Predicting Response to vALIC Deep Brain Stimulation for Refractory Obsessive-Compulsive Disorder

Background: Deep brain stimulation (DBS) for treatment-refractory obsessive-compulsive disorder (OCD) is effective in half of patients, but also is invasive and labor-intensive. Objective: Selecting probable responders beforehand would more optimally allocate treatment resources and prevent patients' disappointment. Some centers use clinical and demographic predictors to exclude patients from DBS treatment, but the evidence base remains uncertain. Methods: This observational cohort study examined the association of baseline demographic and disease characteristics with a 1-year prospective course of OCD and depressive symptoms in a cohort of 70 consecutive patients who received DBS of the ventral anterior limb of the internal capsule (vALIC-DBS) for OCD according to DSM-IV or DSM-5 criteria between April 2005 and October 2017. Baseline characteristics and symptom decrease were analyzed using Fisher exact tests and binary logistic regression to examine whether they could predict individual response (> 35% reduction in Yale-Brown Obsessive Compulsive Scale score and 50% reduction in Hamilton Depression Rating Scale score, respectively). Results: Insight into illness was the only significant predictor of individual response, with a positive predictive value of 84.4%, while the negative predictive value was 44.0% (b = 0.247, χ²₁ = 5.259, P = .022). Late-onset OCD was associated with more symptom decrease (β = -0.29; 95% CI, -0.53 to -0.04; P = .023) and comorbid personality disorder with less symptom decrease over time (β = 0.88; 95% CI -0.29 to 1.47; P = .004), but they could not significantly predict vALIC-DBS response. A later age at onset, comorbid personality disorder, and insight into illness were associated with clinical outcomes after vALIC-DBS, but predictive values were not large enough to facilitate clinical patient selection. Conclusions: Clinical and demographic factors cannot yet predict outcome and should not be used to exclude patients from treatment with vALIC-DBS. These first individual prediction analyses for vALIC-DBS response in OCD are important, given that some centers up until now still exclude patients based on clinical characteristics such as comorbid personality disorders.

Electrical deep neuromodulation in psychiatry

Addressing treatment refractoriness in psychiatric diseases is an essential public health objective. The last two decades have seen an increasing interest for deep brain stimulation (DBS) of several brain targets. In this chapter, we have reviewed the main DBS clinical trials in psychiatric diseases, mainly obsessive compulsive disorders (OCD) and depression, but also emerging research in other psychiatric disorders. While its efficacy and safety are confirmed, DBS is still not considered as standard therapy in psychiatry. However, advances in neuroimaging research combined to behavioral and electrophysiological data uniquely provided by DBS studies improve knowledge on physiopathology in these brain diseases. This will help define the optimal brain targets according to specific phenotype dimensions. Revealing the mechanisms of action and effects of DBS will support that its impact goes beyond a loco-regional brain stimulation and confirms that electrical neuromodulation influences brain networks. Added to the progress in neuromodulation technology, these insights will hopefully facilitate a more widespread application of this promising treatment. Future development of a personalized multimodal assessment of underlying dysfunctional brain networks will open new circuit-specific treatment perspectives that may facilitate better patient outcomes.

Deep brain stimulation modulates directional limbic connectivity in obsessive-compulsive disorder

Deep brain stimulation is effective for patients with treatment-refractory obsessive-compulsive disorder. Deep brain stimulation of the ventral anterior limb of the internal capsule rapidly improves mood and anxiety with optimal stimulation parameters. To understand these rapid effects, we studied functional interactions within the affective amygdala circuit. We compared resting state functional MRI data during chronic stimulation versus 1 week of stimulation discontinuation in patients, and obtained two resting state scans from matched healthy volunteers to account for test-retest effects. Imaging data were analysed using functional connectivity analysis and dynamic causal modelling. Improvement in mood and anxiety following deep brain stimulation was associated with reduced amygdala-insula functional connectivity. Directional connectivity analysis revealed that deep brain stimulation increased the impact of the ventromedial prefrontal cortex on the amygdala, and decreased the impact of the amygdala on the insula. These results highlight the importance of the amygdala circuit in the pathophysiology of obsessive-compulsive disorder, and suggest a neural systems model through which negative mood and anxiety are modulated by stimulation of the ventral anterior limb of the internal capsule for obsessive-compulsive disorder and possibly other psychiatric disorders.

A transdiagnostic perspective of constructs underlying obsessive-compulsive and related disorders: An international Delphi consensus study

BACKGROUND

The Research Domain Criteria seeks to bridge knowledge from neuroscience with clinical practice by promoting research into valid neurocognitive phenotypes and dimensions, irrespective of symptoms and diagnoses as currently conceptualized. While the Research Domain Criteria offers a vision of future research and practice, its 39 functional constructs need refinement to better target new phenotyping efforts. This study aimed to determine which Research Domain Criteria constructs are most relevant to understanding obsessive-compulsive and related disorders, based on a consensus between experts in the field of obsessive-compulsive and related disorders.

METHODS

Based on a modified Delphi method, 46 experts were recruited from Australia, Africa, Asia, Europe and the Americas. Over three rounds, experts had the opportunity to review their opinion in light of feedback from the previous round, which included how their response compared to other experts and a summary of comments given.

RESULTS

Thirty-four experts completed round one, of whom 28 (82%) completed round two and 24 (71%) completed round three. At the final round, four constructs were endorsed by ⩾75% of experts as 'primary constructs' and therefore central to understanding obsessive-compulsive and related disorders. Of these constructs, one came from the Positive Valence System (Habit), two from the Cognitive Control System (Response Selection/Inhibition and Performance Monitoring) and the final construct was an additional item suggested by experts (Compulsivity).

CONCLUSION

This study identified four Research Domain Criteria constructs that, according to experts, cut across different obsessive-compulsive and related disorders. These constructs represent key areas for future investigation, and may have potential implications for clinical practice in terms of diagnostic processes and therapeutic management of obsessive-compulsive and related disorders.

From Many to One: Designing a Unified Flowsheet in the EMR to Replace Multiple Disparate Devices

This study represents a post-implementation qualitative inquiry for a maturing flowsheet design that aims to replace multiple disparate devices used for data entry. The flowsheet has already experienced multiple iterative development cycles based on formal feedback from formative and summative usability studies. This next phase focused on a semi-structured qualitative interview to provide new feedback that will be used to further refine the product. Results of the 9-item interview were both actionable and provocative, revealing multiple avenues of improvement and a new usability map that can inform future studies and design plans.

Utilizing User-Centered EHR Design for Systematic Deep Brain Stimulation Data Collection

This project aims to assess usability and acceptance of a customized Epic-based flowsheet designed to streamline the complex workflows associated with care of patients with implanted Deep Brain Stimulators (DBS). DBS patient care workflows are markedly fragmented, requiring providers to switch between multiple disparate systems. This is the first attempt to systematically evaluate usability of a unified solution built as a flowsheet in Epic. Iterative development processes were applied, collecting formal feedback throughout. Evaluation consisted of cognitive walkthroughs, heuristic analysis, and 'think-aloud' technique. Participants completed 3 tasks and multiple questionnaires with Likert-like questions and long-form written feedback. Results demonstrate that the strengths of the flowsheet are its consistency, mapping, and affordance. System Usability Scale scores place this first version of the flowsheet above the 70th percentile with an 'above average' usability rating. Most importantly, a copious amount of actionable feedback was captured to inform the next iteration of this build.

Impulsivity and Compulsivity After Subthalamic Deep Brain Stimulation for Parkinson's Disease

Impulsivity and compulsivity are prominent non-motor problems in Parkinson’s disease (PD). Despite 20 years of research, there is still an ongoing debate as to whether subthalamic deep brain stimulation (STN DBS) for PD exacerbates or improves these symptoms. Here, we review how STN DBS affects clinical symptoms and neurocognitive aspects of impulsivity and compulsivity. When comparing patients post- to pre-surgery, in the majority of studies STN DBS for PD is associated with a decrease in clinically diagnosed impulse-control disorders and disorders of compulsivity. To avoid confounds, such as post-surgical decreases in dopaminergic medication doses, comparisons can also be made between DBS “On” versus “Off” conditions. These experimentally assayed effects of STN DBS with respect to neurocognitive aspects of impulsivity and compulsivity are more mixed. STN DBS improves behavioral flexibility without impairing negative feedback learning, delay discounting, or inhibitory control, as long as stimulation is restricted to the dorsal STN. However, STN DBS may drive impulsive actions when a subject is faced with competing choices. We discuss how motivated responses may be either enhanced or impaired by STN DBS depending on engagement of dorsal or ventral STN-mediated circuits. Future studies should combine structural and functional circuit measures with behavioral testing in PD patients on and off medication and stimulation. A more sophisticated understanding of how to modulate cortico-striatal-thalamo-cortical loops will increase the likelihood that these circuit manipulation techniques can successfully be applied to a wider range of neuropsychiatric disorders.

Efficacy of Deep Brain Stimulation of the Ventral Anterior Limb of the Internal Capsule for Refractory Obsessive-Compulsive Disorder: A Clinical Cohort of 70 Patients

OBJECTIVE

Deep brain stimulation (DBS) is an effective treatment option for patients with refractory obsessive-compulsive disorder (OCD). However, clinical experience with DBS for OCD remains limited. The authors examined the tolerability and effectiveness of DBS in an open study of patients with refractory OCD.

METHODS

Seventy consecutive patients, including 16 patients from a previous trial, received bilateral DBS of the ventral anterior limb of the internal capsule (vALIC) between April 2005 and October 2017 and were followed for 12 months. Primary effectiveness was assessed by the change in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) from baseline until the 12-month follow-up. Response was defined by a ≥35% decrease in Y-BOCS score, partial response was defined by a 25%-34% decrease, and nonresponse was defined by a <25% decrease. Secondary effectiveness measures were the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression Rating Scale (HAM-D).

RESULTS

Y-BOCS, HAM-A, and HAM-D scores all decreased significantly during the first 12 months of DBS. Twelve months of DBS resulted in a mean Y-BOCS score decrease of 13.5 points (SD=9.4) (40% reduction; effect size=1.5). HAM-A scores decreased by 13.4 points (SD=9.7) (55%; effect size=1.4), and HAM-D scores decreased by 11.2 points (SD=8.8) (54%; effect size=1.3). At the 12-month follow-up, 36 of the 70 patients were categorized as responders (52%), 12 patients as partial responders (17%), and 22 patients as nonresponders (31%). Adverse events included transient symptoms of hypomania, agitation, impulsivity, and sleeping disorders.

CONCLUSIONS

These results confirm the effectiveness and safety of DBS of the vALIC for patients with treatment-refractory OCD in a regular clinical setting.

Physical and Pharmacological Restraints in Hospital Care: Protocol for a Systematic Review

BACKGROUND

Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting.

METHODS

A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied.

DISCUSSION

This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42019116186.

Long-term deep brain stimulation of the ventral anterior limb of the internal capsule for treatment-resistant depression

OBJECTIVE

Deep brain stimulation (DBS) reduces depressive symptoms in approximately 40%-60% of patients with treatment-resistant depression (TRD), but data on long-term efficacy and safety are scarce. Our objective was to assess the efficacy and safety of DBS targeted at the ventral anterior limb of the internal capsule (vALIC) in 25 patients with TRD during a 1-year, open-label, maintenance period, which followed a 1-year optimisation period.

METHODS

Depression severity was measured using the 17-item Hamilton Depression Rating Scale (HAM-D-17), Montgomery-Asberg Depression Rating Scale (MADRS) and self-reported Inventory of Depressive Symptomatology (IDS-SR). Primary outcomes were response rate (≥50% HAM-D-17 score reduction) after the maintenance phase, approximately 2 years after DBS surgery, and changes in depression scores and occurrence of adverse events during the maintenance phase.

RESULTS

Of 25 operated patients, 21 entered and 18 completed the maintenance phase. After the maintenance phase, eight patients were classified as responder (observed response rate: 44.4%; intention-to-treat: 32.0%). During the maintenance phase, HAM-D-17 and MADRS scores did not change, but the mean IDS-SR score decreased from 38.8 (95% CI 31.2 to 46.5) to 35.0 (95% CI 26.1 to 43.8) (p=0.008). Non-responders after optimisation did not improve during the maintenance phase. Four non-DBS-related serious adverse events occurred, including one suicide attempt.

CONCLUSIONS

vALIC DBS for TRD showed continued efficacy 2 years after surgery, with symptoms remaining stable after optimisation as rated by clinicians and with patient ratings improving. This supports DBS as a viable treatment option for patients with TRD.

TRIAL REGISTRATION NUMBER

NTR2118.

Treatment-resistant depression and suicidality

BACKGROUND

Thirty percent of patients with treatment-resistant depression (TRD) attempt suicide at least once during their lifetime. However, it is unclear what the attempted and completed suicide incidences are in TRD patients after initiating a treatment, and whether specific treatments increase or decrease these incidences.

METHODS

We searched PubMed systematically for studies of depressed patients who failed at least two antidepressant therapies and were followed for at least three months after initiating a treatment. We estimated attempted and completed suicide incidences using a Poisson meta-analysis. Given the lack of controlled comparisons, we used a meta-regression to estimate whether these incidences differed between treatments.

RESULTS

We included 30 studies investigating suicidality in 32 TRD samples, undergoing deep brain stimulation (DBS, n = 9), vagal nerve stimulation (VNS, n = 9), electroconvulsive therapy (ECT, n = 5), treatment-as-usual (n = 3), capsulotomy (n = 2), cognitive behavioral therapy (n = 2), ketamine (n = 1), and epidural cortical stimulation (n = 1). The overall incidence of completed suicides was 0.47 per 100 patient years (95% CI: 0.22-1.00), and of attempted suicides 4.66 per 100 patient years (95% CI: 3.53-6.23). No differences were found in incidences following DBS, VNS or ECT.

LIMITATIONS

Suicidality is poorly recorded in many studies limiting the number of studies available.

CONCLUSIONS

The completed and attempted suicide incidences are high (0.47 and 4.66 per 100 patient years respectively), but these incidences did not differ between three end of the line treatments (DBS, VNS or ECT). Given the high suicide risk in TRD patients, clinical trials should consider suicidality as an explicit outcome measure.

Analysis of shared heritability in common disorders of the brain

Disorders of the brain can exhibit considerable epidemiological comorbidity and often share symptoms, provoking debate about their etiologic overlap. We quantified the genetic sharing of 25 brain disorders from genome-wide association studies of 265,218 patients and 784,643 control participants and assessed their relationship to 17 phenotypes from 1,191,588 individuals. Psychiatric disorders share common variant risk, whereas neurological disorders appear more distinct from one another and from the psychiatric disorders. We also identified significant sharing between disorders and a number of brain phenotypes, including cognitive measures. Further, we conducted simulations to explore how statistical power, diagnostic misclassification, and phenotypic heterogeneity affect genetic correlations. These results highlight the importance of common genetic variation as a risk factor for brain disorders and the value of heritability-based methods in understanding their etiology.