Rymaszewska Joanna, Wieczorek Tomasz, Fila-Witecka Karolina, Smarzewska Katarzyna, Weiser Artur, Piotrowski Patryk, Tabakow Paweł
Department of Psychiatry, Wroclaw Medical University, Wrocław, Poland.
Department of Neurosurgery, Wroclaw Medical University, Wrocław, Poland.
Front Psychiatry. 2023 Jan 16;13:1068054. doi: 10.3389/fpsyt.2022.1068054. eCollection 2022.
Treatment-resistant depression remains one of the main concerns of modern psychiatry. Novel methods such as Transcranial Magnetic Stimulation (including deep and theta burst protocols, iTBS) and Deep Brain Stimulation (DBS) can be considered as alternative treatment options.
Twenty-nine-year-old Caucasian female, single, higher-educated was treated with major depressive disorder initially with standard pharmaco- and psychotherapy. Due to diagnosed treatment resistance additional therapeutic approaches were introduced sequentially: Electroconvulsive therapy (efficient only 4 months) and Transcranial Magnetic Stimulation (intermittent Theta Burst Stimulation, iTBS improved just insomnia). Finally the patient was enrolled to the Deep Brain Stimulation (DBS) study with the medial forebrain bundle target. After 20 months of active DBS a reduction of over 80% of depressive symptom severity was observed (Montgomery-Asberg and Hamilton Depression Rating Scales), together with an 87% reduction of anxiety symptoms intensity (Hamilton Anxiety Rating Scale) and a 90% increase in social and occupational functioning. Subjective assessment of the patient performed with questionnaires and visual analog scales showed less pronounced improvement in terms of depressive and anxiety symptoms, and high reduction of anhedonia. Some mild, transient side effects of neurostimulation were eliminated with an adjustment in stimulation parameters.
The presented clinical case confirms the possibility of achieving remission after the use of MFB DBS in treatment-resistant depression, but postponed for many months. Nevertheless, personalization of every combined therapy with DBS is necessary with exploration of individual factors as past traumas and personality traits. More reports on long-term observations in DBS treatment in TRD trials (especially focused on MFB target) are needed.
难治性抑郁症仍然是现代精神病学的主要关注点之一。诸如经颅磁刺激（包括深部和theta爆发方案、间歇性theta爆发刺激[iTBS]）和深部脑刺激（DBS）等新方法可被视为替代治疗选择。
一名29岁的单身高加索女性，受过高等教育，最初患有重度抑郁症，接受了标准的药物和心理治疗。由于诊断为难治性，随后依次引入了其他治疗方法：电休克治疗（仅4个月有效）和经颅磁刺激（间歇性theta爆发刺激，iTBS仅改善了失眠）。最后，该患者被纳入以内侧前脑束为靶点的深部脑刺激（DBS）研究。在积极进行DBS治疗20个月后，观察到抑郁症状严重程度降低了80%以上（蒙哥马利-阿斯伯格和汉密尔顿抑郁量表），焦虑症状强度降低了87%（汉密尔顿焦虑量表），社会和职业功能提高了90%。通过问卷调查和视觉模拟量表对患者进行的主观评估显示，抑郁和焦虑症状的改善不太明显，快感缺失有显著减轻。通过调整刺激参数消除了一些轻微、短暂的神经刺激副作用。
该临床病例证实了使用内侧前脑束DBS治疗难治性抑郁症后实现缓解的可能性，但推迟了数月。然而，对每一种联合DBS治疗进行个性化是必要的，需要探索个体因素，如过去的创伤和人格特质。需要更多关于DBS治疗难治性抑郁症试验的长期观察报告（特别是以内侧前脑束为靶点）。
