Estimulación cerebral profunda en el núcleo accumbens en pacientes con depresión resistente al tratamiento: reporte de casos / Nucleus accumbens deep brain stimulation in patients with treatment-resistant depression: report of four cases

INTRODUCCIÓN: La estimulación cerebral profunda (DBS) se ha propuesto como una alternativa terapéutica para el manejo de la depresión resistente al tratamiento (DRT). Sin embargo, existen múltiples blancos para neuroestimulación y se desconoce el punto neuroanatómico óptimo en esta patología. Como parte del circuito de recompensa, el núcleo accumbens (NAc) ha sido estudiado en modelos de depresión y anhedonia. El objetivo de este artículo fue describir la experiencia clínica de la implantación de electrodos bilaterales de DBS en el NAc. REPORTE DE CASOS: Se describe la experiencia en cuatro mujeres entre los 17 a 41 años con DRT. Los casos presentaban antecedente de múltiples hospitalizaciones e intentos de suicidio serios, a pesar de haber sido tratadas previamente con terapia farmacológica, psicoterapia y TECAR (Terapia electroconvulsiva con anestesia y relajación). A los 6 meses del inicio del DBS, se observó una mejoría de los síntomas depresivos en la escala de Hamilton y un incremento en la escala de funcionalidad global. La anhedonia y la abulia persistieron luego de la cirugía, aunque con menor intensidad. CONCLUSIÓN: La DBS del NAc puede ser una estrategia efectiva en el tratamiento de pacientes con DRT, impactando en la funcionalidad y en la disminución del riesgo suicida.

INTRODUCTION: Deep brain stimulation (DBS) has been proposed as a therapeutic alternative for Treatment-resistant depression (TRD) patients. However, there are multiple targets for neurostimulation and the optimal neuroanatomical landmark for this pathology is unknown. Nucleus accumbens (NAc) is a crucial part of the reward circuit and has been studied extensively in models of depression and anhedonia. The objective of this study was to describe our clinical experience with DBS of the NAc patients with TRD. CASE SERIES: It described the experience in four females between 17 and 41 years of age. All cases presented with a history of multiple hospitalizations and serious suicide attempts, despite having been treated with optimal pharmacological regimes, psychotherapy and ECT (Electroconvulsive therapy). Six months after the initiation of DBS, an improvement in the Hamilton Depression Scale and in the Global Assessment of Functioning Scale was observed. Anhedonia and abulia persisted after the surgery, although less severe. CONCLUSION: DBS of NAc seems to offer favorable surgical outcomes in patients with TRD, impacting functionality and suicidal risk.

The effectiveness of mindfulness-based cognitive therapy for reducing rumination and improving mindfulness and self-compassion in patients with treatment-resistant depression

Abstract Introduction Depression is one of the most important psychiatric disorders, and the rate of recurrence is high. The heavy cost burden of depression is probably due to treatment-resistant depression. The purpose of this study was to determine the effectiveness of mindfulness-based cognitive therapy (MBCT) in patients with treatment-resistant depression (TRD). Method The present study was a quasi-experimental study conducted with twenty-four patients with treatment-resistant depression. Participants were selected by purposive sampling and randomly assigned to two groups, an experimental group and a control group. The experimental group received MBCT and antidepressants, while the control group received antidepressants only. The Hamilton and Beck Depression Inventory, Self-Compassion Scale, Thought Rumination Scale, and Mindfulness Scale were administered. The treatment program was conducted in eight sessions; with a follow-up period of one month subsequent to treatment termination. Data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (analysis of variance for repeated measures and Bonferroni's post-hoc test). Results The results showed that MBCT significantly reduced depression and ruminative thinking in the experimental group and also improved mediators such as mindfulness and self-compassion. Patients maintained gains over the one month follow-up period (p < 0.01). Conclusion The present study provides additional evidence for the effectiveness of MBCT for TRD.

Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review / Terapia cognitivo-comportamental para depressão resistente ao tratamento em adultos e adolescentes: uma revisão sistemática

Abstract Objective To conduct a systematic review of literature on use and efficacy of cognitive-behavioral therapy (CBT) for treatment of treatment-resistant depression in adults and adolescents. Methods We performed a systematic review according to the Prisma Guidelines of literature indexed on the PubMed, SciELO, Psychiatry Online, Scopus, PsycArticles, Science Direct and the Journal of Medical Case Reports databases. Randomized controlled trials, open studies and case reports were included in the review. Results The searches returned a total of 1,580 articles, published from 1985 to 2017. After applying the inclusion criteria, 17 articles were selected, their complete texts were read and 8 were included in this review. Four of these studies were randomized controlled trials with adults, one of which covered a post-study follow-up period; two were randomized controlled trials with adolescents, one of which presented follow-up data; one was an open study; and one was a case report. The studies provide good quality and robust evidence on the topic addressed. Conclusions A combination of CBT with pharmacotherapy for treatment-resistant patients shows a decrease in depressive symptoms. CBT can be an effective type of therapy for adults and adolescents with treatment-resistant depression.

Resumo Objetivos Realizar uma revisão sistemática sobre o uso da terapia cognitivo-comportamental (TCC) e sua eficácia no tratamento da depressão resistente ao tratamento em adultos e adolescentes. Métodos Realizamos uma revisão sistemática utilizando os critérios do Prisma Guidelines, nos seguintes bancos de dados: PubMed, SciELO, Psychiatry Online, Scopus, PsycArticles, Science Direct e Journal of Medical Case Reports. Estudos controlados randomizados, estudos abertos e relatos de casos foram incluídos neste estudo. Resultados A pesquisa retornou um total de 1.580 artigos, publicados de 1985 até 2017. Após aplicarmos os critérios de inclusão, 17 artigos foram selecionados, seus textos completos foram lidos e 8 foram incluídos nesta revisão. Do total, quatro eram estudos controlados randomizados com adultos, tendo um incluído um período de seguimento pós-estudo; dois eram estudos controlados randomizados com adolescentes, tendo um apresentado dados de seguimento; um era um estudo aberto; e o último era um relato de caso. Os estudos apresentaram boa qualidade e evidências robustas sobre o tópico abordado. Conclusões A combinação de TCC com tratamento medicamentoso para pacientes resistentes ao tratamento mostra uma diminuição dos sintomas depressivos. A TCC pode ser um tipo eficaz de terapia para adultos e adolescentes com depressão resistente ao tratamento.

Deep Brain Stimulation for the Treatment of Resistant Depression: Systematic Review of the Literature

Depression is the leading cause of disability worldwide, and it is related to high suicide rates. Furthermore, a great number of patients do not respond to any of the available treatments. Deep brain stimulation (DBS), a versatile technology with expanding indications, is considered a potential treatment for resistant depression. However, in over 10 years of clinical research, its efficacy has not been completely proven. Although new trials using DBS for treatment-resistant depression keep emerging, two of the three Level I evidence-based studies recently conducted have not provided conclusive data. Methodological limitations andmajor biases have compromised the obtention of clearer results. In this systematic review of the literature, we intend to critically assess the clinical trials performed in this field.