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Original Article
Feb 2012

Subcallosal Cingulate Deep Brain Stimulation for Treatment-Resistant Unipolar and Bipolar Depression

Author Affiliations

Author Affiliations: Departments of Psychiatry and Behavioral Sciences (Drs Holtzheimer, Garlow, Riva Posse, Gutman, and Mayberg; Mss Filkowski, Craighead, and Kozarsky; and Mr Chismar), Neurosurgery (Dr Gross), and Neurology (Drs Gross, Mewes, and Mayberg), School of Medicine, Department of Biostatistics and Bioinformatics, School of Public Health (Dr Kelley), and Center for Comprehensive Informatics (Dr Gutman), Emory University, Atlanta, Georgia; Department of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire (Dr Holtzheimer); Department of Psychology, University of Denver, Denver, Colorado (Ms Barrocas); Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, Nevada (Dr Wint); and Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Mr Moreines).

Arch Gen Psychiatry. 2012;69(2):150-158. doi:10.1001/archgenpsychiatry.2011.1456

Context Deep brain stimulation (DBS) may be an effective intervention for treatment-resistant depression (TRD), but available data are limited.

Objective To assess the efficacy and safety of subcallosal cingulate DBS in patients with TRD with either major depressive disorder (MDD) or bipolar II disorder (BP).

Design Open-label trial with a sham lead-in phase.

Setting Academic medical center.

Patients Men and women aged 18 to 70 years with a moderate-to-severe major depressive episode after at least 4 adequate antidepressant treatments. Ten patients with MDD and 7 with BP were enrolled from a total of 323 patients screened.

Intervention Deep brain stimulation electrodes were implanted bilaterally in the subcallosal cingulate white matter. Patients received single-blind sham stimulation for 4 weeks followed by active stimulation for 24 weeks. Patients then entered a single-blind discontinuation phase; this phase was stopped after the first 3 patients because of ethical concerns. Patients were evaluated for up to 2 years after the onset of active stimulation.

Main Outcome Measures Change in depression severity and functioning over time, and response and remission rates after 24 weeks were the primary efficacy end points; secondary efficacy end points were 1 year and 2 years of active stimulation.

Results A significant decrease in depression and increase in function were associated with chronic stimulation. Remission and response were seen in 3 patients (18%) and 7 (41%) after 24 weeks (n = 17), 5 (36%) and 5 (36%) after 1 year (n = 14), and 7 (58%) and 11 (92%) after 2 years (n = 12) of active stimulation. No patient achieving remission experienced a spontaneous relapse. Efficacy was similar for patients with MDD and those with BP. Chronic DBS was safe and well tolerated, and no hypomanic or manic episodes occurred. A modest sham stimulation effect was found, likely due to a decrease in depression after the surgical intervention but prior to entering the sham phase.

Conclusions The findings of this study support the long-term safety and antidepressant efficacy of subcallosal cingulate DBS for TRD and suggest equivalent safety and efficacy for TRD in patients with BP.

Trial Registration clinicaltrials.gov Identifier: NCT00367003