Major Depressive Disorder
Conditions
Keywords
Depression, Unipolar, Bipolar-II, DBS, Imaging
Brief summary
The purpose of this study is to test the safety, efficacy and mechanism of action of subgenual cingulate (Cg25) deep brain stimulation (DBS) for major depression in patients who have not responded to prior antidepressant treatments. Participation in the study will continue for ten years or until the device receives FDA approval for depression. Forty (40) patients will be enrolled in this study.
Detailed description
Major Depression is one of the most common and costly of all psychiatric disorders. While depression can be effectively treated in the majority of patients by either medication or some form of evidence-based psychotherapy, up to 20% of patients fail to respond to standard interventions. For these patients, trial-and-error combinations of multiple medications and electroconvulsive therapy are often required. For patients who remain severely depressed despite these aggressive approaches, new strategies are needed. Converging clinical, biochemical, neuroimaging, and post-mortem data suggest depression is unlikely to be a disease of a single brain region or neurotransmitter system. Rather, it is now generally viewed as a systems-level disorder affecting integrated pathways linking select cortical, subcortical and limbic sites and their related neurotransmitter and molecular mediators. Treatments for depression can be viewed within a limbic-cortical system framework, where different modes of treatment modulate specific regional targets, resulting in a variety of complementary, adaptive chemical and molecular changes that re-establish a normal mood state. Functional neuroimaging studies have played a critical role in characterizing these limbic-cortical pathways. Previous studies have demonstrated consistent involvement of the subgenual cingulate (Cg25) in both acute sadness and antidepressant treatment effects, suggesting a critical role for this region in modulating negative mood states. This study will test whether high frequency deep brain stimulation of the subgenual cingulate white matter (Cg25-DBS) is a safe and efficacious antidepressant treatment in forty patients with treatment resistant depression, and to investigate potential mechanisms of action of this intervention.
Interventions
DEVICEDeep Brain Stimulation
The deep brain stimulation system (consisting of a lead, extension wire, and implanted pulse generator) will be surgically implanted to stimulate the targeted area of the brain. Stimulation will be turned off for 4 weeks following implantation, then participants will use brain stimulation for 6 months. Participants will also take part in Behavioral Activation therapy during the 6 months of active stimulation. Participants will be followed for 10 years, or until the DBS device has been FDA approved, with adjustments made to the stimulator and medications as necessary.
Sponsors
Emory University
The Dana Foundation
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
* Ability to provide written informed consent. * Current Major Depressive Episode (MDE), secondary to either Major Depressive Disorder or Bipolar Disorder (I, II or NOS), diagnosed by structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-IV-text revision (DSM-IV-TR). * Current MDE at least two years duration OR a history of more than 4 lifetime depressive episodes. * Minimum score at study entry of 20 on the 17-item Hamilton Depression Rating Scale (HDRS-17). * Average pre-operative HDRS-17 score of 20 or greater (averaged over four weekly pre-surgical evaluations during the four weeks prior to surgery) and an average pre-operative HDRS-17 score no more than 30% lower than the baseline screening HDRS-17 score. * A maximum Global Assessment of Functioning of 50. * Treatment-resistant depression defined as: * Failure to respond to a minimum of four different antidepressant treatments, including at least three medications from at least three different classes, evidence-based psychotherapy or electroconvulsive therapy (ECT) administered at adequate doses and duration during the current episode. * Failure or intolerance of an adequate course of electroconvulsive therapy (ECT) during any episode (confirmed by medical records), or refusal of ECT due to a reason considered to be valid by the study psychiatrist. * A patient may remain on psychotropic medications during this study. However, doses must remain stable during the 4 weeks prior to surgery, the four weeks post-operatively, and the 24 weeks open stimulation phase. Medications will be changed only if intolerable side effects clearly attributable to the medications develop. * All patients must have an established outpatient psychiatrist and be willing to sign a written release to allow study investigators to give and receive information from this psychiatrist.
Exclusion criteria
* Inability to tolerate general anesthesia. * Significant cerebrovascular risk factors or a previous stroke, documented major head trauma or neurodegenerative disorder. * Other currently active clinically significant Axis I psychiatric diagnosis including schizophrenia, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder or post-traumatic stress disorder. Patients with severe Axis II personality disorders will also be excluded if the personality disorder is likely to interfere with cooperation and adherence to the study protocol. * Current psychotic symptoms. * Evidence of global cognitive impairment. * Substance abuse or dependence not in full sustained remission (i.e., not active for at least one year). * Active suicidal ideation with intent; suicide attempt within the last six months; more than three suicide attempts within the last two years. * Pregnancy or plan to become pregnant during the study period. * General contraindications for DBS surgery (cardiac pacemaker/defibrillator or other implanted devices). * Inability or unwillingness to comply with long-term follow-up. * History of intolerance to neural stimulation of any area of the body. * Participation in another drug, device or biologics trial within the preceding 30 days. * Conditions requiring repeated MRI scans. * Conditions requiring diathermy. * Conditions requiring anticoagulant medication. * Terminal illness associated with expected survival of \<12 months.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Hamilton Depression Rating Scale-17 Score | Baseline, Week 24 post-intervention | The Hamilton Depression Rating Scale (HDRS-17) contains 17 items that are scored from 0 to 2, 3, or 4, where 0 is lack of difficulty and the highest number for an item is the most extreme difficulty. Total scores range from 0 to 53 and higher scores indicate greater depression. For this study, a response to treatment will be defined as a decrease in the HDRS-17 score of 50% or greater from the average pre-surgical baseline. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORPatricio Riva Posse, MD
Emory University
Participant flow
Pre-assignment details
37 participants were consented but only 28 participants underwent Subcallosal Cingulate Deep Brain Stimulation (DBS) between January 2007 and June 2013.
Participants by arm
| Arm | Count |
|---|---|
| Deep Brain Stimulation Participants with treatment resistant depression will have a device implanted for deep brain stimulation.
Deep Brain Stimulation: The deep brain stimulation system (consisting of a lead, extension wire, and implanted pulse generator) will be surgically implanted to stimulate the targeted area of the brain. Stimulation will be turned off for 4 weeks following implantation, then participants will use brain stimulation for 6 months. Participants will also take part in Behavioral Activation therapy during the 6 months of active stimulation. Participants will be followed for 10 years, or until the DBS device has been FDA approved, with adjustments made to the stimulator and medications as necessary. | 28 |
| Total | 28 |
Baseline characteristics
| Characteristic | Deep Brain Stimulation |
|---|---|
| Age, Continuous | 44.9 years STANDARD_DEVIATION 9.8 |
| Hamilton Depression Rating Scale Score | 23.6 score on a scale STANDARD_DEVIATION 2.9 |
| Number of medications at time of implantation surgery | 3.4 number of medications STANDARD_DEVIATION 1.5 |
| Race/Ethnicity, Customized Caucasian | 27 Participants |
| Race/Ethnicity, Customized Not reported | 1 Participants |
| Region of Enrollment United States | 28 participants |
| Sex: Female, Male Female | 19 Participants |
| Sex: Female, Male Male | 9 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 28 |
| other Total, other adverse events | 14 / 28 |
| serious Total, serious adverse events | 6 / 28 |
Outcome results
Primary
Change in Hamilton Depression Rating Scale-17 Score
The Hamilton Depression Rating Scale (HDRS-17) contains 17 items that are scored from 0 to 2, 3, or 4, where 0 is lack of difficulty and the highest number for an item is the most extreme difficulty. Total scores range from 0 to 53 and higher scores indicate greater depression. For this study, a response to treatment will be defined as a decrease in the HDRS-17 score of 50% or greater from the average pre-surgical baseline.
Time frame: Baseline, Week 24 post-intervention
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Deep Brain Stimulation | Change in Hamilton Depression Rating Scale-17 Score | Baseline | 23.6 score on a scale | Standard Deviation 2.9 |
| Deep Brain Stimulation | Change in Hamilton Depression Rating Scale-17 Score | Week 24 post-intervention | 11.66 score on a scale | Standard Deviation 2.6 |