O'Reardon John P, Cristancho Pilar, Peshek Andrew D
Psychiatry (Edgmont). 2006 May;3(5):54-63.
Neuromodulation appears to be emerging gradually as a new therapeutic field in psychiatric treatment. It encompasses neuropsychiatric medical devices, such as vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and electroconvulsive therapy (ECT). As a therapeutic approach to affective disorders, neuromodulation shifts the focus from the monoamine synapse to neural circuitry of the brain, which is dysregulated in depression. This neural circuitry has been elaborated on over the course of 15 years of neuroimaging research in mood disorders and is now believed to encompass disturbances in a frontolimbic network. These include reduced metabolism and blood flow in the prefrontal cortex and anterior cingulate and pathologically increased activity in the subgenual cingulate and amygdala.VNS is an implanted device that has established efficacy in pharmaco-resistant epilepsy. It was approved by the FDA for the treatment of severe, recurrent unipolar and bipolar depression in July of 2005. VNS adopts a bottom-up approach to modulating the neural circuitry of depression by stimulating vagal afferent fibers in the neck, which carry impulses to the brain stem to target there the locus ceruleus and dorsal raphe nucleus. Now that VNS has moved beyond the experimental phase and into the clinic, psychiatrists are faced with deciding who is an appropriate patient for this surgical implant and how to integrate VNS into existing treatment in order to optimize both efficacy and safety.This review of VNS will assess the efficacy and safety data that led to the FDA approval. We will also review for the busy clinician how VNS is likely to translate into clinical practice as a treatment option for patients in need who are suffering from severe depression.
神经调节似乎正逐渐成为精神科治疗中的一个新的治疗领域。它涵盖了神经精神医疗设备，如迷走神经刺激（VNS）、经颅磁刺激（TMS）、深部脑刺激（DBS）和电休克治疗（ECT）。作为一种治疗情感障碍的方法，神经调节将焦点从单胺突触转移到大脑的神经回路，而在抑郁症中该神经回路存在失调。在情绪障碍的15年神经影像学研究过程中，这一神经回路已得到详细阐述，现在人们认为它包括前额叶边缘网络的紊乱。这些紊乱包括前额叶皮质和前扣带回的代谢和血流减少，以及膝下扣带回和杏仁核的病理性活动增加。VNS是一种植入式设备，已在药物难治性癫痫中确立了疗效。2005年7月，它被美国食品药品监督管理局（FDA）批准用于治疗严重的、复发性单相和双相抑郁症。VNS采用自下而上的方法，通过刺激颈部的迷走传入纤维来调节抑郁症的神经回路，这些纤维将冲动传递到脑干，以靶向蓝斑核和中缝背核。既然VNS已走出实验阶段并进入临床，精神科医生面临着决定谁是这种手术植入的合适患者，以及如何将VNS整合到现有治疗中以优化疗效和安全性的问题。这篇关于VNS的综述将评估导致FDA批准的疗效和安全性数据。我们还将为忙碌的临床医生回顾VNS作为一种治疗选择可能如何转化为有严重抑郁症需求的患者的临床实践。
