PICO
Deep brain stimulation for
treatment resistant depression.
Clinical reality ?
Deep brain stimulation in the treatment of depression.
Acta Psychiatr Scand, 2011
Blomstedt P et al.
Subcal.cing. gyrus (no 20)
85% had ECT
HDRS - 52% / 1 year
35% remission
Capsula interna (no 15)
100% had ECT
HDRS -44% / 1 year
40% remission
Nucleus accumbens (no 10)
100% had ECT
HDRS - 36% / 1 year
30% remission
 Subcallosal Cingulate Gyrus Deep Brain Stimulation for TreatmentResistant Depression
 Biological Psychiatry, 2008
 Lozano, et al
Increased activity in the subcallosal cingulate gyrus
 Pharmacotherapy
 Transcranial magnetic stimulation
 Electroconvulsive therapy
Altered activity of the SCG
 Deep brain stimulation
Direct modulation of the SCG
Inclusion
Severe
Chronic
Treatment resistant
Failure to respond to a minimum of four different treatments
 Antidepressant pharmacotherapy of sufficient dose and duration
 Evidence-based psychotherapy
 Electroconvulsive therapy
Exclusion
 comorbid Axis I psychiatric conditions,
 Axis II cluster B diagnosis
 suicidal behaviour within the past year
 concurrent neurological or medical conditions that could interfere with
the treatment.
Subjects (n = 20)
Male/female
9/11
Age at Enrollment (years)
47.4 ± 10.4
Age of Onset of MDD (years)
27.1 ± 8.3
Length of Current Episode (years)
6.9 ± 5.6
Number of Lifetime MDE (n)
3.9 ± 3.1
Received ECT (n)
17/20
Baseline HRSD-17
24.4 ± 3.5
3 patients received no ECT
before DST
All patients received medication
during DST
Adverse Effect
Number of Patients
Wound Infection and Hardware removal
3
Reinsertion of DBS Hardware
1
Wound Infection Managed with Antibiotics Alone
1
Perioperative Seizure
1
Worsening Mood/Irritability
2
Perioperative Headache
4
Pain at Pulse Generator Site
1
No Adverse Effects
7
 Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up
After 3 to 6 Years
 Kennedy, et al.
 Am J Psychiatry, 2011
1 unrelated death
2 suicides
2 lost to follow up
3 devices removed
Argument in favour
 Otherwise intractable depression
 Remission rates around 30 %
 Possible long term benefits
Arguments against
 No clear target-area
 Invasive procedure
 Battery life
 Open label assessment
 Small N
 Concurrent medication use
In conclusion
 Experimental therapy
 Clinical studies
 Multidisciplinary teams