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Dafsari FS, Bewernick B, Böhringer S, Domschke K, Elsaesser M, Löbner M, Luppa M, Schmitt S, Wingenfeld K, Wolf E, Zehender N, Hellmich M, Müller W, Wagner M, Peters O, Frölich L, Riedel-Heller S, Schramm E, Hautzinger M, Jessen F. Perceived Physical Health and Cognitive Behavioral Therapy vs Supportive Psychotherapy Outcomes in Adults With Late-Life Depression: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e245841. [PMID: 38619842 PMCID: PMC11019392 DOI: 10.1001/jamanetworkopen.2024.5841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/06/2024] [Indexed: 04/16/2024] Open
Abstract
Importance Physical diseases co-occur with late-life depression (LLD). The influence of physical diseases and the subjective perception of physical health (PPH) on treatment outcome in LLD, however, is not well understood. Objective To assess the association of physical diseases and PPH with the outcomes of 2 different types of psychotherapy in LLD. Design, Setting, and Participants This post hoc secondary analysis of a multicenter, observer-blinded, controlled, parallel-group randomized clinical trial assessed participants 60 years or older with moderate to severe depression recruited at 7 psychiatric-psychotherapeutic outpatient trial sites in Germany from October 1, 2018, to November 11, 2020. Data analysis was performed from April 1 to October 31, 2023. Interventions Patients received LLD-specific cognitive behavioral therapy (LLD-CBT) or supportive unspecific intervention (SUI). Main Outcomes and Measures Depression severity, response, and remission were measured during treatment and at 6-month follow-up by the change in the 30-item Geriatric Depression Scale (GDS) score. Physical health and PPH were assessed by the number of physical diseases, Charlson Comorbidity Index (CCI), and the World Health Organization Quality of Life Brief Version physical health subscale. Results A total of 251 patients were randomized to LLD-CBT (n = 126) or SUI (n = 125), of whom 229 (mean [SD] age, 70.2 [7.1] years; 151 [66%] female) were included in the intention-to-treat analysis. Patients with low and moderate PPH at baseline had significantly less reduction in the GDS score across both treatment groups than patients with high PPH (estimated marginal mean difference [EMMD], 2.67; 95% CI, 0.37-4.97; P = .02 for low PPH and EMMD, 1.82; 95% CI, 0.22-3.42; P = .03 for moderate vs high PPH). Higher PPH at baseline was associated with higher likelihood of response (odds ratio [OR], 1.04; 95% CI, 1.00-1.06; P = .009) and remission at the end of treatment (OR, 1.04; 95% CI, 1.02-1.08; P = .002) and response (OR, 1.05; 95% CI, 1.02-1.08; P < .001) and remission at follow-up (OR, 1.06; 95% CI, 1.03-1.10; P < .001) across both treatment groups. However, a significant interaction of PPH with treatment group was observed with low PPH at baseline being associated with significantly larger reduction in GDS scores in SUI compared with LLD-CBT at the end of treatment (EMMD, -6.48; 95% CI, -11.31 to -1.64; P = .009) and follow-up (EMMD, -6.49; 95% CI, -11.51 to -1.47; P = .01). In contrast, patients with high PPH at baseline had a significantly greater reduction in GDS scores in LLD-CBT compared with SUI at all time points (week 5: EMMD, -4.08; 95% CI, -6.49 to -1.67; P = .001; end-of-treatment: EMMD, -3.67; 95% CI, -6.72 to -0.61; P = .02; and follow-up: EMMD, -3.57; 95% CI, -6.63 to -0.51; P = .02). The number of physical diseases or CCI at baseline did not have an effect on the change in GDS score, response, or remission, neither across both groups nor within either group. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, subjective PPH was associated with treatment outcome, response, and remission in psychotherapy of LLD. Patients with LLD responded differently to LLD-CBT and SUI, depending on their baseline PPH score. Treatment approaches for patients with LLD should address PPH in personalized interventions. Trial Registration ClinicalTrials.gov Identifier: NCT03735576; Deutsches Register Klinischer Studien Identifier: DRKS00013769.
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Affiliation(s)
- Forugh S. Dafsari
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
| | - Bettina Bewernick
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
| | - Sabine Böhringer
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Elsaesser
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Margrit Löbner
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Sandra Schmitt
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Katja Wingenfeld
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Elena Wolf
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
| | - Nadine Zehender
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Wiebke Müller
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Wagner
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
- German Center for Neurodegenerative Disease, Bonn, Germany
| | - Oliver Peters
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Lutz Frölich
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Steffi Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Hautzinger
- Department of Clinical Psychology and Psychotherapy, Eberhard Karls University, Tübingen, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
- German Center for Neurodegenerative Disease, Bonn, Germany
- Cellular Stress Response in Aging-Associated Diseases Cluster of Excellence, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Dafsari FS, Bewernick B, Böhringer S, Domschke K, Elsaesser M, Löbner M, Luppa M, Preis L, Püsken J, Schmitt S, Szekely AJ, Hellmich M, Müller W, Wagner M, Peters O, Frölich L, Riedel-Heller S, Schramm E, Hautzinger M, Jessen F. Cognitive Behavioral Therapy for Late-Life Depression (CBTlate): Results of a Multicenter, Randomized, Observer-Blinded, Controlled Trial. Psychother Psychosom 2023:1-13. [PMID: 37004508 DOI: 10.1159/000529445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/23/2023] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Different psychotherapeutic interventions for late-life depression (LLD) have been proposed, but their evaluation in large, multicenter trials is rare. OBJECTIVE The present study evaluated the efficacy of a specific cognitive behavioral therapy (CBT) for LLD (LLD-CBT) in comparison with a supportive unspecific intervention (SUI), both administered in a specialist psychiatric outpatient setting. METHODS In this randomized, controlled, parallel group trial, we recruited participants (≥60 years) with moderate to severe depression at 7 trial sites in Germany. Participants were randomly assigned to the LLD-CBT or SUI group. The primary outcome was depression severity at the end of treatment measured by change on the Geriatric Depression Scale (GDS). Secondary outcomes included change in observer-rated depression, anxiety, sleep ratings, and quality of life throughout the treatment phase and at 6-month follow-up. RESULTS Between October 1, 2018, and November 11, 2020, we randomly assigned 251 patients to either LLD-CBT (n = 126) or SUI (n = 125), of whom 229 provided primary-outcome data. There was no significant between-group difference in the change in GDS scores at the end of treatment (estimated marginal mean difference: -1.01 [95% CI: -2.88 to 0.86]; p = 0.287). Secondary analyses showed significant improvements in several outcomes after 8 weeks and at follow-up in both treatment arms. CONCLUSIONS Our data suggest that LLD-specific CBT and a supportive unspecific treatment both provide clinical benefit in patients with moderate to severe LLD without evidence for superiority of LLD-CBT.
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Affiliation(s)
- Forugh S Dafsari
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Bettina Bewernick
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
| | - Sabine Böhringer
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Elsaesser
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Margrit Löbner
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Lukas Preis
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Julia Püsken
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Sandra Schmitt
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Andreea-Johanna Szekely
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Wiebke Müller
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Wagner
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
| | - Oliver Peters
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Lutz Frölich
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Steffi Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Hautzinger
- Department of Clinical Psychology and Psychotherapy, Eberhard Karls University, Tuebingen, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- German Center for Neurodegenerative Disease (DZNE), Bonn, Germany
- Cellular Stress Response in Aging-Associated Diseases (CECAD) Cluster of Excellence, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Hebel T, Grözinger M, Landgrebe M, Padberg F, Schecklmann M, Schlaepfer T, Schönfeldt-Lecuona C, Ullrich H, Zwanzger P, Langguth B, Bajbouj M, Bewernick B, Brinkmann K, Cordes J, Di Pauli J, Eichhammer P, Freundlieb N, Hajak G, Höppner-Buchmann J, Hurlemann R, Kamp D, Kayser S, Kis B, Kreuzer PM, Kuhn J, Lammers M, Lugmayer B, Mielacher C, Nickl-Jockschat T, Nunhofer C, Palm U, Poeppl TB, Polak T, Sakreida K, Sartorius A, Silberbauer C, Zilles-Wegner D. Evidence and expert consensus based German guidelines for the use of repetitive transcranial magnetic stimulation in depression. World J Biol Psychiatry 2022; 23:327-348. [PMID: 34668449 DOI: 10.1080/15622975.2021.1995810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a promising alternative to psychotherapeutic and pharmacological treatments for depression. This paper aims to present a practical guide for its clinical implementation based on evidence from the literature as well as on the experience of a group of leading German experts in the field. METHODS The current evidence base for the use of rTMS in depression was examined via review of the literature. From the evidence and from clinical experience, recommendations for the use of rTMS in clinical practice were derived. All members of the of the German Society for Brain Stimulation in Psychiatry and all members of the sections Clinical Brain Stimulation and Experimental Brain Stimulation of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Mental Health were invited to participate in a poll on whether they consent with the recommendations. FINDINGS Among rTMS experts, a high consensus rate could be identified for clinical practice concerning the setting and the technical parameters of rTMS treatment in depression, indications and contra-indications, the relation of rTMS to other antidepressive treatment modalities and the frequency and management of side effects.
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Affiliation(s)
- Tobias Hebel
- Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | - Michael Grözinger
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH University, Aachen, Germany
| | - Michael Landgrebe
- Department of Psychiatry, Kbo-Lech-Mangfall Clinic, Agatharied, Germany
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, LMU University Munich, Munich, Germany
| | - Martin Schecklmann
- Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | - Thomas Schlaepfer
- Department of Psychiatry and Psychotherapy, Interventional Biological Psychiatry, University Freiburg, Freiburg, Germany
| | | | - Heiko Ullrich
- Department of Psychiatry, Psychotherapy and Psychosomatics, Siegen Hospital, Siegen, Germany
| | - Peter Zwanzger
- Department of Psychiatry and Psychotherapy, LMU University Munich, Munich, Germany.,Clinical Center for Psychiatry, Psychotherapy, Psychosomatic Medicine, Geriatrics and Neurology, Kbo-Inn-Salzach-Klinikum, Wasserburg/Inn, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | | | | | - Bettina Bewernick
- Departments of Geriatric Psychiatry, Psychiatry, and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Klaus Brinkmann
- Center for Psychosocial Medicine, Agaplesion Diakonieklinikum Hospital Rotenburg, Rotenburg, Germany
| | - Joachim Cordes
- Department of Psychiatry and Psychotherapy, Kaiserswerther Diakonie, Düsseldorf, Germany
| | - Jan Di Pauli
- Department of Adult Psychiatry, Rankweil Hospital, Vocklabruck, Austria
| | - Peter Eichhammer
- Clinic for Mental Health, Goldener Steig Hospital, Freyung, Germany
| | - Nils Freundlieb
- Department of Psychiatry and Psychotherapy, Center for Psychosocial Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Göran Hajak
- Department of Psychiatry and Psychotherapy, Sozialstiftung, Bamberg, Germany
| | - Jacqueline Höppner-Buchmann
- Department of Geriatric Psychiatry and Psychotherapy, Helios Hospital Schwerin, Carl-Friedrich-Flemming Hospital, Schwerin, Germany
| | - Rene Hurlemann
- Department of Psychiatry and Psychotherapy, Karl-Jaspers Hospital, University Oldenburg, Bad Zwischenahn, Germany
| | - Daniel Kamp
- Department of Psychiatry and Psychotherapy, LVR Hospital, Heinrich-Heine University, Düsseldorf, Germany
| | - Sarah Kayser
- Department of General Psychiatry, Psychotherapy and Psychosomatics 3/Geriatric Psychiatry, Rheinhessen Hospital Alzey, Alzey, Germany
| | - Bernhard Kis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Catholic Hospitals Ruhrhalbinsel, Hattingen, Germany
| | - Peter M Kreuzer
- Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | - Jens Kuhn
- Department of Psychiatry, Psychotherapy and Psychosomatics, Johanniter Hospital Oberhausen, Oberhausen, Germany
| | - Melisande Lammers
- Hospital for Psychosomatics and Psychotherapy, MediClin Reichshof Hospital, Reichshof-Eckenhagen, Germany
| | - Beatrix Lugmayer
- Department of Psychiatry, Salzkammergut Hospital Vöcklabruck, Vocklabruck, Austria
| | - Clemens Mielacher
- Department of Psychiatry and Psychotherapy, Section Clinical Psychology, University Hospital Bonn, Bonn, Germany
| | - Thomas Nickl-Jockschat
- Departments of Psychiatry, Neuroscience and Pharmacology, Iowa Neuroscience Institute Carver College of Medicine University of Iowa, Iowa City, IA, USA
| | - Christian Nunhofer
- Private Practice in Neurology, Psychiatry and Psychotherapy, Neumarkt, Germany
| | - Ulrich Palm
- Medical Park Chiemseeblick, Bernau-Felden, Germany
| | - Timm B Poeppl
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH University, Aachen, Germany
| | - Thomas Polak
- Department and Clinic of Psychiatry, Psychosomatics and Psychotherapy, Neurovascular Functional Diagnostics, Center for Mental Health, Würzburg University Hospital, Wuerzburg, Germany
| | - Katrin Sakreida
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH University, Aachen, Germany
| | - Alexander Sartorius
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany
| | | | - David Zilles-Wegner
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Georg-August University, Göttingen, Germany
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Dafsari FS, Bewernick B, Biewer M, Christ H, Domschke K, Froelich L, Hellmich M, Luppa M, Peters O, Ramirez A, Riedel-Heller S, Schramm E, Vry MS, Wagner M, Hautzinger M, Jessen F. Cognitive behavioural therapy for the treatment of late life depression: study protocol of a multicentre, randomized, observer-blinded, controlled trial (CBTlate). BMC Psychiatry 2019; 19:423. [PMID: 31881995 PMCID: PMC6935201 DOI: 10.1186/s12888-019-2412-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 12/17/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Late-life depression (LLD) is one of the most prevalent mental disorders in old age. It is associated with various adverse outcomes and frequent use of health care services thereby remaining a serious public health concern. Compared with depression in early adulthood, most treatment options of LLD are less effective. Psychotherapy may be particularly beneficial for LLD due to specific psychological conditions in old age and a low risk of side effects. Although cognitive behavioural therapy (CBT) is highly established and effective in depression in young and mid-life there is only a limited number of small studies on CBT in LLD. An LLD-specific CBT has not yet been compared to an active, but unspecific supportive psychological intervention in a multicentre trial. METHODS Here we present the design of the CBTlate trial, which is a multicentre, randomized, observer-blinded, active-controlled, parallel group trial. CBTlate aims at including 248 patients with LLD of both genders at 7 sites in Germany. The purpose of the study is to test the hypothesis that a 15-session individually-delivered CBT specific for LLD is of superior efficacy in reducing symptoms of depression in comparison with a supportive unspecific intervention (SUI) of the same quantity. The intervention includes 8 weeks of individual treatment sessions twice per week and a follow-up period of 6 months after randomization. The primary end point is the severity of depression at the end of treatment measured by the self-rated 30-item Geriatric Depression Scale (GDS). Secondary endpoints include depressive symptoms at week 5 and at follow-up (6 months after randomization). Additional secondary endpoints include the change of depressive symptoms assessed with a clinician-rating-scale and a patient reported outcome instrument for major depressive disorder, anxiety symptoms, sleep, cognition, quality of life, and overall health status from baseline to end-of treatment and to end of follow-up. Add-on protocols include MRI and the collection of blood samples. DISCUSSION This study is the first multicentre trial of a specific CBT intervention for LLD compared to an unspecific supportive psychological intervention administered in a specialist setting. It has important implications for developing and implementing efficient psychotherapeutic strategies for LLD and may be a significant step to broaden treatment options for people suffering from LLD. TRIAL REGISTRATION ClinicalTrials.gov (NCT03735576, registered on 24 October 2018); DRKS (DRKS00013769, registered on 28 June 2018).
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Affiliation(s)
- Forugh S. Dafsari
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50931 Cologne, Germany
- Max-Planck-Institute for Metabolism Research, Gleueler Str 50, 50931 Cologne, Germany
| | - Bettina Bewernick
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, 53105 Bonn, Germany
| | - Matthias Biewer
- Clinical Trials Centre Cologne, Gleueler Str 269, 50935 Cologne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Kerpener Str 62, 50931 Cologne, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstraße 5, 79104 Freiburg, Germany
| | - Lutz Froelich
- Department of Geriatric Psychiatry Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, 68159 Mannheim, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Kerpener Str 62, 50931 Cologne, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, 01403 Leipzig, Germany
| | - Oliver Peters
- Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Alfredo Ramirez
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50931 Cologne, Germany
| | - Steffi Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, 01403 Leipzig, Germany
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstraße 5, 79104 Freiburg, Germany
| | - Magnus-Sebastian Vry
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstraße 5, 79104 Freiburg, Germany
| | - Michael Wagner
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, 53105 Bonn, Germany
| | - Martin Hautzinger
- Department of Clinical Psychology and Psychotherapy, Eberhard Karls University, Schleichstraße 4, 72076 Tuebingen, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50931 Cologne, Germany
- German Center for Neurodegenerative Disease (DZNE), Sigmund-Freud-Str 27, 53127 Bonn, Germany
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Coenen VA, Schlaepfer TE, Bewernick B, Kilian H, Kaller CP, Urbach H, Li M, Reisert M. Frontal white matter architecture predicts efficacy of deep brain stimulation in major depression. Transl Psychiatry 2019; 9:197. [PMID: 31434867 PMCID: PMC6704187 DOI: 10.1038/s41398-019-0540-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/29/2019] [Accepted: 07/07/2019] [Indexed: 12/13/2022] Open
Abstract
Major depression is a frequent and severe disorder, with a combination of psycho- and pharmacotherapy most patients can be treated. However, ~20% of all patients suffering from major depressive disorder remain treatment resistant; a subgroup might be treated with deep brain stimulation (DBS). We present two trials of DBS to the superolateral medial forebrain bundle (slMFB DBS; FORESEE I and II). The goal was to identify informed features that allow to predict treatment response. Data from N = 24 patients were analyzed. Preoperative imaging including anatomical sequences (T1 and T2) and diffusion tensor imaging (DTI) magnetic resonance imaging sequences were used together with postoperative helical CT scans (for DBS electrode position). Pathway activation modeling (PAM) as well as preoperative structural imaging and morphometry was used to understand the response behavior of patients (MADRS). A left fronto-polar and partly orbitofrontal region was identified that showed increased volume in preoperative anatomical scans. Further statistical analysis shows that the volume of this "HUB-region" is predictive for later MADRS response from DBS. The HUB region connects to typical fiber pathways that have been addressed before in therapeutic DBS in major depression. Left frontal volume growth might indicate intrinsic activity upon disconnection form the main emotional network. The results are significant since for the first time we found an informed feature that might allow to identify and phenotype future responders for slMFB DBS. This is a clear step into the direction of personalized treatments.
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Affiliation(s)
- Volker A. Coenen
- 0000 0000 9428 7911grid.7708.8Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg, Germany ,grid.5963.9Medical Faculty, Freiburg University, Freiburg, Germany ,0000 0000 8786 803Xgrid.15090.3dDepartment of Neurosurgery, Bonn University Medical Center, Bonn, Germany ,grid.5963.9BrainLinks/BrainTools, Cluster of Excellence, Freiburg University, Freiburg, Germany ,grid.5963.9Neuromod, Center for Basics in NeuroModulation, Freiburg University, Freiburg, Germany
| | - Thomas E. Schlaepfer
- grid.5963.9Medical Faculty, Freiburg University, Freiburg, Germany ,grid.5963.9BrainLinks/BrainTools, Cluster of Excellence, Freiburg University, Freiburg, Germany ,0000 0000 9428 7911grid.7708.8Department of Interventional Biological Psychiatry, Freiburg University Medical Center, Freiburg, Germany ,0000 0000 8786 803Xgrid.15090.3dDepartment of Psychiatry and Psychotherapy, Bonn University Medical Center, Bonn, Germany
| | - Bettina Bewernick
- 0000 0000 8786 803Xgrid.15090.3dDepartment of Psychiatry and Psychotherapy, Bonn University Medical Center, Bonn, Germany ,0000 0000 8786 803Xgrid.15090.3dDepartment of Geronto-Psychiatry, Bonn University Medical Center, Bonn, Germany
| | - Hannah Kilian
- grid.5963.9Medical Faculty, Freiburg University, Freiburg, Germany ,0000 0000 9428 7911grid.7708.8Department of Interventional Biological Psychiatry, Freiburg University Medical Center, Freiburg, Germany
| | - Christoph P. Kaller
- grid.5963.9Medical Faculty, Freiburg University, Freiburg, Germany ,grid.5963.9BrainLinks/BrainTools, Cluster of Excellence, Freiburg University, Freiburg, Germany ,0000 0000 9428 7911grid.7708.8Department of Neuroradiology, Freiburg University Medical Center, Freiburg, Germany
| | - Horst Urbach
- grid.5963.9Medical Faculty, Freiburg University, Freiburg, Germany ,0000 0000 9428 7911grid.7708.8Department of Neuroradiology, Freiburg University Medical Center, Freiburg, Germany ,0000 0000 8786 803Xgrid.15090.3dDivision of Neuroradiology/Department of Radiology, Bonn University Medical Center, Bonn, Germany
| | - Meng Li
- 0000 0000 9428 7911grid.7708.8Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg, Germany ,grid.5963.9Medical Faculty, Freiburg University, Freiburg, Germany ,0000 0001 2190 1447grid.10392.39Clinical Affective Neuroimaging Laboratory, Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg, Germany. .,Medical Faculty, Freiburg University, Freiburg, Germany.
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Coenen VA, Sajonz B, Reisert M, Bostroem J, Bewernick B, Urbach H, Jenkner C, Reinacher PC, Schlaepfer TE, Mädler B. Tractography-assisted deep brain stimulation of the superolateral branch of the medial forebrain bundle (slMFB DBS) in major depression. Neuroimage Clin 2018; 20:580-593. [PMID: 30186762 PMCID: PMC6120598 DOI: 10.1016/j.nicl.2018.08.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 01/01/2023]
Abstract
Background Deep brain stimulation (DBS) of the superolateral branch of the medial forebrain bundle (slMFB) emerges as a - yet experimental - treatment for major depressive disorder (MDD) and other treatment refractory psychiatric diseases. First experiences have been reported from two open label pilot trials in major depression (MDD) and long-term effectiveness for MDD (50 months) has been reported. Objective To give a detailed description of the surgical technique for DBS of the superolateral branch of the medial forebrain bundle (slMFB) in MDD. Methods Surgical experience from bilateral implantation procedures in n = 24 patients with MDD is reported. The detailed procedure of tractography-assisted targeting together with detailed electrophysiology in 144 trajectories in the target region (recording and stimulation) is described. Achieved electrode positions were evaluated based on postoperative helical CT and fused to preoperative high resolution anatomical magnetic resonance imaging (MRI; Philips Medical Systems, Best, Netherlands), including the pre-operative diffusion tensor imaging (DTI) tractographic information (StealthViz DTI, Medtronic, USA; Framelink 5.0, Medtronic, USA). Midcommissural point (MCP) coordinates of effective contact (EC) location, together with angles of entry into the target region were evaluated. To investigate incidental stimulation of surrounding nuclei (subthalamic nucleus, STN; substantia nigra, SNr; and red nucleus, RN) as a possible mechanism, a therapeutic triangle (TT) was defined, located between these structures (based on MRI criteria in T2) and evaluated with respect to EC locations. Results Bilateral slMFB DBS was performed in all patients. We identified an electrophysiological environment (defined by autonomic reaction, passive microelectrode recording, acute effects and oculomotor effects) that helps to identify the proper target site on the operation table. Postoperative MCP-evaluation of effective contacts (EC) shows a significant variability with respect to localization. Evaluation of the TT shows that responders will typically have their active contacts inside the triangle and that surrounding nuclei (STN, SNr, RN) are not directly hit by EC, indicating a predominant white matter stimulation. The individual EC position within the triangle cannot be predicted and is based on individual slMFB (tractography) geometry. There was one intracranial bleeding (FORESEE I study) during a first implantation attempt in a patient who later received full bilateral implantation. Typical oculomotor side effects are idiosyncratic for the target region and at inferior contacts. Conclusion The detailed surgical procedure of slMFB DBS implantation has not been described before. The slMFB emerges as an interesting region for the treatment of major depression (and other psychiatric diseases) with DBS. So far it has only been successfully researched in open label clinical case series and in 15 patients published. Stimulation probably achieves its effect through direct white-matter modulation of slMFB fibers. The surgical implantation comprises a standardized protocol combining tractographic imaging based on DTI, targeting and electrophysiological evaluation of the target region. To this end, slMFB DBS surgery is in technical aspects comparable to typical movement disorder surgery. In our view, slMFB DBS should only be performed under tractographic assistance. The slMFB is an emerging target for DBS in therapy refractory Depression. The therapeutic effect is related to modulation of white matter. Surgery for slMFB DBS is tractography assisted surgery. DBS of the slMFB is in many aspects similar to movement disorder surgery.
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Key Words
- CT, computed tomography
- DBS, deep brain stimulation
- DTI FT, DTI fiber tractography
- DTI, diffusion tensor magnetic resonance imaging
- Deep brain stimulation
- Depression
- Diffusion tensor imaging
- EC, effective contact
- FT, fiber tractography
- Fiber tracking
- HF, high frequency
- Hz, Hertz [1/s]
- IPG, internal pulse generator
- MADRS, Montgomery-Åsberg Depression Rating Scale
- MCP, mid-commissural point
- MDD, major depressive disorder
- MRI, magnetic resonance imaging
- Medial forebrain bundle
- OCD
- RN, red nucleus
- SNr, substantia nigra pars reticulata
- STN, subthalamic nucleus
- Stereotactic surgery
- Tractography
- VAT, volume of activated tissue
- VTA, ventral tegmental area
- mA, milli-ampere
- slMFB
- μs, micro second
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Affiliation(s)
- Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany; Department of Neurosurgery, Bonn University Medical Center, Germany; BrainLinks/BrainTools, Cluster of Excellence, Freiburg University, Germany.
| | - Bastian Sajonz
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany
| | - Jan Bostroem
- Department of Neurosurgery, Bonn University Medical Center, Germany
| | - Bettina Bewernick
- Division of Interventional Biological Psychiatry, Department of Psychiatry and Psychotherapy, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany; Department of Psychiatry and Psychotherapy, Geriatric Psychiatry and Neurodegenerative Disorders, Bonn University Medical Center, Germany
| | - Horst Urbach
- Department of Neuroradiology, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany; Division of Neuroradiology, Department of Radiology, Bonn University Medical Center, Germany
| | - Carolin Jenkner
- Clinical Trials Unit, Freiburg University, Germany; Medical Faculty, Freiburg University, Freiburg, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany
| | - Thomas E Schlaepfer
- Division of Interventional Biological Psychiatry, Department of Psychiatry and Psychotherapy, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany; Department of Psychiatry and Psychotherapy, Geriatric Psychiatry and Neurodegenerative Disorders, Bonn University Medical Center, Germany; BrainLinks/BrainTools, Cluster of Excellence, Freiburg University, Germany
| | - Burkhard Mädler
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Germany; Medical Faculty, Freiburg University, Freiburg, Germany; Philips GmbH DACH, Hamburg, Germany
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Coenen V, Schlaepfer T, Bewernick B, Bostroem J, Hattingen E, Urbach H, Li M. Diffusion tensor magnetic resonance imaging tractographic analysis of slMFB DBS in major depression. Brain Stimul 2017. [DOI: 10.1016/j.brs.2017.01.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Allert N, Gippert SM, Sajonz BEA, Nelles C, Bewernick B, Schlaepfer TE, Coenen VA. Arachnophobia alleviated by subthalamic nucleus stimulation for Parkinson's disease. J Neural Transm (Vienna) 2016; 123:631-5. [PMID: 27198699 DOI: 10.1007/s00702-016-1546-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/01/2016] [Indexed: 11/30/2022]
Abstract
We report on a Parkinson patient with motor fluctuations and dyskinesias in whom deep brain stimulation (DBS) of the subthalamic nucleus (STN) not only improved motor symptoms but also pre-existing arachnophobia. Arachnophobia had been unchanged by the course of Parkinson's disease but rapidly improved with STN-DBS. Both, motor effects and the improvement of arachnophobia were stable during 2 years follow-up. To our knowledge this is the first report on STN stimulation effects on a specific phobia.
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Affiliation(s)
- Niels Allert
- Neurological Rehabilitation Center Godeshoehe, Waldstrasse 2-10, 53177, Bonn, Germany.
| | - Sabrina M Gippert
- Department of Psychiatry and Psychotherapy, Bonn University Medical Center, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Bastian E A Sajonz
- Stereotaxy and MR-based OR Techniques/Department of Neurosurgery, Bonn University Medical Center, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany.,Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, 79106, Freiburg im Breisgau, Germany
| | - Christoph Nelles
- Neurological Rehabilitation Center Godeshoehe, Waldstrasse 2-10, 53177, Bonn, Germany
| | - Bettina Bewernick
- Department of Psychiatry and Psychotherapy, Bonn University Medical Center, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Thomas E Schlaepfer
- Department of Psychiatry and Psychotherapy, Bonn University Medical Center, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Volker A Coenen
- Stereotaxy and MR-based OR Techniques/Department of Neurosurgery, Bonn University Medical Center, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany.,Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, 79106, Freiburg im Breisgau, Germany
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Abstract
About 30% of patients suffering from a major depressive disorder do not respond sufficiently to established pharmacological, psychotherapeutic, or somatic treatments. Advances in technology and emerging knowledge about the dysfunctional brain circuits underlying depression have led to the development of different neuromodulation techniques. The aim of the present review is to give an update on noninvasive techniques, such as electroconvulsive therapy (ECT), magnetic seizure therapy (MST), transcranial magnetic stimulation (TMS), and invasive techniques requiring brain surgery, such as vagus nerve stimulation (VNS) and deep brain stimulation (DBS). First, the clinical relevance for therapy-resistant depression, including the current level of evidence, are presented. Neuroethics is concerned with the ethical, legal and social policy implications of neuroscience. A second focus of the review is the application of fundamental ethical principles, such as patient autonomy, patient well-being and justice to neuromodulation therapies. Due to reduced availability and lacking long-term efficacy data, most patients with treatment-resistant depression face a trial-and-error approach to therapeutics. This contravenes the ethical criteria of patient autonomy and justice. In order to raise the level of evidence, financial support of long-term studies, including large samples and randomized control trials, are necessary.
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Affiliation(s)
- Bettina Bewernick
- Department of Psychiatry and Psychotherapy, University Hospital, Bonn, Germany
| | - Thomas E Schlaepfer
- Department of Psychiatry and Psychotherapy, University Hospital, Bonn, Germany
- Departments of Psychiatry and Mental Health, Johns Hopkins University, Baltimore, USA
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Schlaepfer TE, Bewernick B, Kayser S, Lenz D. Modulating affect, cognition, and behavior - prospects of deep brain stimulation for treatment-resistant psychiatric disorders. Front Integr Neurosci 2011; 5:29. [PMID: 21738500 PMCID: PMC3125515 DOI: 10.3389/fnint.2011.00029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 06/14/2011] [Indexed: 11/30/2022] Open
Abstract
Most patients suffering from psychiatric disorders respond to combinations of psycho- and psychopharmacotherapy; however there are patients who profit little if anything even after many years of treatment. Since about a decade different modalities of targeted neuromodulation – among them most prominently – deep brain stimulation (DBS) – are being actively researched as putative approaches to very treatment-resistant forms of those disorders. Recently, promising pilot data have been reported both for major depression (MD) and obsessive–compulsive disorder (OCD). Given the fact that patients included in DBS studies had been treated unsuccessfully for many years with conventional treatment methods, renders these findings remarkable. Remarkable is the fact, that in case of the long-term studies underway for MD, patients show a stable response. This gives hope to a substantial percentage of therapy–resistant psychiatric patients requiring new therapy approaches. There are no fundamental ethic objections to its use in psychiatric disorders, but until substantial clinical data is available, mandatory standards are needed. DBS is a unique and very promising method for the treatment of therapy–resistant psychiatric patients. The method allows manipulating pathological neuronal networks in a very precise way.
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Affiliation(s)
- Thomas E Schlaepfer
- Brain Stimulation Group, Department of Psychiatry and Psychotherapy, University of Bonn Bonn, Germany
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Schläpfer T, Bewernick B, Kayser S, Sturm V, Lenartz D, Schnitzler A. Psychiatrische Indikationen für die tiefe Hirnstimulation. Akt Neurol 2009. [DOI: 10.1055/s-0028-1090172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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