Case Presentation: DBS for Depression Robert McGovern, MS-IV Neurosurgery Grand Rounds, Massachusetts General Hospital July 16 th, 2009

Patient H&P 43 y/o M with hx of severe, medically intractable depression – On multiple medications – 15 ECT trials – Placement of VNS without success – Placement of epidural prefrontal cortical stimulator without success Presents for placement of deep brain stimulating (DBS) electrodes in Ventral Capsule/Ventral Striatum (VC/VS)

Depression WHO estimates 121 million people worldwide – Leading cause of disability worldwide – 4 th leading contributor to global burden of disease Affects almost 1 in 5 persons in US ~ 20% of patients are treatment-resistant Alternative therapies are needed – Electroconvulsive therapy (ECT) – Vagal Nerve Stimulation (VNS) – Transcranial Magnetic Stimulation (TMS) – Deep Brain Stimulation (DBS)

Neuroanatomy of Depression

Rationale for Targeting the Ventral Capsule/Ventral Striatum 1.VS is a central node in the limbic-cortical-subcortical network thought to be involved in emotional processing 2.VS is central in processing reward and pleasure information 3.VS is ideally suited to modulate reward-motivated behavior 4.VC contains white matter tracts connecting VS to areas mentioned above

Targeting the VC/VS IC Caudate Putamen GP

Operative Procedure Stereotactic frame placed Electrodes inserted under local anesthesia Intra-operative testing – Subjective mood, anxiety, energy level ratings Placement of batteries under clavicle

Electrode Placement

Operative Results and Post-op Management Immediate feeling of a “smile” or “giggle” when stimulator turned on Increase in subjective mood immediately, decrease in anxiety – Described pattern of both short term and long tern changes leading to improvement Continued on home medications, recovery period, discharged on POD 3

Long Term Follow-Up Depression rating scales Hamilton depression and anxiety scores (HAM) Montgomery Asberg Depression Rating scale (MADRS) Global Assessment of functioning (GAF) Detailed neuropsych batter Complications

Conclusions DBS offers a safe and effective method of modulating specific brain regions DBS may become a therapeutic alternative for treatment- resistant depression Continued research into the structural and functional basis of depression will enable us to further refine our treatment methods

Acknowledgments Dr. Emad Eskandar

Indications for study Severely debilitated and treatment-resistant depression – Personal and professional disability – Suicide attempts – > 5 years of depression – > 5 courses of medication – Behavioral therapy – Bilateral ECT

Depression Symptoms Depressed mood Anhedonia Sleeplessness Feelings of guilt or worthlessness Loss of energy Lack of concentration Decrease in appetite Psychomotor retardation Suicidality