Deep Brain Stimulation for Psychiatric Disorders

1. Deep Brain Stimulation for Psychiatric Disorders Jahdiel Franco BME 482

2. What is DBS? • A surgically implanted medical device called a brain pacemaker. • Sends electrical impulses to the brain. • Traditionally used to treat movement disorders such as chronic pain, Parkinson’s disease, tremor, and dystonia.

3. Components Three Major Components • Implanted pulse generator (IPG) • battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain to interfere with neural activity at the target site • Lead • coiled wire insulated in polyurethane with four platinum iridium electrodes and is placed in one of three areas of the brain • Extension • insulated wire that runs from the head, down the side of the neck, behind the ear to the IPG, which is placed subcutaneously below the clavicle or in some cases, the abdomen

4. How DBS affects the Brain • DBS directly changes brain activity in a controlled manner • It’s effects are reversible • Often kicks in only after a number of weeks for psychiatric disorders • This phenomenon cannot be wholly explained by a directly inhibiting mechanism • Not yet fully understood

5. Procedure • All three components are surgically implanted into the body • A hole about 14mm is drilled in the skull and the electrode inserted under local anesthesia • IPG and lead installed under general anesthesia • Lead is placed in one of three areas of the brain depending on patient condition

6. Cost and Recovery Time • Costs about $30,000 plus physician and MRI fees • Typically covered by insurance with doctor’s recommendation • Patients typically go home the next day after the lead implantation surgery • After surgery, swelling of the brain tissue, mild disorientation and sleepiness are normal • After 2–4 weeks, there is a follow-up to remove sutures, turn on the neurostimulator and program it • The batteries in the pulse generator must be replaced every three to five years • done with a small incision as an outpatient procedure

7. Relation to Psychiatric Disorders • Psychiatric adverse effects were observed in DBS-treated Parkinson’s disease patients. • Modern knowledge of psychiatric disease, due to modern brain imaging procedures, allows for identification of potential stimulation sites for DBS. • Being studies for treatment of Tourette’s, OCD, and depressive disorders

8. Psychiatric Disorders • Tourette’s Syndrome • chronic but often fluctuating occurrence of vocal (throat clearing, coughing, coprolalia) and motor (blinking, grimacing, jumping) tics • Obsessive-Compulsive Disorder • mental disorder characterized by intrusive thoughts that produce anxiety, by repetitive behaviors aimed at reducing anxiety, or by combinations of such thoughts (obsessions) and behaviors (compulsions) • Major Depression Disorder • mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and loss of interest or pleasure in normally enjoyable activities

9. Statistics of Psychiatric Disorders • Tourette’s, OCD, and depressive disorders affect about 17 million people in the US alone (7.7% of population) • Depressive disorder is the leading cause of disability in the US for ages 15-44 (14.8 million affected in US)

10. Tourette’s Syndrome Study • In 2007, the Neurosurgical Division of Istituto Galeazzi IRCCS in Italy performed a study on 18 patients • The greatest experience in the DBS treatment has been assembled in the thalamus—the internal ventro-oral nucleus, centromedian nucleus, and parafascicular nucleus • The average improvement rate for tic symptoms was around 70%, as measured using the most frequently employed scale, the Yale Global Tic Severity Scale (YGTSS) • The 24-month results of 15 of the 18 patients, documented continued amelioration of the symptoms

11. Other Tourette’s Syndrome Studies

12. Obsessive-Compulsive Disorder Study • In 2006, a study in Korea performed a study on 17 patients • Patients underwent stereotactic bilateral anterior cingulotomies and were followed for 24 months • surgical procedure is the severing of the supracallosal fibres of the cingulum bundle • The mean improvement rate of the Y-BOCS score achieved from the baseline was 48% • Study allowed for identification of possible DBS sites

13. Other OCD Studies

14. Depressive Disorder Study • In 2008, a study in Ontario, Canada was performed on 6 patients • The subgenual cingulum was the target area for DBS • In four of six patients with otherwise refractory depression DBS achieved clear relief of symptoms after 6 months • There was an average 71% reduction in score on the Hamilton Rating Scale for Depression (HAM-D)

15. Other Depressive Disorder Studies

16. Side Effects of DBS • possibility of • Apathy • Hallucinations • Compulsive gambling • Hypersexuality • Cognitive dysfunction • Depression • These are temporary and related to correct placement and calibration of the stimulator and so are potentially reversible • Because the brain can shift slightly during surgery, there is the possibility that the electrodes can become displaced or dislodged • May cause more profound complications such as personality changes • Electrode misplacement is relatively easy to identify using CT or MRI • Complications of surgery include bleeding within the brain

17. Conclusion • The results of DBS for psychiatric disorders that have been published to date are encouraging • They open up a new perspective in the treatment of otherwise intractable disorders. • The efficacy, mechanism of action, and adverse effects of DBS for this indication still need to be further studied