A decade of emerging indications: deep brain stimulation in the United States

Abstract

OBJECTIVE Deep brain stimulation (DBS) is an emerging treatment option for an expanding set of neurological and psychiatric diseases. Despite growing enthusiasm, the patterns and implications of this rapid adoption are largely unknown. National trends in DBS surgery performed for all indications between 2002 and 2011 are reported. METHODS Using a national database of hospital discharges, admissions for DBS for 14 indications were identified and categorized as either FDA approved, humanitarian device exempt (HDE), or emerging. Trends over time were examined, differences were analyzed by univariate analyses, and outcomes were analyzed by hierarchical regression analyses. RESULTS Between 2002 and 2011, there were an estimated 30,490 discharges following DBS for approved indications, 1647 for HDE indications, and 2014 for emerging indications. The volume for HDE and emerging indications grew at 36.1% annually in comparison with 7.0% for approved indications. DBS for emerging indications occurred at hospitals with more neurosurgeons and neurologists locally, but not necessarily at those with the highest DBS caseloads. Patients treated for HDE and emerging indications were younger with lower comorbidity scores. HDE and emerging indications were associated with greater rates of reported complications, longer lengths of stay, and greater total costs. CONCLUSIONS DBS for HDE and emerging indications underwent rapid growth in the last decade, and it is not exclusively the most experienced DBS practitioners leading the charge to treat the newest indications. Surgeons may be selecting younger and healthier patients for their early experiences. Differences in reported complication rates warrant further attention and additional costs should be anticipated as surgeons gain experience with new patient populations and targets.

The application of deep brain stimulation in the treatment of psychiatric disorders

“…In addition to the ventral striatum, regions that are believed to drive striatal dopamine release are also suggested as potential DBS targets, i.e. the hippocampus, substantia nigra, and VTA (Youngerman et al, 2016).…”

“…With increasing knowledge of heterogeneous dysfunctions in brain networks attributed to schizophrenia, DBS targetted at these networks is reappearing as a treatment option. Current theories state that dopaminergic and glutamatergic impairments in the striatum attribute to symptoms of schizophrenia (Youngerman, Chan, Mikell, McKhann, & Sheth, 2016). High-frequency DBS in the NAc is thought to stabilize dopamine transmission in the midbrain, which may control symptoms of schizophrenia.…”

What Do Medical Students Know about Deep Brain Stimulation

“…Also, knowledge gained from new studies on an existing therapy may only change practice after a period of several years [22]. The “EARLYSTIM” study, for example, which compared earlier subthalamic nucleus DBS with best medical treatment in PD patients with beginning fluctuations and showed clearly the superiority of early DBS [23], has not changed practice universally thus far [5,24]. Despite the fact that an increasing number of PD patients have been operated on over the years, often age and disease duration have been stable at the time of surgery in many European countries [8].…”

“…Within the past few years it has been explored increasingly as well in neuropsychiatric disorders and various other conditions [5,6,7]. Although the number of patients undergoing DBS each year is growing steadily worldwide, this therapeutic option is thought to be still underutilized for a variety of different reasons [5,8,9]. Besides economic problems and health care issues, patients' expectations and concerns should be considered but also the knowledge base among medical students and general practitioners.…”

WINCS Harmoni: Closed-loop dynamic neurochemical control of therapeutic interventions

“…For example, electrical stimulation of deep brain structures, known as deep brain stimulation (DBS), has received approval from the United States Food and Drug Administration (FDA) for the treatment of advanced Parkinson’s disease (PD) and tremor111213. Similarly, clinical DBS trials are underway in the United States (with CE Mark approval for clinical use in Europe) for the treatment of depression and epilepsy, with humanitarian device exemptions received for treatment of dystonia and obsessive-compulsive disorder14. Additionally, vagal nerve stimulation (VNS) has received FDA approval for treatment of pharmacoresistant epilepsy and major depressive disorder15.…”