Movement and Neuropsychiatric Disorders: Preventing DBS Failures

Deep brain stimulation (DBS) surgery has emerged as an effective treatment for addressing basal ganglia disorders such as Parkinson disease, essential tremor, and dystonia. Recently, several groups have applied DBS for the treatment of obsessive compulsive disorder, depression, and Tourette syndrome.  Results have, in general been promising, however the introduction of brain implants has added an extra level of complexity for the patients, the families, and the health care system.  Many lessons have emerged from the DBS experience, and the most important has been the critical need to develop teams of health care providers to facilitate short and long-term care of the DBS patient. Many patients with chronic medical diseases will pursue novel therapies such as DBS with the expectation that improvement will be immediate and complete. The expected improvement for many patients has been analogous to flipping on a light switch. Patients may also erroneous believe that they can throw medication bottles away and live “chemically free.”  Thus, there is a serious risk that the false utopia impression of DBS therapy could impact the overall effectiveness of this promising treatment. 

To harness the power of therapies such as DBS, we must work hard on public, patient, and health care provider education.  With over 70,000 patient implants already completed, other physicians besides trained neurologists will need to understand how to approach DBS patients.  Emergency personnel and even primary care physicians and nurses will need to be versed in evaluating and participating in the continuing care of these patients.  Therefore, as DBS moves beyond movement disorders and into neuropsychiatric indications, we should apply the early lessons from DBS failures, work to prevent future failures, and better address existing failures.  We should not fear DBS failures as they may, and will occur even in experienced centers (failures in triage, screening, surgical procedure, programming, and post-operative medication/disease management), however we should understand that to maximize the promise of the therapy we should have a failure prevention strategy in place. We should be aware that as the therapy evolves brain targets and approaches may change, and there will be an increasing need for more carefully performed clinical trials. Finally, we should clearly address the realistic benefits of DBS surgery with each patient and family member, and we should review the lifetime commitment to programming and chronic management prior to device implantation.