Deep-Brain Stimulation for Parkinson's Disease
http://www.100md.com
《新英格兰医药杂志》
To the Editor: We are impressed by the favorable outcome of deep-brain stimulation, as compared with optimal medical management alone, for levodopa-related motor complications of advanced Parkinson's disease in the study reported by Deuschl et al. (Aug. 31 issue).1 However, we disagree with the conclusion that cognition, mood, and overall psychiatric functioning were unchanged by neurostimulation. One patient in the treatment group but none in the control group committed suicide; seven patients in the treatment group but none in the control group had depressive symptoms or cognitive disturbances. The exact nature or putative causes of these adverse events are not mentioned. Second, the use of two psychiatric rating scales without formal clinical assessment by a psychiatrist and only at two points, before and after 6 months of treatment, is insufficient to detect and monitor psychiatric side effects. Given the fact that deep-brain stimulation in different target areas is clearly associated with both psychiatric and other side effects,2,3 careful and comprehensive monitoring of all such effects is imperative in future studies.
Klaus Lieb, M.D.
University Medical Center
79104 Freiburg, Germany
Thomas E. Schlaepfer, M.D.
University Hospital
53105 Bonn, Germany
schlaepf@jhmi.edu
Dr. Schlaepfer reports having served as principal investigator on an investigator-initiated study partly sponsored by Medtronic.
References
Deuschl G, Schade-Brittinger C, Krack P, et al. A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med 2006;355:896-908.
Schlaepfer T, Lieb K. Deep brain stimulation for treatment of refractory depression. Lancet 2005;366:1420-1422.
Piasecki SD, Jefferson JW. Psychiatric complications of deep brain stimulation for Parkinson's disease. J Clin Psychiatry 2004;65:845-849.
The authors reply: All patients in our study were assessed by a psychiatrist if psychiatric effects were reported. Individual patients certainly had psychiatric complications, as reported in our article, a finding that confirms earlier observations.1,2 However, the aim of the trial was to assess with the use of defined outcome variables whether a decline in cognition, mood, or overall psychiatric functioning in the group receiving neurostimulation, as compared with the medication-only group, compromised the effect of motor improvements on the quality of life. This question can be answered only by comparing the groups with the use of established and sensitive rating scales for neuropsychological and psychiatric functioning, not by examining the incidence of psychiatric diagnoses on a case-by-case basis. Outcomes according to these generally accepted scales did not differ between the medically treated control group and the neurostimulation group. Therefore, neurostimulation neither exerts its effect through influences on psychiatric functioning nor impairs overall cognitive and emotional functioning.
Günther Deuschl, M.D., Ph.D.
Jens Volkmann, M.D., Ph.D.
Universit?tsklinikum Schleswig-Holstein, Kiel
D-24105 Kiel, Germany
g.deuschl@neurologie.uni-kiel.de
References
Voon V, Kubu C, Krack P, Houeto JL, Troster AI. Deep brain stimulation: neuropsychological and neuropsychiatric issues. Mov Disord 2006;21:Suppl 14:S305-S327.
Deuschl G, Herzog J, Kleiner-Fisman G, et al. Deep brain stimulation: postoperative issues. Mov Disord 2006;21:Suppl 14:S219-S237.
Klaus Lieb, M.D.
University Medical Center
79104 Freiburg, Germany
Thomas E. Schlaepfer, M.D.
University Hospital
53105 Bonn, Germany
schlaepf@jhmi.edu
Dr. Schlaepfer reports having served as principal investigator on an investigator-initiated study partly sponsored by Medtronic.
References
Deuschl G, Schade-Brittinger C, Krack P, et al. A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med 2006;355:896-908.
Schlaepfer T, Lieb K. Deep brain stimulation for treatment of refractory depression. Lancet 2005;366:1420-1422.
Piasecki SD, Jefferson JW. Psychiatric complications of deep brain stimulation for Parkinson's disease. J Clin Psychiatry 2004;65:845-849.
The authors reply: All patients in our study were assessed by a psychiatrist if psychiatric effects were reported. Individual patients certainly had psychiatric complications, as reported in our article, a finding that confirms earlier observations.1,2 However, the aim of the trial was to assess with the use of defined outcome variables whether a decline in cognition, mood, or overall psychiatric functioning in the group receiving neurostimulation, as compared with the medication-only group, compromised the effect of motor improvements on the quality of life. This question can be answered only by comparing the groups with the use of established and sensitive rating scales for neuropsychological and psychiatric functioning, not by examining the incidence of psychiatric diagnoses on a case-by-case basis. Outcomes according to these generally accepted scales did not differ between the medically treated control group and the neurostimulation group. Therefore, neurostimulation neither exerts its effect through influences on psychiatric functioning nor impairs overall cognitive and emotional functioning.
Günther Deuschl, M.D., Ph.D.
Jens Volkmann, M.D., Ph.D.
Universit?tsklinikum Schleswig-Holstein, Kiel
D-24105 Kiel, Germany
g.deuschl@neurologie.uni-kiel.de
References
Voon V, Kubu C, Krack P, Houeto JL, Troster AI. Deep brain stimulation: neuropsychological and neuropsychiatric issues. Mov Disord 2006;21:Suppl 14:S305-S327.
Deuschl G, Herzog J, Kleiner-Fisman G, et al. Deep brain stimulation: postoperative issues. Mov Disord 2006;21:Suppl 14:S219-S237.