Attempted and completed suicides after subthalamic nucleus stimulation for Parkinson's disease

Abstract

A higher than expected frequency of suicide has been reported among patients undergoing subthalamic nucleus deep brain stimulation (STN DBS) for advanced Parkinson's disease (PD). We conducted a retrospective survey of 200 patients with PD who underwent STN DBS. Two patients (1%) committed suicide and four (2%) attempted suicide, despite clear motor improvements. Suicidal patients did not differ from non-suicidal patients with respect to age, disease duration or preoperative depressive and cognitive status. Suicidal behaviour was associated with postoperative depression and/or altered impulse regulation. Suicidal behaviour is a potential hazard of STN DBS, calling for careful preoperative assessment and close postoperative psychiatric and behavioural follow-up.Despite a high frequency of depression, the incidence of suicide among patients with Parkinson's disease (PD) is similar to 1 or 10 times lower than that recorded in the general population.2 Recently, concerns have been raised about a higher than expected frequency of suicide among patients undergoing subthalamic nucleus deep brain stimulation (STN DBS) for advanced PD. We therefore examined the prevalence and characteristics of completed and attempted suicides in a large cohort of patients who underwent STN DBS in our centre. METHODSWe reviewed the files of all 200 patients with PD (127 men and 73 women; mean age 61.8 (8.6) years; disease duration 14.8 (4.8) years) who underwent bilateral STN DBS in our centre between 1997 and 2006. During the study period, 24 patients died. There were two suicides, two deaths in undetermined circumstances and one death by defenestration 3 days after surgery. This latter patient was in a postoperative confusional state and the stimulator had not yet been switched on; we considered that death was more likely accidental than intentional and did not include this case among the suicides. Six patients were monitored in other centres, for geographic reasons, and 12 patients were lost to follow-up (possibly following unreported death). At the end of the study period, all of the remaining 158 patients were followed-up in our centre by the same neurologist (J-MG). STN DBS was performed under local or general anaesthesia. STN coordinates were calculated from preoperative MRI and intraoperative ventriculographic data and were confirmed by intraoperative recording of neuronal activity with semi-microelectrodes and turn amplitude analysis. Scores on the Mattis Dementia Rating Scale (MDRS, maximum score 144) and the Montgomery-Asberg Depression Scale (MADRS, maximum score 60) were compared with a t test between suicidal patients and the last 75 consecutive non-suicidal patients who had undergone the same preoperative assessment of depression. All patients who attempted suicide were interviewed by a psychologist (TS). RESULTSTwo patients (1%) committed suicide and four patients (2%) attempted suicide, a mean 12.0 (7.2) months after surgery, despite fair to excellent motor improvement. Attempted and completed suicides occurred b...

Neuroimaging and Deep Brain Stimulation

“…88 A higher-than-expected frequency of suicide has also been reported among patients undergoing STN DBS for advanced PD. 89 In a prospective study of 20 patients during the 2 years after surgery, however, Houeto et al 90 showed that provided patients with PD are rigorously selected for neurosurgery, STN stimulation improves mood, anxiety, and quality of life. The procedure does not result in severe permanent psychiatric disorders or modify patients' personalities, and it does not improve social function.…”

Algorithms for the treatment of motor problems in Parkinson's disease

“…Especially, a higher frequency of suicide ideation and suicides has been reported after DBS, but is still not entirely clear 55, 56. Pooled data show increased scores for depression and hypomania, but at varying degrees 54, 57.…”

Cognitive and Behavioural Changes After Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson's Disease

“…After deep brain stimulation of the subthalamic nucleus, suicidal tendencies have been reported in some Parkinsonian patients (Soulas et al, 2008;Voon et al, 2008).…”

“…These latter studies (Soulas et al, 2008;Voon et al, 2008) show that there might be an increased risk of suicidal behaviour in Parkinsonian patients treated with subthalamic implants, suggesting that the main risk factor for attempted and completed suicide is postsurgical depression, which on postoperative follow-up should be adequately diagnosed and treated with anti-depressant drugs.…”

“…In another retrospective survey carried out in a smaller sample (n = 200) of Parkinsonian patients who underwent subthalamic implants (Soulas et al, 2008), despite a remarkable motor improvement, there was a higher than expected frequency of suicide (1% of completed suicide, 2% of attempted suicide) and suicidal behaviour was associated with postoperative depression and altered impulse control. These latter studies (Soulas et al, 2008;Voon et al, 2008) show that there might be an increased risk of suicidal behaviour in Parkinsonian patients treated with subthalamic implants, suggesting that the main risk factor for attempted and completed suicide is postsurgical depression, which on postoperative follow-up should be adequately diagnosed and treated with anti-depressant drugs.…”