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Aibar-Durán JÁ, Corripio Collado I, Roldán Bejarano A, Sánchez Nevado R, Aracil Bolanos I, García-Cornet J, Alonso-Solís A, Grasa Bello EM, de Quintana Schmidt C, Muñoz Hernández F, Molet Teixidó J, Rodríguez RR. Long-term outcomes of deep brain stimulation for treatment-resistant schizophrenia: Exploring potential targets. J Psychiatr Res 2023; 163:296-304. [PMID: 37245316 DOI: 10.1016/j.jpsychires.2023.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/03/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Schizophrenia is a complex and disabling disorder. Around 30% of patients have treatment-resistant schizophrenia (TRS). OBJECTIVE This study summarizes the outcomes after three years follow-up of the first series of patients with TRS treated with deep brain stimulation (DBS) and discuss surgical, clinical and imaging analysis. METHODS Eight patients with TRS treated with DBS in the nucleus accumbens (NAcc) or the subgenual cingulate gyrus (SCG) were included. Symptoms were rated with the PANSS scale and normalized using the illness density index (IDI). A reduction in IDI-PANSS of ≥25% compared to baseline was the criterion of good response. The volume of activated tissue was calculated to perform a connectomic analysis for each patient. An estimation of the tracts and cortical areas modulated was generated. RESULTS Five women and three men were analyzed. After 3 years' follow-up, positive symptoms improved in 50% of the SCG group and 75% of the NAcc group (p = 0.06), and general symptoms improved in 25% and 50% respectively (p = 0.06). The SCG group showed activation of the cingulate bundle and modulation of orbitofrontal and frontomesial regions; in contrast, the NAcc group showed activation of the ventral tegmental area projections pathway and modulation of regions associated with the "default mode network" (precuneus) and Brodmann areas 19 and 20. CONCLUSIONS These results showed a trend toward improvement for positive and general symptoms in patients with TRS treated with DBS. The connectomic analysis will help us understand the interaction of this treatment with the disease to pursue future trial designs.
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Affiliation(s)
- Juan Ángel Aibar-Durán
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Iluminada Corripio Collado
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Alexandra Roldán Bejarano
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain.
| | - Raquel Sánchez Nevado
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Ignacio Aracil Bolanos
- Deparment of Neurology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Julia García-Cornet
- Ingeniering imaging and Signaling, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Anna Alonso-Solís
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Eva Ma Grasa Bello
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Cristian de Quintana Schmidt
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Fernando Muñoz Hernández
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Joan Molet Teixidó
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Rodrigo Rodríguez Rodríguez
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Schwabe K, Krauss JK. What rodent models of deep brain stimulation can teach us about the neural circuit regulation of prepulse inhibition in neuropsychiatric disorders. Schizophr Res 2018; 198:45-51. [PMID: 28663025 DOI: 10.1016/j.schres.2017.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/16/2017] [Accepted: 06/19/2017] [Indexed: 11/29/2022]
Abstract
Deep brain stimulation (DBS) is routinely used for treatment of movement disorders and it is also under investigation for neuropsychiatric disorders with deficient sensorimotor gating, such as schizophrenia, Tourette's syndrome and obsessive compulsive disorder. Electrical stimulation induces excitation and inhibition both at the stimulation site and at projection sites, thus modulating synchrony and oscillatory behavior of neuronal networks. We first provide background information on DBS in neuropsychiatric disorders accompanied by deficient sensorimotor gating. We then introduce prepulse inhibition (PPI) as a measure for sensorimotor gating in these disorders. Thereafter, we report on the use of DBS in rat models with deficient PPI induced by pharmacologic, genetic and neurodevelopmental manipulation. These models offer the opportunity to define the neuronal circuit regulation that is of relevance to PPI and its deficits in neuropsychiatric disorders with disturbed sensorimotor gating. Finally, we report on the use of the PPI paradigm in human patients operated for DBS on/off stimulation, which may further elucidate the neuronal network involved in regulation of PPI.
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Affiliation(s)
- Kerstin Schwabe
- Department of Neurosurgery, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
| | - Joachim K Krauss
- Department of Neurosurgery, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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Gault JM, Davis R, Cascella NG, Saks ER, Corripio-Collado I, Anderson WS, Olincy A, Thompson JA, Pomarol-Clotet E, Sawa A, Daskalakis ZJ, Lipsman N, Abosch A. Approaches to neuromodulation for schizophrenia. J Neurol Neurosurg Psychiatry 2018; 89:777-787. [PMID: 29242310 DOI: 10.1136/jnnp-2017-316946] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/09/2017] [Accepted: 10/29/2017] [Indexed: 11/03/2022]
Abstract
Based on the success of deep brain stimulation (DBS) for treating movement disorders, there is growing interest in using DBS to treat schizophrenia (SZ). We review the unmet needs of patients with SZ and the scientific rationale behind the DBS targets proposed in the literature in order to guide future development of DBS to treat this vulnerable patient population. SZ remains a devastating disorder despite treatment. Relapse, untreated psychosis, intolerable side effects and the lack of effective treatment for negative and cognitive symptoms contribute to poor outcome. Novel therapeutic interventions are needed to treat SZ and DBS is emerging as a potential intervention. Convergent genetic, pharmacological and neuroimaging evidence implicating neuropathology associated with psychosis is consistent with SZ being a circuit disorder amenable to striatal modulation with DBS. Many of the DBS targets proposed in the literature may modulate striatal dysregulation. Additional targets are considered for treating tardive dyskinesia and negative and cognitive symptoms. A need is identified for the concurrent development of neurophysiological biomarkers relevant to SZ pathology in order to inform DBS targeting. Finally, we discuss the current clinical trials of DBS for SZ, and their ethical considerations. We conclude that patients with severe symptoms despite treatment must have the capacity to consent for a DBS clinical trial in which risks can be estimated, but benefit is not known. In addition, psychiatric populations should have access to the potential benefits of neurosurgical advances.
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Affiliation(s)
- Judith M Gault
- Department of Neurosurgery, University of Colorado at Denver Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Rachel Davis
- Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Nicola G Cascella
- Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elyn R Saks
- University of Southern California Law School, Los Angeles, California, USA
| | - Iluminada Corripio-Collado
- Psychiatric Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ann Olincy
- Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado at Denver Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edith Pomarol-Clotet
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
| | - Akira Sawa
- Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zafiris J Daskalakis
- Centre for Addiction and Mental Health Collaborative Program in Neuroscience, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado at Denver Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Targeted neural network interventions for auditory hallucinations: Can TMS inform DBS? Schizophr Res 2018; 195:455-462. [PMID: 28969932 PMCID: PMC8141945 DOI: 10.1016/j.schres.2017.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/30/2017] [Accepted: 09/14/2017] [Indexed: 12/30/2022]
Abstract
The debilitating and refractory nature of auditory hallucinations (AH) in schizophrenia and other psychiatric disorders has stimulated investigations into neuromodulatory interventions that target the aberrant neural networks associated with them. Internal or invasive forms of brain stimulation such as deep brain stimulation (DBS) are currently being explored for treatment-refractory schizophrenia. The process of developing and implementing DBS is limited by symptom clustering within psychiatric constructs as well as a scarcity of causal tools with which to predict response, refine targeting or guide clinical decisions. Transcranial magnetic stimulation (TMS), an external or non-invasive form of brain stimulation, has shown some promise as a therapeutic intervention for AH but remains relatively underutilized as an investigational probe of clinically relevant neural networks. In this editorial, we propose that TMS has the potential to inform DBS by adding individualized causal evidence to an evaluation processes otherwise devoid of it in patients. Although there are significant limitations and safety concerns regarding DBS, the combination of TMS with computational modeling of neuroimaging and neurophysiological data could provide critical insights into more robust and adaptable network modulation.
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MacKay MAB, Paylor JW, Wong JTF, Winship IR, Baker GB, Dursun SM. Multidimensional Connectomics and Treatment-Resistant Schizophrenia: Linking Phenotypic Circuits to Targeted Therapeutics. Front Psychiatry 2018; 9:537. [PMID: 30425662 PMCID: PMC6218602 DOI: 10.3389/fpsyt.2018.00537] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/10/2018] [Indexed: 01/08/2023] Open
Abstract
Schizophrenia is a very complex syndrome that involves widespread brain multi-dysconnectivity. Neural circuits within specific brain regions and their links to corresponding regions are abnormal in the illness. Theoretical models of dysconnectivity and the investigation of connectomics and brain network organization have been examined in schizophrenia since the early nineteenth century. In more recent years, advancements have been achieved with the development of neuroimaging tools that have provided further clues to the structural and functional organization of the brain and global neural networks in the illness. Neural circuitry that extends across prefrontal, temporal and parietal areas of the cortex as well as limbic and other subcortical brain regions is disrupted in schizophrenia. As a result, many patients have a poor response to antipsychotic treatment and treatment failure is common. Treatment resistance that is specific to positive, negative, and cognitive domains of the illness may be related to distinct circuit phenotypes unique to treatment-refractory disease. Currently, there are no customized neural circuit-specific and targeted therapies that address this neural dysconnectivity. Investigation of targeted therapeutics that addresses particular areas of substantial regional dysconnectivity is an intriguing approach to precision medicine in schizophrenia. This review examines current findings of system and circuit-level brain dysconnectivity in treatment-resistant schizophrenia based on neuroimaging studies. Within a connectome context, on-off circuit connectivity synonymous with excitatory and inhibitory neuronal pathways is discussed. Mechanistic cellular, neurochemical and molecular studies are included with specific emphasis given to cell pathology and synaptic communication in glutamatergic and GABAergic systems. In this review we attempt to deconstruct how augmenting treatments may be applied within a circuit context to improve circuit integration and treatment response. Clinical studies that have used a variety of glutamate receptor and GABA interneuron modulators, nitric oxide-based therapies and a variety of other strategies as augmenting treatments with antipsychotic drugs are included. This review supports the idea that the methodical mapping of system-level networks to both on (excitatory) and off (inhibitory) cellular circuits specific to treatment-resistant disease may be a logical and productive approach in directing future research toward the advancement of targeted pharmacotherapeutics in schizophrenia.
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Affiliation(s)
- Mary-Anne B MacKay
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - John W Paylor
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - James T F Wong
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Ian R Winship
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Glen B Baker
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Serdar M Dursun
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
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Casquero-Veiga M, Hadar R, Pascau J, Winter C, Desco M, Soto-Montenegro ML. Response to Deep Brain Stimulation in Three Brain Targets with Implications in Mental Disorders: A PET Study in Rats. PLoS One 2016; 11:e0168689. [PMID: 28033356 PMCID: PMC5199108 DOI: 10.1371/journal.pone.0168689] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/05/2016] [Indexed: 12/11/2022] Open
Abstract
Objective To investigate metabolic changes in brain networks by deep brain stimulation (DBS) of the medial prefrontal cortex (mPFC), nucleus accumbens (NAcc) and dorsomedial thalamus (DM) using positron emission tomography (PET) in naïve rats. Methods 43 male Wistar rats underwent stereotactic surgery and concentric bipolar platinum-iridium electrodes were bilaterally implanted into one of the three brain sites. [18F]-fluoro-2-deoxy-glucose-PET (18FDG-PET) and computed tomography (CT) scans were performed at the 7th (without DBS) and 9th day (with DBS) after surgery. Stimulation period matched tracer uptake period. Images were acquired with a small-animal PET-CT scanner. Differences in glucose uptake between groups were assessed with Statistical Parametric Mapping. Results DBS induced site-specific metabolic changes, although a common increased metabolic activity in the piriform cortex was found for the three brain targets. mPFC-DBS increased metabolic activity in the striatum, temporal and amygdala, and reduced it in the cerebellum, brainstem (BS) and periaqueductal gray matter (PAG). NAcc-DBS increased metabolic activity in the subiculum and olfactory bulb, and decreased it in the BS, PAG, septum and hypothalamus. DM-DBS increased metabolic activity in the striatum, NAcc and thalamus and decreased it in the temporal and cingulate cortex. Conclusions DBS induced significant changes in 18FDG uptake in brain regions associated with the basal ganglia-thalamo-cortical circuitry. Stimulation of mPFC, NAcc and DM induced different patterns of 18FDG uptake despite interacting with the same circuitries. This may have important implications to DBS research suggesting individualized target selection according to specific neural modulatory requirements.
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Affiliation(s)
- Marta Casquero-Veiga
- CIBER de Salud Mental (CIBERSAM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ravit Hadar
- Department of Psychiatry and Psychotherapy, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Javier Pascau
- CIBER de Salud Mental (CIBERSAM), Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
| | - Christine Winter
- Department of Psychiatry and Psychotherapy, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Manuel Desco
- CIBER de Salud Mental (CIBERSAM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
- * E-mail:
| | - María Luisa Soto-Montenegro
- CIBER de Salud Mental (CIBERSAM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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