Deep brain stimulation for psychiatric disorders

Abstract

Medications, psychotherapy, and other treatments are effective for many patients with psychiatric disorders. However, with currently available interventions, a substantial number of patients experience incomplete resolution of symptoms, and relapse rates are high. In the search for better treatments, increasing interest has focused on focal neuromodulation. This focus has been driven by improved neuroanatomical models of mood, thought, and behavior regulation, as well as by more advanced strategies for directly and focally altering neural activity. Deep brain stimulation (DBS) is one of the most invasive focal neuromodulation techniques available; data have supported its safety and efficacy in a number of movement disorders. Investigators have produced preliminary data on the safety and efficacy of DBS for several psychiatric disorders, as well. In this review, we describe the development and justification for testing DBS for various psychiatric disorders, carefully consider the available clinical data, and briefly discuss potential mechanisms of action.

Figure 1

Diagram of a deep brain stimulation (DBS) system. Electrodes are implanted via stereotactic neurosurgery and attached to an implanted pulse generator via subcutaneous extension wires. Image courtesy of David Peace, Department of Neurosurgery, University of Florida School of Medicine.

Figure 2

Postoperative MRI scans of three ablative neurosurgical procedures currently available for psychiatric disorders: (a) anterior cingulotomy, (b) anterior capsulotomy, and (c) subcaudate tractotomy. A limbic leucotomy is achieved by combining an anterior cingulotomy (a) with a subcaudate tractotomy (c). Images courtesy of G. Rees Cosgrove, Department of Neurosurgery, Brown University.

Figure 3

Location of various targets for ablation or DBS for psychiatric disorders. Abbreviations: CGT, cingulotomy; CPT, capsulotomy; HAB, habenula; ITP, inferior thalamic peduncle; SCC, subcallosal cingulate; SCT, subcaudate tractotomy; VC/VS, ventral capsule/ventral striatum. Note that the current VC/VS target is more posterior and inferior to the classic CPT target (Greenberg et al. 2010); the VC/VS and NAcc targets span a very similar area (Greenberg et al. 2010, Schlaepfer et al. 2008); the SCC target is more medial and anterior to the classic SCT target; and the classic CGT target is in the dorsal anterior cingulate (not rostral or subcallosal).