Elsevier

Biological Psychiatry

Volume 64, Issue 6, 15 September 2008, Pages 461-467
Biological Psychiatry

Priority Communication
Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment-Resistant Depression

https://doi.org/10.1016/j.biopsych.2008.05.034Get rights and content

Background

A preliminary report in six patients suggested that deep brain stimulation (DBS) of the subcallosal cingulate gyrus (SCG) may provide benefit in treatment-resistant depression (TRD). We now report the results of these and an additional 14 patients with extended follow-up.

Methods

Twenty patients with TRD underwent serial assessments before and after SCG DBS. We determined the percentage of patients who achieved a response (50% or greater reduction in the 17-item Hamilton Rating Scale for Depression [HRSD-17]) or remission (scores of 7 or less) after surgery. We also examined changes in brain metabolism associated with DBS, using positron emission tomography.

Results

There were both early and progressive benefits to DBS. One month after surgery, 35% of patients met criteria for response with 10% of patients in remission. Six months after surgery, 60% of patients were responders and 35% met criteria for remission, benefits that were largely maintained at 12 months. Deep brain stimulation therapy was associated with specific changes in the metabolic activity localized to cortical and limbic circuits implicated in the pathogenesis of depression. The number of serious adverse effects was small with no patient experiencing permanent deficits.

Conclusions

This study suggests that DBS is relatively safe and provides significant improvement in patients with TRD. Subcallosal cingulate gyrus DBS likely acts by modulating brain networks whose dysfunction leads to depression. The procedure is well tolerated and benefits are sustained for at least 1 year. A careful double-blind appraisal is required before the procedure can be recommended for use on a wider scale.

Section snippets

Patients

Twenty patients with TRD received DBS of the SCG between May 2003 and November 2006 (Table 1). Referrals came from hospital and community psychiatrists who were aware of the protocol and were not directly involved in its implementation. All patients met criteria for major depressive disorder (MDD), were in a current major depressive episode (MDE) as determined by the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P) (18), and had a minimum score of 20 on the

Primary Outcome Measures

The clinical and demographic features of 20 patients with TRD undergoing SCG DBS are shown in Table 1. We treated 9 men and 11 women with SCG DBS. All had failed multiple trials of pharmacotherapy and psychotherapy and all but three (who refused) also received a course of electroconvulsive therapy during the current episode without response. The mean duration of the current major depressive episode was 6.9 years (SD 5.6). One patient who initially was diagnosed with unipolar depression had more

Impact of DBS on TRD

We found that SCG DBS produced robust improvements in depression in patients with TRD. Benefits were seen across multiple domains of depression as reflected by improvements in each of the mood, anxiety, somatic, and sleep subcomponents of the HRSD-17 scale. The maximal benefits were delayed and progressive. They reached a plateau at 6 months and were generally sustained up to last time point measured at 12 months. Patients who showed a benefit at 1 month were likely to maintain response 6 and

Conclusion

We conclude that SCG DBS improves many of the symptoms of severe depression in patients who have failed to respond to conventional treatments. Improvements are seen within 1 month and last for at least 1 year. The procedure is well tolerated and no patient suffered a permanent serious adverse effect. In contrast to previously utilized ablative neurosurgical procedures for depression, DBS is adjustable and stimulation is reversible. These features increase safety and may offer advantages for

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