Artikel
Lateral habenular complex deep brain stimulation for refractory major depression – Presentation of two cases with off-stimulation relapses
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Veröffentlicht: | 21. Mai 2013 |
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Objective: Major depression (MD) is a common psychiatric disease with profound socio-economic and personal impact on quality of life. For severe cases of refractory MD concepts of deep brain stimulation (DBS) are evaluated for different targets. The Lateral Habenular complex (LHb-c) is an intricate target area that gears monoamine-producing brain stem nuclei closely involved in depressive pathology. LHb-c in depressive patients show volume reduction and hypermetabolism. Therefore our institutions chose the LHb-c as the target for bilateral DBS.
Method: Two female patients (n=2) underwent bilateral LHb-c DBS, initial inpatient and later outpatient psychiatric follow-up with documentation of Hamilton Depression Scale (HAMD21) and stimulation parameters. Patient 1 was treated for MD since the age of 18 had several suicide attempts (SA) and was on maintenance electroconvulsive therapy (mECT) for more than 2 years and underwent LHb-DBS at the age of 64. Patient 2 suffered from MD for more than 20 years refractory to medical treatment with several SAs and was receiving mECT for more than a year before undergoing LHb-DBS at the age of 68.
Results: Patient 1 had a peak HAMD21-score of 45 before undergoing DBS after 13 weeks of stimulation with 10.5 V, the patient reached full and stable remission with HAMD21-score of 3. After incidental off-stimulation after a bicycle accident at week 53 and pacer exhaustion at week 70 the patient had clinical relevant relapses with HAMD21-scores of 39 and 22. Full remission was achieved with full stimulation again after 12 and 15 weeks respectively. Patient 2 underwent LHb-DBS after a peak HAMD21-score of 30 and dropped to 11 after 9 weeks of stimulation with a maximum of 6V when device infection was noted and explantation was necessary. Off-Stimulation the patient demonstrated an immediate increase with a peak HAMD21 to 34 and attempted suicide. At week 17, the patient underwent successful re-implantation of the DBS-system and dropped afterwards to a HAMD21 of 15 under stimulation with 9V and is currently still improving. Patient one has undergone more than 80, patient 2 more than 30 weeks of follow-up so far.
Conclusions: In 2 cases of LHb-DBS for MD, full or partial remission was achieved after several weeks of stimulation. In both cases, off-stimulation led to severe and immediate clinical relapses. LHb-c is a promising target for DBS of severe refractory MD, needing more clinical experience and a clinical study at best.