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342 The APA Publishing Textbook of Mood Disorders, Second Edition
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resistant OCD is approved by the FDA according to the Humanitarian Device Exemp­tion (U.S. Food and Drug Administration 2020).
Development
Since about the turn of the century, DBS has also been under investigation for the treatment of treatment-resistant depression (TRD). Although it is approved for OCD, DBS is not yet approved for TRD therapy by the FDA. As outlined in the introduction to this chapter, depression is now conceptualized as a complex brain disorder involv­ing several key brain circuits. Therefore, various potential structures within these cir­cuits are under investigation as DBS targets for TRD (Drobisz and Damborská 2019). The following targets have been studied most thoroughly (Döbrössy et al. 2021; Fig­ure 20–3): subgenual cingulate gyrus (SCG), capsular targets (ALIC and ventral cap­sule/ventral striatum [VC/VS]), nucleus accumbens, and superolateral medial forebrain bundle (slMFB).
Subgenual Cingulate Gyrus
Converging findings from clinical, anatomical, neurochemical, and functional imag­ing studies of depression, as well as studies using induced sadness in healthy sub­jects, resulted in a neuroanatomical model that describes depression as a “failure of the coordinated interactions of a distributed network of limbic-cortical pathways” (Mayberg 1997, p. 471). The SCG (also area Cg25 or Brodmann area 25) is highlighted as a switching point in this network. The prominent position of the SCG led to the hypothesis that high-frequency electrical stimulation of this area could result in a de crease in depressive symptoms by decreasing SCG activity. The first positive results with open-label stimulation (Mayberg et al. 2005) promoted further research on the neuropathology and optimal stimulation target for treatment purposes.
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Capsular Targets: Anterior Limb of the Internal Capsule and Ventral Capsule/Ventral Striatum
Unlike the SCG, the ALIC and VC/VS were chosen mainly based on clinical observa­tions. Both targets form part of the striatum, which is involved in the cortico-striato­thalamo-cortical (CSTC) network, seen as highly relevant in the pathophysiology of OCD (Alexander et al. 1986; Karas et al. 2019). The VC/VS contains the ventral half of the ALIC and impinges inferiorly on the VS (Greenberg et al. 2006). Due to their extreme spatial and functional proximity, the ALIC and VC/VS are summarized as capsular targets. Ablative procedures in the CSTC network have led to improvements in OCD and in TRD in about 35%–70% of treated patients (Greenberg et al. 2003). In addition to ablative procedures, DBS applied to CSTC targets has also improved OCD symptoms (Alonso et al. 2015; Blomstedt et al. 2013). In two trials intending to treat treatment-resistant OCD using DBS applied to the capsular targets, not only was a de­crease in OCD symptoms reported, but also a decrease in depressive symptoms (Greenberg et al. 2006; Nuttin et al. 2003). These observations, along with the antide­pressant effects of ablative procedures, led to the first study on VC/VS stimulation in TRD (Malone et al. 2009).
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FIGURE 20–3. Experimental targets for deep brain stimulation in treatment-resistant depression.
To view this figure in color, see Plate 8 in Color Gallery in middle of book.
ALIC= anterior limb of the internal capsule; CG25=Brodmann area 25; NAcc=nucleus accumbens; SCG= subgenual cingulate gyrus; slMFB=superolateral branch of the medial forebrain bundle; VCVS=ventral capsule/ventral striatum.
Source. Adapted from Figure 2 (Volker A. Coenen, 2019; p. 92) in Döbrössy M, Ramanathan C, Ashouri Vajari D, et al.: “Neuromodulation in Psychiatric Disorders: Experimental and Clinical Evidence for Re ward and Motivation Network Deep Brain Stimulation: Focus on the Medial Forebrain Bundle.” European Journal of Neuroscience 53(1):89–113, 2021. Available at: https://onlinelibrary.wiley.com/doi/10.1111/ ejn.14975. Accessed October 26, 2021. Copyright © 2020, The Authors, used under the terms of the Creative Commons Attribution License.
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Nucleus Accumbens
The nucleus accumbens forms part of the VS and is therefore located very close to the capsular stimulation targets. It is highly involved in processing reward and pleasure information: neuronal activity and dopamine release increase in the nucleus accum­bens during expectation and experience of rewards (Adinoff 2004; Doyon et al. 2005; Schultz 2004), and increased VS activity is associated with induced euphoria (Aharon et al. 2001; Drevets et al. 2001; Knutson et al. 2001). A translational study found that long-term administration of an antidepressant could re-regulate activity of the nucleus accumbens in socially stressed mice (Berton et al. 2006). Based on these findings, it has been proposed that anhedonia—a key symptom of depression (American Psychiatric Association 2013)—represents a lack of reward-motivated behavior and is related to activity in the nucleus accumbens (Schlaepfer et al. 2008a). On a neuroanatomical level, the nucleus accumbens is interconnected with other brain areas involved in emotion processing, including the DBS target SCG, described earlier (Hamani et al. 2009; Vergani et al. 2016). It has therefore been concluded that stimulating the nucleus accumbens would result in modulation of other parts of emotion-related networks as well and would decrease anhedonia (Schlaepfer et al. 2008a).
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Superolateral Branch of the Medial Forebrain Bundle
Similar to the nucleus accumbens, the medial forebrain bundle is highly associated with reward processing. It is located at the center of a distributed network that is con sidered the neural substrate of the reward circuitry and has been studied thoroughly in rodents (Wise 22005). This system—among others—is engaged in predicting and computing rewards, initiating exploration, and eliciting hedonic consummatory be havior (Carlezon and Chartoff 2007; Waraczynski 2006). Although well known in ro­dents, it was not until 2009 that the full structure of this network was visualized in humans (Coenen et al. 2009). Using diffusion tensor imaging, a procedure based on MRI analysis that allows imaging of fiber connections based on the anisotropy of the brain tissue, it has been shown that the human medial forebrain bundle originates in the ventral tegmental area and then splits into a lower and a superolateral branch.
The slMFB is of particular interest for DBS because of its neuroanatomical structure. The superolateral branch “shears out laterally, under-crosses the thalamus and ascends to the interior portion of the anterior limb of the internal capsule (ALIC)” (Coenen et al. 2011, p. 1974). The slMFB also accesses the ventral striatum and the nucleus accum bens directly, whereas direct connections with the white matter tracts surrounding the SCG are seen inconsistently (Coenen et al. 2011). This neuroanatomical description demonstrates the connecting position of the slMFB with the targets described earlier. In a diffusion tensor imaging study of healthy subjects, it was demonstrated that the historically most commonly chosen lesion targets for depression treatment are actu ally interconnected by fiber tracts that are mainly part of the slMFB (Schoene-Bake et al. 2010). In retrospect, this means that although these targets might have been se lected for other reasons originally, the efficacy of the described DBS targets in TRD is best explained by their shared involvement in the reward system. Because the slMFB is a central connecting element in this system, it has been promoted as a stimulation target in itself (Coenen et al. 2011; Schlaepfer et al. 2014).
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State of the Art
Table 20–A in the Appendix shows all published studies we know of that involved stimulation of the DBS targets described earlier for the treatment of TRD and included a response rate. The most commonly used clinician-rated instruments for assessing de pression severity are the Hamilton Depression Rating Scale (HAM-D; Hamilton 1960) and the Montgomery-Åsberg Depression Rating Scale (MADRS; Montgomery and Åsberg 1979; Santor et al. 2006); different versions of the HAM-D may be used. Re­sponse is usually defined as greater than 50% improvement compared with baseline. In general, a substantial rate of response and even remission is achieved—especially in relation to the treatment-resistant illness in this population. Apparently, none of the targets presented seems to be substantially superior to the others. Due to the small number of RCTs, even a meta-analysis could not reliably determine a superior target (Kisely et al. 2018). Despite the generally high response rates, predominantly in open­label studies, response and remission rates vary substantially among studies and fluc­tuate over time. This is typical for studies with small sample sizes (Khan et al. 2018) and indicates that RCTs and meta-analyses are needed for a better estimation of the actual treatment efficacy. Although many study protocols set the end of study at 6 or 12 months (see Appendix Table 20–A), clinical long-term observations over many
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years have been reported in several publications. Thus, DBS for depression is a long­term treatment.
As mentioned, one of the great advantages of DBS over lesion procedures is that sham-controlled trials become feasible. Therefore, after some very promising open­label pilot trials and small well-designed sham-controlled studies were started, with sample sizes determined on the basis of power analyses (Dougherty et al. 2015; Holtzheimer et al. 2017). Un fortunately, both studies were stopped after preliminary futility analyses did not find significant group differences in depressive symptoms between sham and active stim ulation.
Nevertheless, instead of discarding DBS as treatment for TRD due to these prelim­inary findings, we should seek explanations for the failed trials of Dougherty et al. (2015 and Holtzheimer et al. (2017). First, these RCTs were highly underpowered. Their sample sizes (30 and 90, respectively) were much smaller than expected (208 and 201, respectively) and made them quite unlikely to yield statistically significant and replicable results (see Khan et al. 2018 for deeper insight into the problems of trial design in antidepressant treatment). The lack of a significant group difference does not necessarily point toward an ineffective treatment. Looking at the study design pre sented in Dougherty et al. (2015), one can argue that a treatment duration of 4 months before response assessment might be too brief in relation to the duration of illness in this severely ill and treatment-resistant population (Schlaepfer 2015). Furthermore, the time period for individual parameter adjustment was limited to a few days only, which seems much too short for this complex intervention. On the other hand, pa rameter adjustment in the study by Holtzheimer et al. (2017) followed a plan that might have been too strict. Reaching a stable response can take time (Bergfeld et al.
2016), a factor that should be considered in future trial designs (Mayberg et al. 2016).
Beyond these issues, it is also questionable whether the commonly used outcome parameters—the HAM-D and the MADRS—are sensitive enough for the assessment of symptom changes in severe depression. The chronically severe depression in the study population might result in ceiling effects. Therefore, DBS-specific measures of severe depression are urgently needed (Schlaepfer 2015). Furthermore, the HAM-D and MADRS are multidimensional measures that try to assess the whole depression syndrome. Efficacy analyses usually focus on the sum score. Unfortunately, similar sum scores can be achieved by a great number of unique symptom combinations and thereby cover up the nuances of the present depression manifestation (Fried and Nesse 2015). At the same time, a sum score reduction does not give any information about which aspects of the illness actually did improve (Khan et al. 2018). To improve interpretability, it therefore makes sense to look at single symptoms and to find mea surements that contain fewer dimensions (Fried and Nesse 2015).
Finally, the HAM-D and MADRS actually ask for the patient’s depressive symp­toms in the past week. Comparing depression severity at baseline and at an arbitrarily chosen follow-up time point can be influenced by many variables other than treatment and does not tell anything about the course of treatment response (Schlaepfer 2015). For assessment of the whole process from baseline to end of study, the area under the curve has been proposed (Bewernick et al. 2017b; Schlaepfer 2015); this measure is the product of time and depression severity and contains all measuring points and thereby gives information about stability of illness/response. Especially for studies
controlled trials (see Appendix Table 20–A), two large,
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with long-term follow-up, this seems to be a more meaningful outcome parameter than the mere comparison between two points in time. In October 2018, a new large­scale RCT on the treatment of TRD with DBS was started, taking into account the dif ficulties of the studies by Dougherty et al. (2015) and Holtzheimer et al. (2017). The stimulation target is the slMFB (clinical trial identifier NCT03653858). Although no results have been reported yet, this study might be a milestone for DBS in TRD.
DBS has been in use for a while now, yet the exact mode of action remains unclear. Different hypotheses on the electrochemical processes induced by DBS have been put forward, the most common ones being direct inhibition of neural activity, direct exci tation of neural activity, informational lesion, and synaptic filtering. These concepts focus on the acute effects of DBS in movement disorders; for an explanation of these concepts and the current evidence, see Lozano et al. (2019). Currently under investi gation are neuroplastic changes induced by DBS in rodent models of depression (Fa­lowski et al. 2011; Veerakumar et al. 2014).
Where does all this leave us? DBS is a promising treatment for depression with im­pressive results in open-label studies. Surprisingly, RCTs have not been as successful so far. This might be at least partially related to methodological difficulties that should be addressed in future studies. Further well-designed comparable studies on treatment efficacy that allow for meta-analysis are therefore urgently needed. At the same time, careful patient selection that considers individual risks is indispensable, because DBS is an invasive procedure that comes with certain risks (see the next sec­tion, “Safety”). Several targets are under investigation, and at this point we cannot de­termine which is the most effective—neither in general nor in the individual case. Generally, antidepressant effects may vary due to interactions of DBS target, param eter settings, and individual clinical characteristics (Dandekar et al. 2018). Deeper in­sight into this relationship could be a basis for personalized treatment, which is why clinical research should focus on single symptoms as well as on the whole syndrome. Ultimately, a better understanding of the mode of action of DBS is needed to improve target selection and parameter adjustment. So far, DBS should only be considered as a treatment alternative once all approved and well-evaluated treatment procedures have been exhausted. If this requirement is fulfilled, DBS, administered by an expert team in the context of clinical studies, may offer a chance for significant illness im provement.
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Safety
Like any other treatment, DBS is associated with side effects. These side effects can be surgery-, stimulation-, or device-related. Broad overviews of adverse events reported thus far in DBS for TRD are presented in reviews by Kisely et al. (2018) and Dandekar et al. (2018). The main surgery-associated side effects are wound infection, erosion, lead migration, device-related infection, and hemorrhage. These adverse effects may be permanent but are transient in most cases. The incidence rate of hemorrhage in functional neurosurgery (lesion procedures and DBS in general) is about 5.0% (Zrinzo et al. 2012).
Stimulation-related adverse effects such as hypomanic symptoms, disinhibition, restlessness, anxiety, sweating, or headaches are mostly transient (Kisely et al. 2018). Parameter adjustment is required if adverse effects are persistent or experienced as
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stressful (Schlaepfer et al. 2014). Suicide attempts and completed suicides have been reported as well (i.e., Bergfeld et al. 2016; Bewernick et al. 2010; Kennedy et al. 2011). Because prospective studies indicate an increased risk of suicide in patients with TRD (Oquendo et al. 2006), this should be expected and demonstrates the necessity of close psychiatric supervision during studies and follow-up.
Symptom aggravation due to unintended (i.e., battery depletion) or planned (i.e., blinded stimulation) stimulation discontinuation has been reported (i.e., Bergfeld et al. 2016; Holtzheimer et al. 2012; Kilian et al. 2019). Although one study did not find clinical changes after a planned 48-hour stimulation discontinuation, metabolic changes become apparent after this short time period (Martin-Blanco et al. 2015). These findings support the hypothesis that continuous stimulation is essential for effective treatment.
Besides these general adverse events, different stimulation targets seem to be asso­ciated with specific side effects (see Dandekar et al. 2018). Due to small sample sizes and only partial data available from control groups, data on the efficacy and safety of DBS in TRD must be considered preliminary.
Ethical Considerations
Applying DBS for TRD should be and is discussed in light of ethical principles. Quite frequently, concerns regarding possible personality changes under DBS are voiced (Grant et al. 2014; Hildt 2006; Synofzik and Schlaepfer 2008). To address these con­cerns, it is necessary to reflect on what is meant by the term personality—a question that exceeds the scope of this chapter. In short, a quantitative analysis of personality traits before and after DBS for TRD did not reveal any changes (Bewernick et al. 2018). In qualitative analyses in DBS for Parkinson’s disease and OCD, patients occasionally report feelings of strangeness or unfamiliarity with themselves (de Haan et al. 2015; Gilbert et al. 2017; Schüpbach et al. 2006). At the same time, effective treatment of psy­chiatric disorders can be conceptualized as purposefully changing aspects of an indi­vidual’s personality (Synofzik and Schlaepfer 2008) and therefore leads to the question of whether a change in personality is inevitably undesirable (Grant et al. 2014; Syn ofzik and Schlaepfer 2008).
Regarding interpersonal relationships, poor social adjustment, especially in mari­tal relationships and professional lives, has been reported after DBS for Parkinson’s disease, despite the successful reduction of motor symptoms. This leads to the as­sumption that rapid improvement of a disabling condition might have a destabilizing effect (Baertschi et al. 2019; Schüpbach et al. 2006) that should be taken into account when informing patients about the potential risks and benefits of DBS and when de­fining outcome measures in studies on treatment efficacy, especially because very rapid improvement of depressive symptomatology has been observed in DBS for TRD (Schlaepfer et al. 2013). These considerations of DBS for psychiatric purposes are extended by a body of literature (i.e., Grant et al. 2014; Kuhn et al. 2009; Synofzik and Schlaepfer 2008) focused on the well-established principles of bioethical nonmalefi­cence, justice, and autonomy expounded by Beauchamp and Childress (2009). To en­sure that these principles are not only discussed in general but also taken into account in every individual case and in planning clinical trials, guidelines for patient selection have been proposed (Nuttin et al. 2014).
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Without question, DBS remains an invasive treatment and comes with certain risks. Thus, careful selection of patients and targets is important to ensure that pa tients receive the best treatment available. Regarding risk-benefit estimations, it is an advantage that surgery-related side effects are already well known due to the appli cation of DBS in neurology (Kleiner-Fisman et al. 2006). Additionally, the side-effect risks of DBS must be balanced against the immense burden of disease (Mrazek et al.
2014) and the side effects of alternative treatments such as electroconvulsive therapy (Kolshus et al. 2017). As discussed earlier, depression is a complex syndrome. We should therefore aim for individualized patient care that takes into account the indi­vidual depression manifestation (Fried and Nesse 2015) and assesses the best-fitting DBS target. Ultimately, DBS pursues the same goal as all biological interventions for depression—reestablishing the balance of brain circuits involved in maintaining de pression in general and TRD in particular.
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