Abstract

Background: How “success” is defined in clinical trials of deep brain stimulation (DBS) for refractory psychiatric conditions has come into question. Standard quantitative psychopathology measures are unable to capture all changes experienced by patients and may not reflect subjective beliefs about the benefit derived. The decision to undergo DBS for treatment-resistant depression (TRD) is often made in the context of high desperation and hopelessness that can challenge the informed consent process. Partners and family can observe important changes in DBS patients and play a key role in the recovery process. Their perspectives, however, have not been investigated in research to-date. The aim of this study was to qualitatively examine patient and caregivers’ understanding of DBS for TRD, their expectations of life with DBS, and how these compare with actual experiences and outcomes.Methods: A prospective qualitative design was adopted. Semi-structured interviews were conducted with participants (six patients, five caregivers) before DBS-implantation and 9-months after stimulation initiation. All patients were enrolled in a clinical trial of DBS of the bed nucleus of the stria terminalis. Interviews were thematically analyzed with data saturation achieved at both timepoints.Results: Two primary themes identified were: (1) anticipated vs. actual outcomes, and (2) trial decision-making and knowledge. The decision to undergo DBS was driven by the intolerability of life with severe depression coupled with the exhaustion of all available treatment options. Participants had greater awareness of surgical risks compared with stimulation-related risks. With DBS, patients described cognitive, emotional, behavioral and physical experiences associated with the stimulation, some of which were unexpected. Participants felt life with DBS was like “a roller coaster ride”—with positive, yet unsustained, mood states experienced. Many were surprised by the lengthy process of establishing optimum stimulation settings and felt the intervention was still a “work in progress.”Conclusion: These findings support existing recommendations for iterative informed consent procedures in clinical trials involving long-term implantation of neurotechnology. These rich and descriptive findings hold value for researchers, clinicians, and individuals and families considering DBS. Narrative accounts capture patient and family needs and should routinely be collected to guide patient-centered approaches to DBS interventions.

Highlights

  • There is a pressing need for novel and effective treatments for people living with treatment-resistant depression (TRD)

  • The current study extends upon the existing research by exploring how these important pre-intervention ethical issues are related to participants’ post-intervention outcomes and experiences

  • This article reports on the experiences of a subset of participants enrolled in a clinical trial of Deep brain stimulation (DBS) for TRD (Australian New Zealand Clinical Trials Registry: ACTRN12613000412730)1

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Summary

Introduction

There is a pressing need for novel and effective treatments for people living with treatment-resistant depression (TRD). Deep brain stimulation (DBS) is a potential treatment for depression currently being investigated. While valuable for assessing subjective changes in depression symptoms as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), these measures do not provide a comprehensive picture of the intervention’s overall impact and often do not fully capture participants’ beliefs about the benefit they have gained (de Haan et al, 2015; Mayberg, 2018). How “success” is defined in clinical trials of deep brain stimulation (DBS) for refractory psychiatric conditions has come into question. Partners and family can observe important changes in DBS patients and play a key role in the recovery process. Their perspectives, have not been investigated in research to-date. The aim of this study was to qualitatively examine patient and caregivers’ understanding of DBS for TRD, their expectations of life with DBS, and how these compare with actual experiences and outcomes

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