What Does Deep Brain Stimulation Do?
Deep brain stimulation (DBS) is used to treat a variety of movement disorders, and it has been studied as a treatment for many years. There is a large body of research demonstrating safety and the effectiveness of DBS on movement disorders (Cleary et al., 2015). The research is conclusive, and DBS is currently approved by the United States Food and Drug Administration (FDA) as a treatment for various movement-related disorders, including dystonia, Parkinson’s disease, essential tremor, and treatment-refractory epilepsy (Mahoney et al., 2022). Research has also found some support for DBS as a possible treatment for some psychiatric disorders, such as Obsessive-Compulsive Disorder and Major Depressive Disorder (Mahoney et al., 2022).
How Does Deep Brain Stimulation Work?
Deep brain stimulation is a surgical procedure in which small holes are drilled in one or both sides of a person’s skull in order to implant electrodes into specific areas of the brain (Mahoney et al., 2022). In addition, there is a pulse generator with a cable that is connected to the electrodes in the brain that is surgically implanted under the skin (Mahoney et al., 2022). This pulse generator (IPG) is most frequently implanted under the clavicle or in the abdomen (Jakobs et al., 2023). IPG devices can either be non-rechargeable (nr-IPGs) or rechargeable (r-IPGs) (Jakobs et al., 2023). If a nr-IPG has been implanted, it will eventually need to be replaced, as there is a fixed battery life (Jakobs et al., 2023). On the other hand, r-IPGs require charging at intervals to ensure the battery does not run out (Jakobs et al., 2023).
After a patient has recovered from surgery to implant a DBS device, the device is programmed to have frequency, amplitude, and pulse-width that is most effective and tolerable for the individual and their symptoms (Mahoney et al., 2022). DBS can specifically target certain brain regions and can be adjusted depending on how much stimulation is required (Cleary et al., 2015).
Areas of the brain that are targeted by DBS are specific to the disorder being treated. For example, DBS treatment of Parkinson’s Disease and dystonia targets the internal globus pallidus and subthalamic nucleus, whereas DBS treatment for tremors targets the thalamus (Holtzheimer & Mayberg, 2011). Adjusting DBS programming for movement disorders is somewhat straightforward due to the ability to observe motor movements (Mahoney et al., 2022). Adjusting DBS programming for psychiatric disorders, however, can be more time-consuming and complex (Mahoney et al., 2022).
DBS as a Treatment for Psychiatric Disorders
Exploration of brain stimulation as a form of psychiatric treatment dates back to the 1950s, though there was a paucity of published research studies at the time (Holtzheimer & Mayberg, 2011). According to Holtzheimer and Mayberg (2011), a 1999 study by Nuttin et al. examined the impact of DBS on treatment-refractory obsessive-compulsive disorder (OCD), which caused DBS to be seen as a potential treatment avenue for some psychiatric conditions. A psychiatric diagnosis is referred to as treatment-refractory when standard behavioral and/or pharmacological therapies do not have an adequate effect on reducing symptoms (Mahoney et al., 2022). DBS has been explored in the research as a possible treatment for several psychiatric diagnoses, including Obsessive-Compulsive Disorder and Major Depressive Disorder.
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder (OCD) is a psychiatric condition in which individuals experience distress from both intrusive thoughts (obsessions) and repetitive behaviors (compulsions) (Mahoney et al., 2022). Compulsions are frequently performed to minimize or reduce the anxiety caused by obsessions (Mahoney et al., 2022). Standard treatments for OCD involve both pharmacological interventions, specifically medications, such as serotonin reuptake inhibitors (SSRIs), and psychotherapy, such as cognitive behavioral therapy (Mahoney et al., 2022). Research indicates that OCD has a lifetime prevalence of about 2 to 3 percent, and that standard treatments for OCD do not bring about adequate symptom reduction in 25 to 40 percent of individuals diagnosed with OCD (Mahoney et al., 2022). In 2009, DBS was approved by the FDA under a humanitarian device exemption (HDE) for treatment-refractory OCD (Wu et al., 2021). In order to receive HDE approval, a treatment is not held to the same efficacy standards as FDA approved treatments, though there must be evidence that the treatment does not pose “unreasonable risks,” (Wu et al., 2021).
Research thus far has indicated that DBS is effective at treating OCD when other methods have been unsuccessful, though DBS carries risks, is expensive, and involves continued care and follow up with medical professionals (Wu et al., 2021). Additional research is needed in order to better predict treatment outcomes, more fully understand the most effective areas of the brain to target with DBS, and understand how much stimulation is sufficient for treatments, among other things (Mahoney et al., 2022).
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Depression
Major Depressive Disorder (MDD) is a psychiatric disorder that involves low mood and/or loss of pleasure, along with impacts on energy levels, concentration, sleeping, motor movements, self-esteem, eating, and thoughts of suicide (Holtzheimer & Mayberg, 2011). MDD is one of the most common psychiatric disorders and is a leading cause of disability worldwide (Holtzheimer & Mayberg, 2011). In 2020, approximately 8.4% of adults in the United States experienced at least one depressive episode (NIMH, 2022).
Standard treatments for MDD include psychotherapies, including cognitive behavioral therapy (CBT), and pharmacological interventions such as SSRIs (Zhou et al., 2018). However, approximately 30 percent of individuals with MDD experience depression that is treatment-refractory (Mahoney et al., 2022). Those with depression that dos not respond adequately to standard treatments, experience more challenges, such as increased rates of disability, hospitalization, and suicide (Crowell et al., 2019).
There are some nonstandard treatments for depression that have shown promise in the literature. Multiple randomized controlled trials (RCTs) demonstrated ketamine’s effectiveness on treating MDD (Mahoney et al., 2022). In additional, a procedure called transcranial magnetic stimulation (TMS) is approved by the FDA for treatment-refractory depression (Mahoney et al., 2022), as is a treatment called vagus nerve stimulation (Crowell et al., 2019).
DBS has also been studied as an intervention for treatment-refractory MDD. In individuals with MDD, specific areas of the brain have been found to function differently, so specific areas of the brain, including the subcallosal cingulate cortex (SCC), nucleus accumbens (NAcc) and the medial forebrain bundle (MFB), have been targeted in the research (Cleary et al., 2015). A 2018 review of research studies on DBS for treatment-refractory MDD found that DBS effectively improved symptoms (Zhou, 2018). A 2019 study found that DBS that targeted the subcallosal cingulate cortex (SCC) was safe and effective in the long-term for individuals with MDD and bipolar II disorder (Crowell et al., 2019). Thus far, the existing literature demonstrates that DBS is a treatment that is effective for treatment-refractory MDD, though additional research is needed in order to establish DBS as an approved treatment (Mahoney et al., 2022).
DBS is just one emerging treatment for significant psychiatric illness, though there are a plethora of options for mental health treatment. If you or someone you love is struggling with symptoms of MDD, OCD, or another mental health challenge, you can visit the New York Behavioral Health website to learn more about our team and your treatment options.
References
Cleary, D. R., Ozpinar, A., Raslan, A. M., & Ko, A. L. (2015). Deep brain stimulation for psychiatric disorders: Where we are now. Neurosurgical Focus, 38(6), E2. https://doi.org/10.3171/2015.3.FOCUS1546
Crowell, A. L., Riva-Posse, P., Holtzheimer, P. E., Garlow, S. J., Kelley, M. E., Gross, R. E., Denison, L., Quinn, S., & Mayberg, H. S. (2019). Long-term outcomes of subcallosal cingulate deep brain stimulation for treatment-resistant depression. The American Journal of Psychiatry, 176(11), 949–956. https://doi.org/10.1176/appi.ajp.2019.18121427
Holtzheimer, P. E., & Mayberg, H. S. (2011). Deep brain stimulation for psychiatric disorders. Annual Review of Neuroscience, 34, 289–307. https://doi.org/10.1146/annurev-neuro-061010-113638
Jakobs, M., Hajiabadi, M. M., Aguirre-Padilla, D. H., Giaccobe, P., Unterberg, A. W., & Lozano, A. M. (2023). Recharge PSYCH: A study on rechargeable implantable pulse generators in deep brain stimulation for psychiatric disorders. World Neurosurgery, 170, e331–e339. https://doi.org/10.1016/j.wneu.2022.11.017
Mahoney, J. J., 3rd, Koch-Gallup, N., Scarisbrick, D. M., Berry, J. H., & Rezai, A. R. (2022). Deep brain stimulation for psychiatric disorders and behavioral/cognitive-related indications: Review of the literature and implications for treatment. Journal of the Neurological Sciences, 437, 120253. https://doi.org/10.1016/j.jns.2022.120253
National Institute of Mental Health (January, 2022). Major depression. https://www.nimh.nih.gov/health/statistics/major-depression
Wu, H., Hariz, M., Visser-Vandewalle, V., Zrinzo, L., Coenen, V. A., Sheth S. A., Bervoets, C., Naesström, M., Blomstedt, P., Coyne, T., Hamani, C., Slavin, K., Krauss, J. K., Kahlm, K. G., Taira, T., Zhang, C., Sun, B., Toda, H., Schlaepfer, T., Chang, J. W., Régis, J., Schuurman, R., Schulder, M., Doshi, P., Mosley, P., Poologaindran, A., Lázaro-Muñoz, G., Pepper, J., Schechtmann, G., Fytagoridis, A., Huys, D., Gonçalves-Ferreira, A., D’Haese, P., Neimat, J., Broggi, G., Vilela-Filho, O., Voges, J., Alkhani, A., Nakajima, T., Richieri, R., Djurfeldt, D., Fontaine, P., Martinez-Alvarez, R., Okamura, Y., Chandler, J., Watanabe, K., Barcia, J. A., Reneses, B., Lozano, A., Gabriëls, L., De Salles, A., Halpern, C. H., Matthews, K., Fins, J. J., & Nuttin, B. (2021). Deep brain stimulation for refractory obsessive-compulsive disorder (OCD): Emerging or established therapy?. Molecular Psychiatry, 26(1), 60–65. https://doi.org/10.1038/s41380-020-00933-x
Zhou, C., Zhang, H., Qin, Y., Tian, T., Xu, B., Chen, J., Zhou, X., Zeng, L., Fang, L., Qi, X., Lian, B., Wang, H., Hu, Z., & Xie, P. (2018). A systematic review and meta-analysis of deep brain stimulation in treatment-resistant depression. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 82, 224–232. https://doi.org/10.1016/j.pnpbp.2017.11.012
