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Bittlinger M, Müller S. Opening the debate on deep brain stimulation for Alzheimer disease - a critical evaluation of rationale, shortcomings, and ethical justification. BMC Med Ethics 2018; 19:41. [PMID: 29886845 PMCID: PMC5994654 DOI: 10.1186/s12910-018-0275-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 05/01/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) as investigational intervention for symptomatic relief from Alzheimer disease (AD) has generated big expectations. Our aim is to discuss the ethical justification of this research agenda by examining the underlying research rationale as well as potential methodological pitfalls. The shortcomings we address are of high ethical importance because only scientifically valid research has the potential to be ethical. METHOD We performed a systematic search on MEDLINE and EMBASE. We included 166 publications about DBS for AD into the analysis of research rationale, risks and ethical aspects. Fifty-eight patients were reported in peer-reviewed journals with very mixed results. A grey literature search revealed hints for 75 yet to be published, potentially enrolled patients. RESULTS The results of our systematic review indicate methodological shortcomings in the literature that are both scientific and ethical in nature. According to our analysis, research with human subjects was performed before decisive preclinical research was published examining the specific research question at stake. We also raise the concern that conclusions on the potential safety and efficacy have been reported in the literature that seem premature given the design of the feasibility studies from which they were drawn. In addition, some publications report that DBS for AD was performed without written informed consent from some patients, but from surrogates only. Furthermore, registered ongoing trials plan to enroll severely demented patients. We provide reasons that this would violate Art. 28 of the Declaration of Helsinki, because DBS for AD involves more than minimal risks and burdens, and because its efficacy and safety are not yet empirically established to be likely. CONCLUSION Based on our empirical analysis, we argue that clinical research on interventions of risk class III (Food and Drug Administration and European Medicines Agency) should not be exploratory but grounded on sound, preclinically tested, and disease-specific a posteriori hypotheses. This also applies to DBS for dementia as long as therapeutic benefits are uncertain, and especially when research subjects with cognitive deficits are involved, who may foreseeably progress to full incapacity to provide informed consent during the required follow-up period.
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Affiliation(s)
- Merlin Bittlinger
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department for Psychiatry and Psychotherapy, CCM, Division of Mind and Brain Research, Charitéplatz 1, 10117 Berlin, Germany
| | - Sabine Müller
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department for Psychiatry and Psychotherapy, CCM, Division of Mind and Brain Research, Charitéplatz 1, 10117 Berlin, Germany
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Mulders AEP, Leentjens AFG, Schruers K, Duits A, Ackermans L, Temel Y. Choreatic Side Effects of Deep Brain Stimulation of the Anteromedial Subthalamic Nucleus for Treatment-Resistant Obsessive-Compulsive disorder. World Neurosurg. 2017;104:1048.e9-1048.e13. [PMID: 28532905 DOI: 10.1016/j.wneu.2017.05.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with treatment-resistant obsessive-compulsive disorder (OCD) are potential candidates for deep brain stimulation (DBS). The anteromedial subthalamic nucleus (STN) is among the most commonly used targets for DBS in OCD. CASE DESCRIPTION We present a patient with a 30-year history of treatment-resistant OCD who underwent anteromedial STN-DBS. Despite a clear mood-enhancing effect, stimulation caused motor side effects, including bilateral hyperkinesia, dyskinesias, and sudden large amplitude choreatic movements of arms and legs when stimulating at voltages greater than approximately 1.5 V. DBS at lower amplitudes and at other contact points failed to result in a significant reduction of obsessions and compulsions without inducing motor side effects. Because of this limitation in programming options, we decided to reoperate and target the ventral capsule/ventral striatum (VC/VS), which resulted in a substantial reduction in key obsessive and compulsive symptoms without serious side effects. CONCLUSIONS Choreatic movements and hemiballismus have previously been linked to STN dysfunction and have been incidentally reported as side effects of DBS of the dorsolateral STN in Parkinson disease (PD). However, in PD, these side effects were usually transient, and they rarely interfered with DBS programming. In our patient, the motor side effects were persistent, and they made optimal DBS programming impossible. To our knowledge, such severe and persistent motor side effects have not been described previously for anteromedial STN-DBS.
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Dougherty DD, Rezai AR, Carpenter LL, Howland RH, Bhati MT, O'Reardon JP, Eskandar EN, Baltuch GH, Machado AD, Kondziolka D, Cusin C, Evans KC, Price LH, Jacobs K, Pandya M, Denko T, Tyrka AR, Brelje T, Deckersbach T, Kubu C, Malone DA. A Randomized Sham-Controlled Trial of Deep Brain Stimulation of the Ventral Capsule/Ventral Striatum for Chronic Treatment-Resistant Depression. Biol Psychiatry 2015; 78:240-8. [PMID: 25726497 DOI: 10.1016/j.biopsych.2014.11.023] [Citation(s) in RCA: 293] [Impact Index Per Article: 32.6] [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] [Received: 03/18/2014] [Revised: 10/23/2014] [Accepted: 11/04/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND Multiple open-label trials of deep brain stimulation (DBS) for treatment-resistant depression (TRD), including those targeting the ventral capsule/ventral striatum target, have shown encouraging response rates. However, no randomized controlled trials of DBS for TRD have been published. METHODS Thirty patients with TRD participated in a sham-controlled trial of DBS at the ventral capsule/ventral striatum target for TRD. Patients were randomized to active versus sham DBS treatment in a blinded fashion for 16 weeks, followed by an open-label continuation phase. The primary outcome measure was response, defined as a 50% or greater improvement on the Montgomery-Åsberg Depression Rating Scale from baseline. RESULTS There was no significant difference in response rates between the active (3 of 15 subjects; 20%) and control (2 of 14 subjects; 14.3%) treatment arms and no significant difference between change in Montgomery-Åsberg Depression Rating Scale scores as a continuous measure upon completion of the 16-week controlled phase of the trial. The response rates at 12, 18, and 24 months during the open-label continuation phase were 20%, 26.7%, and 23.3%, respectively. CONCLUSION The results of this first randomized controlled study of DBS for the treatment of TRD did not demonstrate a significant difference in response rates between the active and control groups at the end of the 16-week controlled phase. However, a range of 20% to 26.7% of patients did achieve response at any time during the open-label continuation phase. Future studies, perhaps utilizing alternative study designs and stimulation parameters, are needed.
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Affiliation(s)
- Darin D Dougherty
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Ali R Rezai
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
| | - Linda L Carpenter
- Butler Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Robert H Howland
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh
| | - Mahendra T Bhati
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P O'Reardon
- Department of Psychiatry, University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Stratford, New Jersey
| | - Emad N Eskandar
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gordon H Baltuch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andre D Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York University, New York, New York
| | - Cristina Cusin
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Karleyton C Evans
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence H Price
- Butler Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Karen Jacobs
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
| | - Mayur Pandya
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
| | - Timothey Denko
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh
| | - Audrey R Tyrka
- Butler Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cynthia Kubu
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
| | - Donald A Malone
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
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Riva-Posse P, Holtzheimer PE, Garlow SJ, Mayberg HS. Practical considerations in the development and refinement of subcallosal cingulate white matter deep brain stimulation for treatment-resistant depression. World Neurosurg 2012; 80:S27.e25-34. [PMID: 23246630 DOI: 10.1016/j.wneu.2012.11.074] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [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: 05/23/2012] [Revised: 11/12/2012] [Accepted: 11/27/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Deep brain stimulation has been investigated in the past decade as a viable intervention for treatment-resistant depression. METHODS Several anatomic targets have been tested, with the most extensive published experience found for the subcallosal cingulate (SCC) white matter. RESULTS This article reviews the current state of clinical research of SCC deep brain stimulation for treatment-resistant depression, including an overview of the rationale for targeting SCC, practical considerations for subject recruitment and evaluation, surgical planning, and stimulation parameters. CONCLUSION Clinical management of patients in the initial and long-term naturalistic phases of treatment, including the potential role for psychotherapeutic rehabilitation, is discussed.
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Affiliation(s)
- Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
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