2019.00051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/08/2019] [Indexed: 11/13/2022] Open
Abstract
In this article, we explore a specific controversy about animal experimentation and animal models in the recent history of deep brain stimulation (DBS), and we question its ramifications. DBS development intertwines clinical practice with fundamental research and stands at the crossroads of multiple legacies. We take up the various issues and controversies embedded in this rarely addressed dispute, from a standpoint that combines socio-anthropological and legal aspects. Our starting point is a debate on the role of animal experimentation in the development of DBS between Jarrod Bailey, a researcher promoting the abolition of animal experimentation, and Alim Louis Benabid, Marwan Hariz, and Mahlon DeLong, three key figures in the area of DBS and neuroscience. By clarifying the positions of the different protagonists and retracing the issues raised in these discussions, our objective is to show how this specific debate has extended from its initial space and how it provides an object of study with heuristic scope. We first present this partially polemic discussion about the history of DBS, and its link with a more general debate on the validity and use of animal models and the need for animal experiments. Then, we raise the issue of the relations and interactions between experiments on animals and on humans in the logics of biomedical innovation. The third step is to situate the discussion within the wider framework of opposition towards animal experimentation and the promotion of animal' rights. Finally, combining these interweaved issues, possible implications emerge regarding the future of DBS. We show that behind these several controversies lie the question of translational research and the model of medicine upheld by DBS. We describe how the technology contributes to blurring the lines between research (fundamental, preclinical and clinical research) and care, as well as between humans and animals as substrates and objects of knowledge. The dynamics of DBS future development might then become a point of convergence for neuroscientists and animal rights defenders' interests.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- Centre National de la Recherche Scientifique (CNRS), Nantes, France
- Droit et Changement Social, UMR 6297, Université de Nantes, Nantes, France
| | - Baptiste Moutaud
- Centre National de la Recherche Scientifique (CNRS), Nantes, France
- Laboratoire d’ethnologie et de sociologie comparative, UMR 7186, Université Paris Nanterre, Nanterre, France
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Calvert JS, Grahn PJ, Zhao KD, Lee KH. Emergence of Epidural Electrical Stimulation to Facilitate Sensorimotor Network Functionality After Spinal Cord Injury. Neuromodulation 2019; 22:244-252. [PMID: 30840354 DOI: 10.1111/ner.12938] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 01/15/2019] [Accepted: 01/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) disrupts signaling pathways between the brain and spinal networks below the level of injury. In cases of severe SCI, permanent loss of sensorimotor and autonomic function can occur. The standard of care for severe SCI uses compensation strategies to maximize independence during activities of daily living while living with chronic SCI-related dysfunctions. Over the past several years, the research field of spinal neuromodulation has generated promising results that hold potential to enable recovery of functions via epidural electrical stimulation (EES). METHODS This review provides a historical account of the translational research efforts that led to the emergence of EES of the spinal cord to enable intentional control of motor functions that were lost after SCI. We also highlight the major limitations associated with EES after SCI and propose future directions of spinal neuromodulation research. RESULTS Multiple, independent studies have demonstrated return of motor function via EES in individuals with chronic SCI. These enabled motor functions include intentional, controlled movement of previously paralyzed extremities, independent standing and stepping, and increased grip strength. In addition, improvements in cardiovascular health, respiratory function, body composition, and urologic function have been reported. CONCLUSIONS EES holds promise to enable functions thought to be permanently lost due to SCI. However, EES is currently restricted to scientific investigation in humans with SCI and requires further validation of factors such as safety and efficacy before clinical translation.
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Affiliation(s)
| | - Peter J Grahn
- Department of Neurologic Surgery, Rochester, MN, USA.,Department of Physical Medicine and Rehabilitation, Rehabilitation Medicine Research Center, Rochester, MN, USA
| | - Kristin D Zhao
- Department of Physical Medicine and Rehabilitation, Rehabilitation Medicine Research Center, Rochester, MN, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Kendall H Lee
- Department of Neurologic Surgery, Rochester, MN, USA.,Department of Physical Medicine and Rehabilitation, Rehabilitation Medicine Research Center, Rochester, MN, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Peripheral nerve bionic interface: a review of electrodes. INTERNATIONAL JOURNAL OF INTELLIGENT ROBOTICS AND APPLICATIONS 2019. [DOI: 10.1007/s41315-019-00086-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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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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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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Van Norman GA. Expanded Patient Access to Investigational New Devices: Review of Emergency and Nonemergency Expanded Use, Custom, and 3D-Printed Devices. JACC Basic Transl Sci 2018; 3:533-544. [PMID: 30175277 PMCID: PMC6115642 DOI: 10.1016/j.jacbts.2018.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 06/29/2018] [Indexed: 12/21/2022]
Abstract
U.S. Food and Drug Administration (FDA) approval of Class III medical devices can take from 3 to 7 years. Although this is shorter than times for drug approvals, patients with serious or life-threatening diseases and disorders may not have time to wait for device approval to access needed treatments. The FDA has a number of pathways, similar to drug approval processes, for expanded use of unapproved medical devices in patients for whom no reasonable alternative therapy is available. Additionally, the FDA regulates the manufacture and use of "custom" medical devices-those made for use by 1 specific patient. With the advent of 3-dimensional printing and bioprinting, new rules are evolving to address concerns that lines may be blurred between "custom" treatments and unregulated human experimentation.
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Key Words
- 3D printing
- 3D, 3-dimensional
- AM, additive manufacturing
- CDE, custom device exemption
- CUR, compassionate use request
- DBS, deep brain stimulator(s)
- EA, expanded access
- FDA device approval
- FDA, U.S. Food and Drug Administration
- HDE
- HDE, humanitarian device exemption
- IDE, investigational device exemption
- IRB, institutional review board
- OCD, obsessive-compulsive disorder
- PMA, pre-market approval
- TIDE, treatment investigational device exemption
- compassionate use
- custom medical devices
- device regulations
- expanded access
- medical devices
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Affiliation(s)
- Gail A. Van Norman
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Seattle, Washington
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Bittlinger M, Müller S. Opening the debate on deep brain stimulation for Alzheimer disease - a critical evaluation of rationale, shortcomings, and ethical justification. BMC Med Ethics 2018; 19:41. [PMID: 29886845 PMCID: PMC5994654 DOI: 10.1186/s12910-018-0275-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 05/01/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) as investigational intervention for symptomatic relief from Alzheimer disease (AD) has generated big expectations. Our aim is to discuss the ethical justification of this research agenda by examining the underlying research rationale as well as potential methodological pitfalls. The shortcomings we address are of high ethical importance because only scientifically valid research has the potential to be ethical. METHOD We performed a systematic search on MEDLINE and EMBASE. We included 166 publications about DBS for AD into the analysis of research rationale, risks and ethical aspects. Fifty-eight patients were reported in peer-reviewed journals with very mixed results. A grey literature search revealed hints for 75 yet to be published, potentially enrolled patients. RESULTS The results of our systematic review indicate methodological shortcomings in the literature that are both scientific and ethical in nature. According to our analysis, research with human subjects was performed before decisive preclinical research was published examining the specific research question at stake. We also raise the concern that conclusions on the potential safety and efficacy have been reported in the literature that seem premature given the design of the feasibility studies from which they were drawn. In addition, some publications report that DBS for AD was performed without written informed consent from some patients, but from surrogates only. Furthermore, registered ongoing trials plan to enroll severely demented patients. We provide reasons that this would violate Art. 28 of the Declaration of Helsinki, because DBS for AD involves more than minimal risks and burdens, and because its efficacy and safety are not yet empirically established to be likely. CONCLUSION Based on our empirical analysis, we argue that clinical research on interventions of risk class III (Food and Drug Administration and European Medicines Agency) should not be exploratory but grounded on sound, preclinically tested, and disease-specific a posteriori hypotheses. This also applies to DBS for dementia as long as therapeutic benefits are uncertain, and especially when research subjects with cognitive deficits are involved, who may foreseeably progress to full incapacity to provide informed consent during the required follow-up period.
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Affiliation(s)
- Merlin Bittlinger
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department for Psychiatry and Psychotherapy, CCM, Division of Mind and Brain Research, Charitéplatz 1, 10117 Berlin, Germany
| | - Sabine Müller
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department for Psychiatry and Psychotherapy, CCM, Division of Mind and Brain Research, Charitéplatz 1, 10117 Berlin, Germany
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Kohl S, Baldermann JC. Progress and challenges in deep brain stimulation for obsessive-compulsive disorder. Pharmacol Ther 2018; 186:168-175. [PMID: 29406245 DOI: 10.1016/j.pharmthera.2018.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mandarelli G, Moretti G, Pasquini M, Nicolò G, Ferracuti S. Informed Consent Decision-Making in Deep Brain Stimulation. Brain Sci 2018; 8:E84. [PMID: 29751598 PMCID: PMC5977075 DOI: 10.3390/brainsci8050084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) has proved useful for several movement disorders (Parkinson’s disease, essential tremor, dystonia), in which first and/or second line pharmacological treatments were inefficacious. Initial evidence of DBS efficacy exists for refractory obsessive-compulsive disorder, treatment-resistant major depressive disorder, and impulse control disorders. Ethical concerns have been raised about the use of an invasive surgical approach involving the central nervous system in patients with possible impairment in cognitive functioning and decision-making capacity. Most of the disorders in which DBS has been used might present with alterations in memory, attention, and executive functioning, which may have an impact on the mental capacity to give informed consent to neurosurgery. Depression, anxiety, and compulsivity are also common in DBS candidate disorders, and could also be associated with an impaired capacity to consent to treatment or clinical research. Despite these issues, there is limited empirical knowledge on the decision-making levels of these patients. The possible informed consent issues of DBS will be discussed by focusing on the specific treatable diseases.
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Affiliation(s)
- Gabriele Mandarelli
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Germana Moretti
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Massimo Pasquini
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Giuseppe Nicolò
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Stefano Ferracuti
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
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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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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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Securing a future for responsible neuromodulation in children: The importance of maintaining a broad clinical gaze. Eur J Paediatr Neurol 2017; 21:49-55. [PMID: 27257018 PMCID: PMC5282397 DOI: 10.1016/j.ejpn.2016.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/27/2016] [Indexed: 12/30/2022]
Abstract
AIM This perspective paper provides an overview of several key tensions and challenges within the social context of neuromodulation, and it suggests a means of securing the future of paediatric neuromodulation in light of these. RESULTS Tensions and challenges relate to: the considerable clinical and economic need for new therapies to manage neurological diseases; significant commercial involvement in the field; funding pressures; public perceptions (particularly unrealistic expectations); and the emerging Responsible Research and Innovation initiative. This paper argues that managing these challenges and tensions requires that clinicians working within the field adopt what could be called a broad clinical gaze. This paper will define the broad clinical gaze, and it will propose several ways in which a broad clinical gaze can be - and indeed is being - operationalised in recent advances in neuromodulation in children. These include the use of multidisciplinary and interdisciplinary clinical team structures, the adoption of clinical assessment tools that capture day-to-day functionality, and the use of patient registries. CONCLUSION By adopting a broad clinical gaze, clinicians and investigators can ensure that the field as a whole can responsibly and ethically deliver on its significant clinical potential.
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Fayad SM, Guzick AG, Reid AM, Mason DM, Bertone A, Foote KD, Okun MS, Goodman WK, Ward HE. Six-Nine Year Follow-Up of Deep Brain Stimulation for Obsessive-Compulsive Disorder. PLoS One 2016; 11:e0167875. [PMID: 27930748 PMCID: PMC5145226 DOI: 10.1371/journal.pone.0167875] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 10/18/2016] [Indexed: 01/20/2023] Open
Abstract
Objective Deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) region has shown promise as a neurosurgical intervention for adults with severe treatment-refractory obsessive-compulsive disorder (OCD). Pilot studies have revealed improvement in obsessive-compulsive symptoms and secondary outcomes following DBS. We sought to establish the long-term safety and effectiveness of DBS of the VC/VS for adults with OCD. Materials and Methods A long term follow-up study (73–112 months) was conducted on the six patients who were enrolled in the original National Institute of Mental Health pilot study of DBS for OCD. Qualitative and quantitative data were collected. Results Reduction in OCD symptoms mirrored the one-year follow-up data. The same four participants who were treatment responders after one year of treatment showed a consistent OCD response (greater than 35% reduction in Yale Brown Obsessive Compulsive Scale (YBOCS)). Another subject, classified as a non-responder, achieved a 26% reduction in YBOCS score at long term follow-up. The only patient who did not achieve a 25% or greater reduction in YBOCS was no longer receiving active DBS treatment. Secondary outcomes generally matched the one-year follow-up with the exception of depressive symptoms, which significantly increased over the follow-up period. Qualitative feedback indicated that DBS was well tolerated by the subjects. Discussion These data indicate that DBS was safe and conferred a long-term benefit in reduction of obsessive-compulsive symptoms. DBS of the VC/VS region did not reveal a sustained response for comorbid depressive symptoms in patients with a primary diagnosis of OCD.
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Affiliation(s)
- Sarah M. Fayad
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Andrew G. Guzick
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States of America
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, United States of America
| | - Adam M. Reid
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States of America
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dana M. Mason
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Agustina Bertone
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Kelly D. Foote
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Michael S. Okun
- Department of Neurology, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Wayne K. Goodman
- Department of Psychiatry, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Herbert E. Ward
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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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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Kohl S, Baldermann JC, Denys D, Kuhn J. A Synergistic Treatment Strategy for Severe Obsessive Compulsive Disorder. Neuromodulation 2016; 19:542-4. [DOI: 10.1111/ner.12461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sina Kohl
- Department of Psychiatry and Psychotherapy; University of Cologne; Cologne Germany
| | | | - Damiaan Denys
- Department of Psychiatry; Academic Medical Center; Amsterdam The Netherlands
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy; University of Cologne; Cologne Germany
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Drugs, Devices, and the FDA: Part 2: An Overview of Approval Processes: FDA Approval of Medical Devices. JACC Basic Transl Sci 2016; 1:277-287. [PMID: 30167516 PMCID: PMC6113340 DOI: 10.1016/j.jacbts.2016.03.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 03/31/2016] [Accepted: 03/31/2016] [Indexed: 11/24/2022]
Abstract
As with new drugs, the U.S. Food and Drug Administration’s approval process is intended to provide consumers with assurance that, once it reaches the market place, a medical device is safe and effective in its intended use. Bringing a device to market takes an average of 3 to 7 years, compared with an average of 12 years for drugs. However, there are concerns that Food and Drug Administration processes may not be sufficient to meet the assurances of safety and efficacy as intended. This second part of a 2-part series reviews the basic steps in development and Food and Drug Administration approval of medical devices, and summarizes post-marketing processes for drugs and devices.
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Fins JJ. Commentary: Deep Brain Stimulation as Clinical Innovation: An Ethical and Organizational Framework to Sustain Deliberations About Psychiatric Deep Brain Stimulation. Neurosurgery 2016; 79:11-3. [PMID: 27171326 DOI: 10.1227/neu.0000000000001253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, New York; Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College and The Rockefeller University, New York, New York; Yale Law School, New Haven, Connecticut
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Fins JJ, Wright MS, Kraft C, Rogers A, Romani MB, Godwin S, Ulrich MR. Whither the "Improvement Standard"? Coverage for Severe Brain Injury after Jimmo v. Sebelius. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2016; 44:182-193. [PMID: 27256134 DOI: 10.1177/1073110516644209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
As improvements in neuroscience have enabled a better understanding of disorders of consciousness as well as methods to treat them, a hurdle that has become all too prevalent is the denial of coverage for treatment and rehabilitation services. In 2011, a settlement emerged from a Vermont District Court case, Jimmo v. Sebelius, which was brought to stop the use of an "improvement standard" that required tangible progress over an identifiable period of time for Medicare coverage of services. While the use of this standard can have deleterious effects on those with many chronic conditions, it is especially burdensome for those in the minimally conscious state (MCS), where improvements are unpredictable and often not manifested through repeatable overt behaviors. Though the focus of this paper is on the challenges of brain injury and the minimally conscious state, which an estimated 100,000 to 200,000 individuals suffer from in the United States, the post-Jimmo arguments presented can and should have a broad impact as envisioned by the plaintiffs who brought the case on behalf of multiple advocacy groups representing patients with a range of chronic care conditions.
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Affiliation(s)
- Joseph J Fins
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
| | - Megan S Wright
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
| | - Claudia Kraft
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
| | - Alix Rogers
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
| | - Marina B Romani
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
| | - Samantha Godwin
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
| | - Michael R Ulrich
- Joseph J. Fins, M.D., M.A.C.P., is The E. William Davis, Jr. M.D. Professor of Medical Ethics and Chief of the Division of Medical Ethics at Weill Cornell Medical College where he is a Tenured Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Health Care Policy and Research, and Professor of Medicine in Psychiatry. He Co-Directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell and Rockefeller University, is a Senior Research Scholar in Law at the Yale Law School, an elected Member of the Institute of Medicine of the National Academy of Sciences, a Fellow of the American Academy of Arts and Sciences and an Academico de Honor (Honored Academic) of the Real Academia Nacional de Medicina de Espana (the Royal Academy of Medicine of Spain). He received his B.A. with Honors from Wesleyan University (Middletown, CT) and M.D. from Cornell University (New York, NY). Megan S. Wright, Ph.D., is a J.D. candidate (2016) at Yale Law School (New Haven, CT). She earned a Ph.D. in Sociology from the University of Arizona (Tucson, Arizona). Claudia Kraft is a third-year law student at Yale Law School (New Haven, CT). She received a B.A. in Human Biology from the University of Virginia (Charlottesville, VA). Alix Rogers, M.Phil., is concurrently pursuing a J.D. at Yale Law School (New Haven, CT), and a Ph.D. in the History and Philosophy of Science at the University of Cambridge (Cambridge, United Kingdom). She holds a M.Phil from the University of Cambridge (Cambridge, United Kingdom), and a B.A. from the University of Pennsylvania (Philadelphia, PA). Marina Romani is a J.D Candidate (2016) at Yale Law School (New Haven, CT). She received a B.S. in Biology from Dartmouth College (Hanover, NH). Samantha Godwin, J.D., is a Ph.D candidate and Gates Cambridge Scholar at Cambridge University and an LL.M student at Yale Law School. She received her B.A. and MA from University College London department of philosophy and her J.D. from
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Ineichen C, Christen M. Analyzing 7000 texts on deep brain stimulation: what do they tell us? Front Integr Neurosci 2015; 9:52. [PMID: 26578908 PMCID: PMC4620160 DOI: 10.3389/fnint.2015.00052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/27/2015] [Indexed: 01/15/2023] Open
Abstract
The enormous increase in numbers of scientific publications in the last decades requires quantitative methods for obtaining a better understanding of topics and developments in various fields. In this exploratory study, we investigate the emergence, trends, and connections of topics within the whole text corpus of the deep brain stimulation (DBS) literature based on more than 7000 papers (title and abstracts) published between 1991 to 2014 using a network approach. Taking the co-occurrence of basic terms that represent important topics within DBS as starting point, we outline the statistics of interconnections between DBS indications, anatomical targets, positive, and negative effects, as well as methodological, technological, and economic issues. This quantitative approach confirms known trends within the literature (e.g., regarding the emergence of psychiatric indications). The data also reflect an increased discussion about complex issues such as personality connected tightly to the ethical context, as well as an apparent focus on depression as important DBS indication, where the co-occurrence of terms related to negative effects is low both for the indication as well as the related anatomical targets. We also discuss consequences of the analysis from a bioethical perspective, i.e., how such a quantitative analysis could uncover hidden subject matters that have ethical relevance. For example, we find that hardware-related issues in DBS are far more robustly connected to an ethical context compared to impulsivity, concrete side-effects or death/suicide. Our contribution also outlines the methodology of quantitative text analysis that combines statistical approaches with expert knowledge. It thus serves as an example how innovative quantitative tools can be made useful for gaining a better understanding in the field of DBS.
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Affiliation(s)
- Christian Ineichen
- Institute of Biomedical Ethics and History of Medicine, University of Zurich Zurich, Switzerland ; Preclinical Laboratory for Translational Research into Affective Disorders, Clinic for Affective Disorders and General Psychiatry, Psychiatric University Hospital Zurich Zurich, Switzerland
| | - Markus Christen
- Institute of Biomedical Ethics and History of Medicine, University of Zurich Zurich, Switzerland ; University Research Priority Program Ethics, University of Zurich Zurich, Switzerland
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Evans MC, Clark VW, Manning PJ, De Ridder D, Reynolds JN. Optimizing Deep Brain Stimulation of the Nucleus Accumbens in a Reward Preference Rat Model. Neuromodulation 2015; 18:531-40; discussion 540-1. [DOI: 10.1111/ner.12339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/01/2015] [Accepted: 06/29/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Maggie C. Evans
- Department of Anatomy; Brain Health Research Centre; School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Vincent W. Clark
- Department of Anatomy; Brain Health Research Centre; School of Medical Sciences; University of Otago; Dunedin New Zealand
- Department of Surgical Sciences; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Patrick J. Manning
- Department of Medicine; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Dirk De Ridder
- Department of Surgical Sciences; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - John N.J. Reynolds
- Department of Anatomy; Brain Health Research Centre; School of Medical Sciences; University of Otago; Dunedin New Zealand
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Cleary DR, Ozpinar A, Raslan AM, Ko AL. Deep brain stimulation for psychiatric disorders: where we are now. Neurosurg Focus 2015; 38:E2. [DOI: 10.3171/2015.3.focus1546] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.
Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.
This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.
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Affiliation(s)
- Daniel R. Cleary
- 1Department of Neurology, Yale Medical School, New Haven, Connecticut
| | - Alp Ozpinar
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Ahmed M. Raslan
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Andrew L. Ko
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington
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Pepper J, Hariz M, Zrinzo L. Deep brain stimulation versus anterior capsulotomy for obsessive-compulsive disorder: a review of the literature. J Neurosurg 2015; 122:1028-37. [DOI: 10.3171/2014.11.jns132618] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a chronic and debilitating psychiatric condition. Traditionally, anterior capsulotomy (AC) was an established procedure for treatment of patients with refractory OCD. Over recent decades, deep brain stimulation (DBS) has gained popularity. In this paper the authors review the published literature and compare the outcome of AC and DBS targeting of the area of the ventral capsule/ventral striatum (VC/VS) and nucleus accumbens (NAcc).
Patients in published cases were grouped according to whether they received AC or DBS and according to their preoperative scores on the Yale-Brown Obsessive-Compulsive Scale (YBOCS), and then separated according to outcome measures: remission (YBOCS score < 8); response (≥ 35% improvement in YBOCS score); nonresponse (< 35% improvement in YBOCS score); and unfavorable (i.e., worsening of the baseline YBOCS score).
Twenty studies were identified reporting on 170 patients; 62 patients underwent DBS of the VC/VS or the NAcc (mean age 38 years, follow-up 19 months, baseline YBOCS score of 33), and 108 patients underwent AC (mean age 36 years, follow-up 61 months, baseline YBOCS score of 30). In patients treated with DBS there was a 40% decrease in YBOCS score, compared with a 51% decrease for those who underwent AC (p = 0.004). Patients who underwent AC were 9% more likely to go into remission than patients treated with DBS (p = 0.02). No difference in complication rates was noted.
Anterior capsulotomy is an efficient procedure for refractory OCD. Deep brain stimulation in the VC/VS and NAcc area is an emerging and promising therapy. The current popularity of DBS over ablative surgery for OCD is not due to nonefficacy of AC, but possibly because DBS is perceived as more acceptable by clinicians and patients.
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Affiliation(s)
- Joshua Pepper
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square
| | - Marwan Hariz
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square
- 2Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Ludvic Zrinzo
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square
- 3Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and
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Sedrak M, Wong W, Wilson P, Bruce D, Bernstein I, Khandhar S, Pappas C, Heit G, Sabelman E. Deep brain stimulation for the treatment of severe, medically refractory obsessive-compulsive disorder. Perm J 2014; 17:47-51. [PMID: 24361021 DOI: 10.7812/tpp/13-005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Deep brain stimulation is a rapidly expanding therapy initially designed for the treatment of movement disorders and pain syndromes. The therapy includes implantation of electrodes in specific targets of the brain, delivering programmable small and safe electric impulses, like a pacemaker, that modulates both local and broad neurologic networks. The effects are thought to primarily involve a focus in the brain, probably inhibitory, which then restores a network of neural circuitry. Psychiatric diseases can be refractory and severe, leading to high medical costs, significant morbidity, and even death. Whereas surgery for psychiatric disease used to include destructive procedures, deep brain stimulation allows safe, reversible, and adjustable treatment that can be tailored for each patient. Deep brain stimulation offers new hope for these unfortunate patients, and the preliminary results are promising.
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Affiliation(s)
- Mark Sedrak
- Director of Stereotactic and Functional Neurosurgery for The Permanente Medical Group and a Neurosurgeon at the Redwood City Medical Center in CA.
| | - William Wong
- Psychiatrist at the Redwood City Medical Center in CA.
| | - Paul Wilson
- Chief of Psychiatry and a Psychiatrist at the Redwood City Medical Center in CA.
| | - Diana Bruce
- Physician Assistant in Functional Neurosurgery at Redwood City Medical Center in CA.
| | - Ivan Bernstein
- Physician Assistant in Functional Neurosurgery at the Redwood City Medical Center in CA.
| | - Suketu Khandhar
- Director of Movement Disorders for The Permanente Medical Group and a Neurologist at the Sacramento Medical Center in CA.
| | - Conrad Pappas
- Neurosurgeon at the Sacramento Medical Center in CA.
| | - Gary Heit
- Former Director of Stereotactic and Functional Neurosurgery for The Permanente Medical Group in Redwood City, CA.
| | - Eric Sabelman
- Bioengineer in Functional Neurosurgery at Redwood City Medical Center in CA.
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Williams NR, Taylor JJ, Kerns S, Short EB, Kantor EM, George MS. Interventional psychiatry: why now? J Clin Psychiatry 2014; 75:895-7. [PMID: 25191910 PMCID: PMC4221242 DOI: 10.4088/jcp.13l08745] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Interventional psychiatry offers substantial therapeutic benefits in some neuropsychiatric disorders and enormous potential in treating others. However, as interventional diagnostics and therapeutics require specialized knowledge and skill foreign to many psychiatrists, the emerging subspecialty of interventional psychiatry must be more formally integrated into the continuum of psychiatric training to ensure both safe application and continued growth. By establishing training paradigms for interventional psychiatry, academic medical centers can help fill this knowledge gap. The cultivation of a properly trained cohort of interventional psychiatrists will better meet the challenges of treatment-resistant psychiatric illness through safe and ethical practice, while facilitating a more informed development and integration of novel neuromodulation techniques.
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Affiliation(s)
- Nolan R. Williams
- Department of Psychiatry, Medical University of South Carolina,Department of Neurosciences, Medical University of South Carolina
| | - Joseph J. Taylor
- Department of Psychiatry, Medical University of South Carolina,Department of Neurosciences, Medical University of South Carolina
| | - Suzanne Kerns
- Department of Psychiatry, Medical University of South Carolina
| | - E. Baron Short
- Department of Psychiatry, Medical University of South Carolina
| | | | - Mark S. George
- Department of Psychiatry, Medical University of South Carolina,Department of Neurosciences, Medical University of South Carolina,Ralph H. Johnson VA Medical Center, Charleston, SC
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Garnaat SL, Greenberg BD, Sibrava NJ, Goodman WK, Mancebo MC, Eisen JL, Rasmussen SA. Who qualifies for deep brain stimulation for OCD? Data from a naturalistic clinical sample. J Neuropsychiatry Clin Neurosci 2014; 26:81-6. [PMID: 24515679 PMCID: PMC4093791 DOI: 10.1176/appi.neuropsych.12090226] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A few patients with obsessive-compulsive disorder (OCD) remain severely impaired despite exhausting best-practice treatments. For them, neurosurgery (stereotactic ablation or deep brain stimulation) might be considered. The authors investigated the proportion of treatment-seeking OCD patients, in a naturalistic clinical sample, who met contemporary neurosurgery selection criteria. Using comprehensive baseline data on diagnosis, severity, and treatment history for adult patients from the NIMH-supported Brown Longitudinal OCD Study, only 2 of 325 patients met screening criteria for neurosurgery. This finding prompts consideration of new models for clinical trials with limited samples as well as methods of refining entry criteria for such invasive treatments.
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Affiliation(s)
- Sarah L. Garnaat
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
| | - Benjamin D. Greenberg
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
| | - Nicholas J. Sibrava
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
| | - Wayne K. Goodman
- Department of Psychiatry, Mt. Sinai Hospital, New York, NY 10029, USA
| | - Maria C. Mancebo
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
| | - Jane L. Eisen
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
| | - Steven A. Rasmussen
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
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Williams NR, Okun MS. Deep brain stimulation (DBS) at the interface of neurology and psychiatry. J Clin Invest 2013; 123:4546-56. [PMID: 24177464 DOI: 10.1172/jci68341] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) is an emerging interventional therapy for well-screened patients with specific treatment-resistant neuropsychiatric diseases. Some neuropsychiatric conditions, such as Parkinson disease, have available and reasonable guideline and efficacy data, while other conditions, such as major depressive disorder and Tourette syndrome, have more limited, but promising results. This review summarizes both the efficacy and the neuroanatomical targets for DBS in four common neuropsychiatric conditions: Parkinson disease, Tourette syndrome, major depressive disorder, and obsessive-compulsive disorder. Based on emerging new research, we summarize novel approaches to optimization of stimulation for each neuropsychiatric disease and we review the potential positive and negative effects that may be observed following DBS. Finally, we summarize the likely future innovations in the field of electrical neural-network modulation.
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Hariz M, Blomstedt P, Zrinzo L. Future of brain stimulation: new targets, new indications, new technology. Mov Disord 2013; 28:1784-92. [PMID: 24123327 DOI: 10.1002/mds.25665] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 06/27/2013] [Accepted: 08/09/2013] [Indexed: 01/15/2023] Open
Abstract
In the last quarter of a century, DBS has become an established neurosurgical treatment for Parkinson's disease (PD), dystonia, and tremors. Improved understanding of brain circuitries and their involvement in various neurological and psychiatric illnesses, coupled with the safety of DBS and its exquisite role as a tool for ethical study of the human brain, have unlocked new opportunities for this technology, both for future therapies and in research. Serendipitous discoveries and advances in structural and functional imaging are providing abundant "new" brain targets for an ever-increasing number of pathologies, leading to investigations of DBS in diverse neurological, psychiatric, behavioral, and cognitive conditions. Trials and "proof of concept" studies of DBS are underway in pain, epilepsy, tinnitus, OCD, depression, and Gilles de la Tourette syndrome, as well as in eating disorders, addiction, cognitive decline, consciousness, and autonomic states. In parallel, ongoing technological development will provide pulse generators with longer battery longevity, segmental electrode designs allowing a current steering, and the possibility to deliver "on-demand" stimulation based on closed-loop concepts. The future of brain stimulation is certainly promising, especially for movement disorders-that will remain the main indication for DBS for the foreseeable future-and probably for some psychiatric disorders. However, brain stimulation as a technique may be at risk of gliding down a slippery slope: Some reports indicate a disturbing trend with suggestions that future DBS may be proposed for enhancement of memory in healthy people, or as a tool for "treatment" of "antisocial behavior" and for improving "morality."
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Affiliation(s)
- Marwan Hariz
- Unit of Functional Neurosurgery, UCL Institute of Neurology, London, UK; Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
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O’Rawe JA, Fang H, Rynearson S, Robison R, Kiruluta ES, Higgins G, Eilbeck K, Reese MG, Lyon GJ. Integrating precision medicine in the study and clinical treatment of a severely mentally ill person. PeerJ 2013; 1:e177. [PMID: 24109560 PMCID: PMC3792182 DOI: 10.7717/peerj.177] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/16/2013] [Indexed: 01/02/2023] Open
Abstract
Background. In recent years, there has been an explosion in the number of technical and medical diagnostic platforms being developed. This has greatly improved our ability to more accurately, and more comprehensively, explore and characterize human biological systems on the individual level. Large quantities of biomedical data are now being generated and archived in many separate research and clinical activities, but there exists a paucity of studies that integrate the areas of clinical neuropsychiatry, personal genomics and brain-machine interfaces. Methods. A single person with severe mental illness was implanted with the Medtronic Reclaim(®) Deep Brain Stimulation (DBS) Therapy device for Obsessive Compulsive Disorder (OCD), targeting his nucleus accumbens/anterior limb of the internal capsule. Programming of the device and psychiatric assessments occurred in an outpatient setting for over two years. His genome was sequenced and variants were detected in the Illumina Whole Genome Sequencing Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory. Results. We report here the detailed phenotypic characterization, clinical-grade whole genome sequencing (WGS), and two-year outcome of a man with severe OCD treated with DBS. Since implantation, this man has reported steady improvement, highlighted by a steady decline in his Yale-Brown Obsessive Compulsive Scale (YBOCS) score from ∼38 to a score of ∼25. A rechargeable Activa RC neurostimulator battery has been of major benefit in terms of facilitating a degree of stability and control over the stimulation. His psychiatric symptoms reliably worsen within hours of the battery becoming depleted, thus providing confirmatory evidence for the efficacy of DBS for OCD in this person. WGS revealed that he is a heterozygote for the p.Val66Met variant in BDNF, encoding a member of the nerve growth factor family, and which has been found to predispose carriers to various psychiatric illnesses. He carries the p.Glu429Ala allele in methylenetetrahydrofolate reductase (MTHFR) and the p.Asp7Asn allele in ChAT, encoding choline O-acetyltransferase, with both alleles having been shown to confer an elevated susceptibility to psychoses. We have found thousands of other variants in his genome, including pharmacogenetic and copy number variants. This information has been archived and offered to this person alongside the clinical sequencing data, so that he and others can re-analyze his genome for years to come. Conclusions. To our knowledge, this is the first study in the clinical neurosciences that integrates detailed neuropsychiatric phenotyping, deep brain stimulation for OCD and clinical-grade WGS with management of genetic results in the medical treatment of one person with severe mental illness. We offer this as an example of precision medicine in neuropsychiatry including brain-implantable devices and genomics-guided preventive health care.
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Affiliation(s)
- Jason A. O’Rawe
- Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, NY, USA
- Stony Brook University, Stony Brook, NY, USA
| | - Han Fang
- Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, NY, USA
- Stony Brook University, Stony Brook, NY, USA
| | - Shawn Rynearson
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Reid Robison
- Utah Foundation for Biomedical Research, Salt Lake City, UT, USA
| | | | | | - Karen Eilbeck
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | | | - Gholson J. Lyon
- Stanley Institute for Cognitive Genomics, Cold Spring Harbor Laboratory, NY, USA
- Stony Brook University, Stony Brook, NY, USA
- Utah Foundation for Biomedical Research, Salt Lake City, UT, USA
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A history of deep brain stimulation: Technological innovation and the role of clinical assessment tools. SOCIAL STUDIES OF SCIENCE 2013; 43. [PMCID: PMC3785222 DOI: 10.1177/0306312713483678] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Deep brain stimulation involves using a pacemaker-like device to deliver constant electrical stimulation to problematic areas within the brain. It has been used to treat over 40,000 people with Parkinson’s disease and essential tremor worldwide and is currently undergoing clinical trials as a treatment for depression and obsessive–compulsive disorder. This article will provide an historical account of deep brain stimulation in order to illustrate the plurality of interests involved in the development and stabilization of deep brain stimulation technology. Using Latour’s notion of immutable mobiles, this article will illustrate the importance of clinical assessment tools in shaping technological development in the era of medical device regulation. Given that such tools can serve commercial and professional interests, this article suggests that it is necessary to scrutinise their application in research contexts to ensure that they capture clinical changes that are meaningful for patients and their families. This is particularly important in relation to potentially ethically problematic therapies such as deep brain stimulation for psychiatric disorders.
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Anderson D, Kartha N. Deep Brain Stimulation in Nonparkinsonian Movement Disorders and Emerging Technologies, Targets, and Therapeutic Promises in Deep Brain Stimulation. Neurol Clin 2013; 31:809-26. [DOI: 10.1016/j.ncl.2013.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Fins JJ, Shapiro ZE. Deep Brain Stimulation, Brain Maps and Personalized Medicine: Lessons from the Human Genome Project. Brain Topogr 2013; 27:55-62. [DOI: 10.1007/s10548-013-0297-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/25/2013] [Indexed: 10/26/2022]
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Lozano A, Lipsman N. Probing and Regulating Dysfunctional Circuits Using Deep Brain Stimulation. Neuron 2013; 77:406-24. [DOI: 10.1016/j.neuron.2013.01.020] [Citation(s) in RCA: 423] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2013] [Indexed: 01/04/2023]
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Riva-Posse P, Holtzheimer PE, Garlow SJ, Mayberg HS. Practical considerations in the development and refinement of subcallosal cingulate white matter deep brain stimulation for treatment-resistant depression. World Neurosurg 2012; 80:S27.e25-34. [PMID: 23246630 DOI: 10.1016/j.wneu.2012.11.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 11/12/2012] [Accepted: 11/27/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Deep brain stimulation has been investigated in the past decade as a viable intervention for treatment-resistant depression. METHODS Several anatomic targets have been tested, with the most extensive published experience found for the subcallosal cingulate (SCC) white matter. RESULTS This article reviews the current state of clinical research of SCC deep brain stimulation for treatment-resistant depression, including an overview of the rationale for targeting SCC, practical considerations for subject recruitment and evaluation, surgical planning, and stimulation parameters. CONCLUSION Clinical management of patients in the initial and long-term naturalistic phases of treatment, including the potential role for psychotherapeutic rehabilitation, is discussed.
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Affiliation(s)
- Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
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