1.3.3 DBS, rTMS and Psychosurgery
The Indications, Benefits, Risks and Outcomes of DBS, rTMS and Psychosurgery
Deep brain stimulation:
Deep brain stimulation (DBS) is a neurosurgical procedure that involves implanting electrodes in specific regions of the brain to treat a range of neurological and psychiatric disorders. In this article, we will discuss the indications, benefits, risks, and outcomes of DBS.
Indications: DBS is primarily used to treat movement disorders such as Parkinson’s disease, essential tremor, and dystonia. It is also used to treat other neurological disorders such as epilepsy, chronic pain, and Tourette syndrome. In recent years, DBS has been studied as a potential treatment for psychiatric disorders such as obsessive-compulsive disorder (OCD), major depressive disorder (MDD), and treatment-resistant depression.
Benefits: The main benefit of DBS is a significant improvement in symptoms, particularly in movement disorders such as Parkinson’s disease. DBS has been shown to improve motor function, reduce tremors, and improve quality of life for patients with movement disorders. In psychiatric disorders such as OCD and MDD, DBS has shown promise in reducing symptoms and improving overall functioning in some patients.
Risks: As with any surgical procedure, DBS carries some risks. These include bleeding in the brain, infection, stroke, and neurological damage. There is also a risk of device malfunction, which may require additional surgery to correct. Some patients may experience side effects such as mood changes, speech problems, and muscle weakness.
Outcomes: The outcomes of DBS vary depending on the specific disorder being treated and the individual patient’s response to the procedure. In general, DBS has been shown to be an effective treatment for movement disorders such as Parkinson’s disease, with long-term improvement in symptoms. In psychiatric disorders such as OCD and MDD, the outcomes are less clear and require further study.
| Indication | Benefits | Risks |
| Parkinson’s disease | Improved motor function, reduced tremors, improved quality of life | Bleeding, infection, stroke, neurological damage, device malfunction |
| Essential tremor | Improved tremor control, improved quality of life | Bleeding, infection, stroke, neurological damage, device malfunction |
| Dystonia | Improved motor function, reduced muscle contractions, improved quality of life | Bleeding, infection, stroke, neurological damage, device malfunction |
| Epilepsy | Reduced seizure frequency, improved quality of life | Bleeding, infection, stroke, neurological damage, device malfunction |
| Chronic pain | Reduced pain, improved quality of life | Bleeding, infection, stroke, neurological damage, device malfunction |
| Tourette syndrome | Reduced tics, improved quality of life | Bleeding, infection, stroke, neurological damage, device malfunction |
| OCD | Reduced symptoms, improved functioning | Bleeding, infection, stroke, neurological damage, device malfunction |
| MDD | Reduced symptoms, improved functioning | Bleeding, infection, stroke, neurological damage, device malfunction |
Repetitive transcranial magnetic stimulation:
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neurostimulation technique that involves the use of magnetic fields to stimulate specific regions of the brain. In this article, we will discuss the indications, benefits, risks, and outcomes of rTMS.
Indications: rTMS is primarily used to treat psychiatric disorders such as major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and anxiety disorders. It has also been studied as a potential treatment for other neurological disorders such as Parkinson’s disease, schizophrenia, and chronic pain.
Benefits: The main benefit of rTMS is a significant improvement in symptoms, particularly in depression. rTMS has been shown to improve mood, reduce symptoms of anxiety, and improve overall functioning in patients with MDD. In OCD, rTMS has been shown to reduce symptoms and improve overall functioning in some patients. In chronic pain, rTMS has been shown to reduce pain and improve quality of life.
Risks: rTMS is generally considered safe, with few serious side effects reported. The most common side effect is mild to moderate headache, which typically resolves within a few hours of the session. Some patients may experience other mild side effects such as scalp discomfort, facial muscle twitching, and dizziness.
Outcomes: The outcomes of rTMS vary depending on the specific disorder being treated and the individual patient’s response to the procedure. In general, rTMS has been shown to be an effective treatment for depression, with long-term improvement in symptoms. In OCD and anxiety disorders, the outcomes are less clear and require further study.
| Indication | Benefits | Risks |
| Major depressive disorder | Improved mood, improved functioning | Headache, scalp discomfort, facial muscle twitching, dizziness |
| Obsessive-compulsive disorder | Reduced symptoms, improved functioning | Headache, scalp discomfort, facial muscle twitching, dizziness |
| Anxiety disorders | Reduced symptoms, improved functioning | Headache, scalp discomfort, facial muscle twitching, dizziness |
| Parkinson’s disease | Reduced motor symptoms, improved quality of life | Headache, scalp discomfort, facial muscle twitching, dizziness |
| Schizophrenia | Reduced symptoms, improved functioning | Headache, scalp discomfort, facial muscle twitching, dizziness |
| Chronic pain | Reduced pain, improved quality of life | Headache, scalp discomfort, facial muscle twitching, dizziness |
Psychosurgery:
Psychosurgery, a surgical intervention targeting the brain to treat mental disorders, has a storied history in psychiatry. Though controversial and less commonly used today, it remains an option for certain treatment-resistant conditions. Modern psychosurgery is more refined and targeted compared to its historical counterparts. We will discuss the indications, benefits, risks, and outcomes of psychosurgery, as well as provide a table of information on the different procedures.
Indications: Psychosurgery isn’t a first-line treatment. It’s typically considered when other treatments, whether they be psychotherapy, medications, or electroconvulsive therapy (ECT), haven’t yielded the desired results. The main patient populations that might be considered for this approach suffer from severe, treatment-resistant depression, especially when conventional treatments fall short. Similarly, individuals with Obsessive-Compulsive Disorder (OCD) that significantly impairs daily living, or those with debilitating Tourette’s Syndrome, might be candidates. Additionally, certain cases of chronic pain and anxiety might also be explored through this lens. However, the decision to proceed with psychosurgery is complex and requires careful evaluation by a multidisciplinary team, including a neurosurgeon, psychiatrist, and psychologist.
Benefits: Psychosurgery has been shown to provide significant benefits for patients with severe, treatment-resistant mental illnesses. For some patients, it can offer long-term relief from symptoms that once seemed intractable. The interventions today are targeted, honing in on specific areas of the brain correlated with the disorder at hand, which can sometimes lead to a reduction or complete cessation of medications.
Risks: However, as with any surgical procedure, there are inherent risks. These range from the general surgical risks, such as infections, to more specific ones like potential cognitive effects. Some patients report changes in memory, attention, or other cognitive domains. Emotional changes, like personality shifts or an emotional numbness, can also occur. More severe risks include potential neurological effects, such as movement issues or even seizures. And, of course, there are the unpredictable changes in behavior or mood that might arise.
Outcomes: The outcomes of psychosurgery are as varied as the individuals receiving it. Some experience a dramatic reduction in symptoms, while others might only see marginal benefits. Often, benefits might take time to become apparent, manifesting gradually over several months. Moreover, undergoing psychosurgery doesn’t negate the need for ongoing psychiatric care. Continued therapy and, in some cases, medications might still be part of a patient’s post-surgical treatment plan.
| Type of Psychosurgery | Indications | Benefits | Risks |
|---|---|---|---|
| Lobotomy/Leucotomy | Severe mental disorders (historically used) | Temporary reduction of severe symptoms | Cognitive deficits, personality changes, incontinence |
| Cingulotomy | OCD, major depression | 50-70% patients show improvement | Seizures, headaches, cognitive changes |
| Capsulotomy | OCD, anxiety disorders | Significant improvement in OCD symptoms | Weight gain, apathy, cognitive issues |
| Subcaudate Tractotomy | Depression, OCD | Effective in reducing depressive and obsessive symptoms | Seizures, hemorrhage |
| Deep Brain Stimulation (DBS) | Treatment-resistant depression, OCD, Tourette’s | Adjustable, reversible, can target various brain regions | Infection, bleeding, hardware-related complications |
| Gamma Knife Radiosurgery | OCD | Non-invasive, improvement in OCD symptoms | Radiation risks, potential long-term unknown effects |
| Transcranial Magnetic Stimulation | Depression | Non-invasive, can be used outpatient, some immediate relief | Headaches, seizures |
References:
- Nuttin, B., Wu, H., Mayberg, H., Hariz, M., Gabriëls, L., Galert, T., … & Régis, J. (2014). Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders. Journal of neurology, neurosurgery, and psychiatry, 85(9), 1003-1008.
- Lefaucheur, J. P., André-Obadia, N., Antal, A., Ayache, S. S., Baeken, C., Benninger, D. H., … & De Ridder, D. (2014). Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clinical Neurophysiology, 125(11), 2150
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