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PICO

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)

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PICO

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  1. PICO Deep brain stimulation for treatment resistant depression. Clinical reality ?

  2. Deep brain stimulation in the treatment of depression. Acta Psychiatr Scand, 2011 Blomstedt P et al.

  3. 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

  4. Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment-Resistant Depression • Biological Psychiatry, 2008 • Lozano, et al

  5. Increased activity in the subcallosal cingulate gyrus

  6. Pharmacotherapy • Transcranial magnetic stimulation • Electroconvulsive therapy Altered activity of the SCG • Deep brain stimulation Direct modulation of the SCG

  7. 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

  8. 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.

  9. 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 Subjects (n = 20) 3 patients received no ECT before DST All patients received medication during DST

  10. 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

  11. Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up After 3 to 6 Years • Kennedy, et al. • Am J Psychiatry, 2011

  12. 1 unrelated death 2 suicides 2 lost to follow up 3 devices removed

  13. Argument in favour • Otherwise intractable depression • Remission rates around 30 % • Possible long term benefits

  14. Arguments against • No clear target-area • Invasive procedure • Battery life • Open label assessment • Small N • Concurrent medication use

  15. In conclusion • Experimental therapy • Clinical studies • Multidisciplinary teams

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