DBS for Depression: Current Status, Future Goals

The first studies of DBS for treatment resistant depression were initiated in 2003 with follow-up data on patients now exceeding 7 years. Published findings to date have restricted enrollment to patients with intractable major depressive disorder unresponsive to medication, psychotherapy and electroconvulsive therapy and have tested two primary targets: the subcallosal cingulate white matter and ventral capsule/ventral striatum. Both surgical approaches demonstrate evidence of sustained clinical effects with primary endpoints generally examining a minimum of 6 months of continuous DBS.  While these two targets have already proceeded to separate industry sponsored, placebo-controlled clinical trials, continued research is still needed to (1) identify biomarkers that might improve patient selection, (2) refine surgical targeting, (3) optimize programming of the device, (4) determine long-term efficacy and potential rare side effects and (4) rationally integrate post-operative medication and psychotherapy management to best synergize with the chronic electrical stimulation. Given the chronic, pervasive and highly disruptive nature of severe depression, it is essential to develop directed rehabilitative strategies, including shaping realistic expectations of the patient, family, physicians and other treating clinicians. Optimizing treatments and support from all these sources will be necessary to maximize recovery, including successful re-integration into society.