Long-Term Outcome of Neurosurgery for the Treatment of Resistant Depression
ABSTRACT Between 1973 and 1995, a total of 76 patients were treated with bilateral stereotactic, orbitomedial lesions for resistant severe depression at the Neuropsychiatric Institute, Sydney, Australia. On follow up after a mean 14.4 years, 24 (31.6%) subjects were confirmed dead, with six having committed suicide. Of the 52 patients still alive (mean age 62.9 years), 23 were interviewed in detail, and lesions verified in 18 with magnetic resonance imaging (MRI). On a 6-point global outcome rating scale, rated by consensus between two independent psychiatrists, five (22.7%) were judged to be completely recovered and another 11 (50%) showed significant improvement. The improvement was noted within days or weeks of the surgery. Adverse effects were epilepsy (2 subjects), marked personality change (1), weight gain (2), and mild personality change (5). Any reported cognitive impairment was mild. No definite predictors of improvement were identified.
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ABSTRACT: The introduction of new medical treatments based on invasive technologies has often been surrounded by both hopes and fears. Hope, since a new intervention can create new opportunities either in terms of providing a cure for the disease or impairment at hand; or as alleviation of symptoms. Fear, since an invasive treatment involving implanting a medical device can result in unknown complications such as hardware failure and undesirable medical consequences. However, hopes and fears may also arise due to the cultural embeddedness of technology, where a therapy due to ethical, social, political and religious concerns could be perceived as either a blessing or a threat. While Deep Brain Stimulation (DBS) for treatment resistant depression (TRD) is still in its cradle, it is important to be proactive and try to scrutinize both surfacing hopes and fears. Patients will not benefit if a promising treatment is banned or avoided due to unfounded fears, nor will they benefit if DBS is used without scrutinizing the arguments which call for caution. Hence blind optimism is equally troublesome. We suggest that specificity, both in terms of a detailed account of relevant scientific concerns as well as ethical considerations, could be a way to analyse expressed concerns regarding DBS for TRD. This approach is particularly fruitful when applied to hopes and fears evoked by DBS for TRD, since it can reveal if our comprehension of DBS for TRD suffer from various biases which may remain unnoticed at first glance. We suggest that such biases exist, albeit a further analysis is needed to explore this issue in full. KeywordsDepression–Deep brain stimulation–Ethics–Beneficence–Nonmaleficence–TimeNeuroethics 01/2013; DOI:10.1007/s12152-011-9112-x · 1.04 Impact Factor
- Acta Neuropsychiatrica 02/2007; 19(1):2 - 5. DOI:10.1111/j.1601-5215.2006.00173.x · 0.64 Impact Factor
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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.Biological psychiatry 06/2008; 64(6):449-54. DOI:10.1016/j.biopsych.2008.04.009 · 9.47 Impact Factor