Article

Prospective Assessment of Stereotactic Ablative Surgery for Intractable Major Depression

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02129, USA.
Biological psychiatry (Impact Factor: 9.47). 06/2008; 64(6):449-54. DOI: 10.1016/j.biopsych.2008.04.009
Source: PubMed

ABSTRACT Despite therapeutic advances for major depression, a subset of patients with this disorder does not respond to conventional treatment. Stereotactic ablative procedures such as anterior cingulotomy have been performed in severely affected, treatment-resistant patients, but the long-term results of such procedures are not fully understood.
Findings are reported for 33 patients with severe treatment-resistant major depression who underwent ablative stereotactic procedures (dorsal anterior cingulotomy followed if necessary by subcaudate tractotomy). Preoperative and long-term postoperative Beck Depression Inventory scores were obtained along with postoperative Clinical Global Improvement values. Both were analyzed to evaluate patients' responses to the surgical procedure(s).
At mean follow-up of 30 months after one or more stereotactic ablative procedures, 11 patients (33.3%) were classified as responders, 14 (42.4%) were partial responders, and 8 (24.2%) did not respond to the surgical procedure(s). Among those (17) who underwent only one procedure, seven (41.2%) responded, whereas six (35.3%) and four (23.5%) showed partial or no response, respectively. Among patients who required multiple surgical procedures, four patients (25%) responded, whereas eight (50%) and four (25%) patients demonstrated partial or no responses, respectively, at long-term follow-up evaluations.
Approximately 75% of depression patients previously resistant to antidepressant therapies received partial or substantial benefit from stereotactic ablative procedures. Those requiring only a single anterior cingulotomy tended to demonstrate more pronounced responses than patients who underwent multiple surgical procedures.

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    • "Furthermore, the findings of this study accord with previous studies of neuroanatomically specific treatments for mood and anxiety disorders, such as psychosurgery and exogenous brain stimulation. Subcaudate tractotomy, a surgical procedure that interrupts white matter tracts connecting the vmPFC to subcortical structures, has shown efficacy in reducing symptoms of depression and anxiety (Cosgrove, 2000; Shields et al., 2008). And as would be predicted by the results of our study, vegetative symptoms of depression (e.g., changes in appetite, sleep, and energy) were less likely to improve with subcaudate tractotomy than depressed mood or anxiety (Hodgkiss et al., 1995). "
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