Deep brain stimulation as a new therapeutic approach in therapy-resistant mental disorders: ethical aspects of investigational treatment

  • Jens Kuhn
  • Wolfgang Gaebel
  • Joachim Klosterkoetter
  • Christiane Woopen


Deep brain stimulation (DBS) is an established treatment option for some movement disorders, in particular Parkinson’s disease. Only recently, a number of promising studies with small samples of patients have been published in which impressive therapeutic outcomes achieved by DBS in otherwise treatment-resistant obsessive–compulsive disorder, major depression, and Tourette’s syndrome were reported. It seems probable that the investigational approach to treat mental disorders by DBS will increase substantially. Neurosurgical interventions in psychiatric patients raise ethical considerations not only based on the disreputable experiences of the era of psychosurgery. Therefore, it is necessary to implement transparent and well-defined regulations for the protection of the patients as well as appropriate support for therapeutic research. The current article aims to provide a synopsis of the DBS approach in mental disorders and the hitherto existing criteria for research. It suggests some additional requirements for ethically justifiable therapeutic research employing DBS in psychiatric patients.


Deep brain stimulation Neuroethics Mental disorders Major depression Obsessive–compulsive disorder Tourette’s syndrome 


Conflicts of interest statement

The authors, Jens Kuhn, W. Gaebel, J. Klosterkötter, and Christiane Woopen, have no financial interests in the subject matter of this article.


  1. 1.
    Comité Consultatif National d’Ethique (2002) Functional neurosurgery for severe psychiatric disorders. Accessed 20 May 2009
  2. 2.
    Dostrovsky JO, Lozano AM (2002) Mechanisms of deep brain stimulation. Mov Disord 17:S63–S68CrossRefPubMedGoogle Scholar
  3. 3.
    German Parkinson Study Group (GPS) (2009) Controlled trial of deep brain stimulation in early patients with Parkinson’s disease. Accessed 20 May 2009
  4. 4.
    Greenberg BD, Gabriels LA, Malone DA Jr, Rezai AR, Friehs GM, Okun MS, Shapira NA, Foote KD, Cosyns PR, Kubu CS, Malloy PF, Salloway SP, Giftakis JE, Rise MT, Machado AG, Baker KB, Stypulkowski PH, Goodman WK, Rasmussen SA, Nuttin BJ (2008) Deep brain stimulation of the ventral internal capsule/ventral striatum for obsessive–compulsive disorder: worldwide experience. Mol Psychiatry [Epub ahead of print]Google Scholar
  5. 5.
    Huff W, Lenartz D, Schormann M, et al. (2009) Unilateral deep brain stimulation of the nucleus accumbens in patients with treatment resistant obsessive compulsive disorder—outcomes after one-year stimulation. Clin Neurol Neurosurg (in press)Google Scholar
  6. 6.
    Knapp CM, Tozier L, Pak A, Ciraulo DA, Kornetsky C (2009) Deep brain stimulation of the nucleus accumbens reduces ethanol consumption in rats. Pharmacol Biochem Behav 92:474–479CrossRefPubMedGoogle Scholar
  7. 7.
    Kringelbach ML, Jenkinson N, Owen SLF, Aziz TZ (2007) Translational principles of deep brain stimulation. Nat Rev Neurosci 8:623–635CrossRefPubMedGoogle Scholar
  8. 8.
    Kuhn J, Lenartz D, Mai JK et al (2007) Deep brain stimulation of the nucleus accumbens and the internal capsule in therapeutically refractory Tourette-syndrome. J Neurol 254:963–965CrossRefPubMedGoogle Scholar
  9. 9.
    Lozano AM, Mayberg HS, Giacobbe P, Hamani C, Craddock RC, Kennedy SH (2008) Subcallosal cingulate gyrus deep brain stimulation for treatment-resistant depression. Biol Psychiatry 64:461–467CrossRefPubMedGoogle Scholar
  10. 10.
    Maciunas RJ, Maddux BN, Riley DE, Whitney CM, Schoenberg MR, Ogrocki PJ, Albert JM, Gould DJ (2007) Prospective randomized double-blind trial of bilateral thalamic deep brain stimulation in adults with Tourette syndrome. J Neurosurg 107:1004–1014CrossRefPubMedGoogle Scholar
  11. 11.
    Mallet L, Polosan M, Jaafari N, Baup N, Welter ML, Fontaine D, du Montcel ST, Yelnik J, Chéreau I, Arbus C, Raoul S, Aouizerate B, Damier P, Chabardès S, Czernecki V, Ardouin C, Krebs MO, Bardinet E, Chaynes P, Burbaud P, Cornu P, Derost P, Bougerol T, Bataille B, Mattei V, Dormont D, Devaux B, Vérin M, Houeto JL, Pollak P, Benabid AL, Agid Y, Krack P, Millet B, Pelissolo A; STOC Study Group (2008) Subthalamic nucleus stimulation in severe obsessive–compulsive disorder. N Engl J Med 359:2121–2134Google Scholar
  12. 12.
    Malone DA Jr, Dougherty DD, Rezai AR et al (2009) Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry 65(4):267–275CrossRefPubMedGoogle Scholar
  13. 13.
    Mayberg HS, Lozano AM, Voon V, McNeely HE, Seminowicz D, Hamani C, Schwalb JM, Kennedy SH (2005) Deep brain stimulation for treatment-resistant depression. Neuron 45:651–660CrossRefPubMedGoogle Scholar
  14. 14.
    McCracken CB, Grace AA (2009) Nucleus accumbens deep brain stimulation produces region-specific alterations in local field potential oscillations and evoked responses in vivo. J Neurosci 29:5354–5363CrossRefPubMedGoogle Scholar
  15. 15.
    McIntyre CC, Savasta M, Kerkerian-Le Goff L, Vitek JL (2004) Uncovering the mechanism(s) of action of deep brain stimulation: activation, inhibition, or both. Clin Neurophysiol 115:1239–1248CrossRefPubMedGoogle Scholar
  16. 16.
    Merkel R, Boer G, Fegert J, Galert T, Hartmann D, Nuttin B, Rosahl S (2007) Intervening in the brain: changing psyche and society. Springer, HeidelbergGoogle Scholar
  17. 17.
    Miller FG, Fins JJ (2006) Protecting human subjects in brain research: a pragmatic perspective. In: Illes J (ed) Neuroethics: defining the issues in theory, practice. Oxford University Press, Oxford, pp 123–140Google Scholar
  18. 18.
    Mink JW, Walkup JF, Kirk A, Como P, Cath D, Delong MR, Erenberg G, Jankovic J, Juncos J, Leckman JF, Swerdlow N, Visser-Vandewalle V, Vitek JL (2006) Patient selection and assessment recommendations for deep brain stimulation in Tourette syndrome. Mov Disord 21:1831–1838CrossRefPubMedGoogle Scholar
  19. 19.
    Moniz E (1937) Prefrontal leucotomy in the treatment of mental disorders. Am J Psychiatry 93:1379–1385Google Scholar
  20. 20.
    Nuttin B, Cosyns P, Demeulemeester H, Gybels J, Meyerson B (1999) Electrical stimulation in anterior limbs of internal capsules in patients with obsessive–compulsive disorder. Lancet 354:1526CrossRefPubMedGoogle Scholar
  21. 21.
    Nuttin B, Gybels J, Cosyns P, Gabriels L, Meyerson B, Andréewitch S, Rasmussen S, Greenberg B, Friehs G, Rezai AR, Montgomery E, Malone D, Fins JJ (2002) Deep brain stimulation for psychiatric disorders. Neurosurgery 51:519CrossRefGoogle Scholar
  22. 22.
    Nuttin BJ, Gabriels L, van Kuyck K, Cosyns P (2003) Electrical stimulation of the anterior limbs of the internal capsules in patients with severe obsessive–compulsive disorder: anecdotal reports. Neurosurg Clin N Am 14:267–274CrossRefPubMedGoogle Scholar
  23. 23.
    Perlmutter JS, Mink JW (2006) Deep brain stimulation. Annu Rev Neurosci 29:229–257CrossRefPubMedGoogle Scholar
  24. 24.
    Ressler KJ, Mayberg HS (2007) Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic. Nat Neurosci 10:1116–1124CrossRefPubMedGoogle Scholar
  25. 25.
    Schlaepfer TE, Cohen MX, Frick C et al (2008) Deep brain stimulation to reward circuitry alleviates anhedonia in refractory major depression. Neuropsychopharmacology 33(2):368–377CrossRefPubMedGoogle Scholar
  26. 26.
    Schüpbach M, Gargiulo M, Welter ML, Mallet L, Béhar C, Houeto JL, Maltête D, Mesnage V, Agid Y (2006) Neurosurgery in Parkinson disease: a distressed mind in a repaired body? Neurology 66:1811–1816CrossRefPubMedGoogle Scholar
  27. 27.
    Servello D, Porta M, Sassi M, Brambilla A, Robertson MM (2008) Deep brain stimulation in 18 patients with severe Gilles de la Tourette syndrome refractory to treatment: the surgery and stimulation. J Neurol Neurosurg Psychiatry 79:136–142CrossRefPubMedGoogle Scholar
  28. 28.
    Synofzik M, Schlaepfer TE (2008) Stimulating personality: ethical criteria for deep brain stimulation in psychiatric patients and for enhancement purposes. Biotechnol J 3:1511–1520CrossRefPubMedGoogle Scholar
  29. 29.
    U.S. Food and Drug Administration (2009) New humanitarian device approval. Accessed 26 May 2009
  30. 30.
    Vassoler FM, Schmidt HD, Gerard ME, Famous KR, Ciraulo DA, Kornetsky C, Knapp CM, Pierce RC (2008) Deep brain stimulation of the nucleus accumbens shell attenuates cocaine priming-induced reinstatement of drug seeking in rats. J Neurosci 28:8735–8739CrossRefPubMedGoogle Scholar
  31. 31.
    Vandewalle V, van der Linden C, Groenewegen HJ et al (1999) Stereotactic treatment of Gilles de la Tourette syndrome by high frequency stimulation of thalamus. Lancet 353:724CrossRefPubMedGoogle Scholar
  32. 32.
    Yamamoto T, Kobayashi K, Kasai M, Oshima H, Fukaya C, Katayama Y (2005) DBS therapy for the vegetative state and minimally conscious state. Acta Neurochir Suppl 93:101–104CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Jens Kuhn
    • 1
  • Wolfgang Gaebel
    • 3
  • Joachim Klosterkoetter
    • 1
  • Christiane Woopen
    • 2
  1. 1.Department of Psychiatry and PsychotherapyUniversity of CologneCologneGermany
  2. 2.Institute for the History of Medicine and Medical Ethics, Research Center in EthicsUniversity of CologneCologneGermany
  3. 3.LVR-Klinikum Düsseldorf, Department of Psychiatry and PsychotherapyHeinrich-Heine-UniversityDüsseldorfGermany

Personalised recommendations