Deep Brain Stimulation: Unproven treatment promoted with a conflict of interest in JAMA: Psychiatry [again]

“Even with our noisy ways and cattle prods in the brain, we have to take care of sick people, now,” – Helen Mayberg

“All of us—researchers, journalists, patients and their loved ones–are desperate for genuine progress in treatments for severe mental illness. But if the history of such treatments teaches us anything, it is that we must view claims of dramatic progress with skepticism, or we will fall prey to false hopes.” – John Horgan

An email alert announced the early release of an article in JAMA: Psychiatry reporting effects of brain stimulation therapy for depression (DBS). The article was accompanied by an editorial commentary.

Oh no! Is an unproven treatment once again being promoted by one of the most prestigious psychiatry journals with an editorial commentary reeking of vested interests?

Indeed it is, but we can use the article and commentary as a way of honing our skepticism about such editorial practices and to learn better where to look to confirm or dispel our suspicions when they arise.

Xray depictionLike many readers of this blog, there was a time when I would turn to a trusted, prestigious source like JAMA: Psychiatry with great expectations. Not being an expert in a particular area like DBS, I would be inclined to accept uncritically what I read. But then I noticed how much of what I read conflicted with what I already knew about research design and basic statistics. Time and time again, this knowledge proved sufficient to detect serious hype, exaggeration, and simply false claims.

The problem was no longer simply one of the authors adopting questionable research practices. It expanded to journals and professional organizations adopting questionable publication practices that fit with financial, political, and other, not strictly scientific agendas.

What is found in the most prestigious biomedical journals is not necessarily the most robust and trustworthy of scientific findings. Rather, content is picked in terms of its ability to be portrayed as innovative and breakthrough medicine. But beyond that, the content is consistent with prevailing campaigns to promote particular viewpoints and themes. There is apparently no restriction on those who might most personally profit being selected for accompanying commentaries.

We need to recognize that editorial commentaries often receive weak or no peer review. Invitations from editors to provide commentaries are often a matter of sharing nonscientific agenda and simple cronyism.

Coming to these conclusions, I have been on a mission to learn better how to detect hype and hokum and I have invited readers of my blog posts to come along.

This installment builds on my recent discussion of an article claiming remission of suicidal ideation by magnetic seizure therapy. Like the editorial commentary accompanying previous JAMA: Psychiatry article, the commentary discussed here had an impressive conflict of interest disclosure. The disclosure probably would not have prompted me to search on the Internet for other material about one of the authors. Yet, a search revealed some information that is quite relevant to our interpretation of the new article and its commentary.  We can ponder whether this information should have been withheld. I think it should have been disclosed.

The lesson that I learned is a higher level of vigilance is needed to interpret highly touted article-commentary combos in prestigious journals. Unless we are going to simply dismiss them as advertisements or propaganda, rather than a highlighting of solid biomedical science.

Sadly, though, this exercise convinced me that efforts to scrutinize claims by turning to seemingly trustworthy supplementary sources can provide a misleading picture.

The article under discussion is:

Bergfeld IO, Mantione M, Hoogendoorn MC, et al. Deep Brain Stimulation of the Ventral Anterior Limb of the Internal Capsule for Treatment-Resistant Depression: A Randomized Clinical Trial. JAMA Psychiatry. Published online April 06, 2016. doi:10.1001/jamapsychiatry.2016.0152.

The commentary is:

Mayberg HS, Riva-Posse P, Crowell AL. Deep Brain Stimulation for Depression: Keeping an Eye on a Moving Target. JAMA Psychiatry. Published online April 06, 2016. doi:10.1001/jamapsychiatry.2016.0173.

The trial registration is

Deep Brain Stimulation in Treatment-refractory patients with Major Depressive Disorder.

Pursuing my skepticism by searching on the Internet, I immediately discovered a series of earlier blog posts about DBS by Neurocritic [1] [2] [3] that saved me a lot of time and directed me to still other useful sources. I refer to what I learned from Neurocritic in this blog post. But as always, all opinions are entirely my responsibility, along with misstatements and any inaccuracies.

But what I learned from immediately from Neurocritic is that BSD is a hot area of research, even if it continues to produce disappointing outcomes.

DBS had a commitment of $70 million from President Obama’s Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative . Premised on the causes of psychopathology being in precise, isolated neural circuitry, it is the poster children of the Research Domain Criteria (RDoC) of former NIMH director Thomas Insel. Neurocritic points to Insel promotion of “electroceuticals” like DBS in his NIMH Director’s Blog 10 Best of 2013:

The key concept: if mental disorders are brain circuit disorders, then successful treatments need to tune circuits with precision. Chemicals may be less precise than electrical or cognitive interventions that target specific circuits.

The randomized trial of deep brain stimulation for depression.

The objective of the trial was:

To assess the efficacy of DBS of the ventral anterior limb of the internal capsule (vALIC), controlling for placebo effects with active and sham stimulation phases.

Inclusion criteria were a diagnosis of major depressive disorder designated as being treatment resistant (TRD) on the basis of

A failure of at least 2 different classes of second-generation antidepressants (eg, selective serotonin reuptake inhibitor), 1 trial of a tricyclic antidepressant, 1 trial of a tricyclic antidepressant with lithium augmentation, 1 trial of a monoamine oxidase inhibitor, and 6 or more sessions of bilateral electroconvulsive therapy.

Twenty-five patients with TRD from 2 Dutch hospitals first received surgery that implanted four contact electrodes deep within their brains. The electrodes were attached to tiny wires leading to a battery-powered pulse generator implanted under their collar bones.

The standardized DBS treatment started after a three-week recovery from the surgery. Brain stimulation was continuous one week after surgery, but at three weeks, patients begin visits with psychiatrists or psychologists on what was at first a biweekly basis, but later less frequently.

deep brain stimulation teamAt the visits, level of depression was assessed and adjustments were made to various parameters of the DBS, such as the specific site targeted in the brain, voltage, and pulse  frequency and amplitude. Treatment continued until optimization – either four weeks of sustained improvement on depression rating scales or the end of the 52 week period. In the original protocol, this this phase of the study was limited to six months, but was extended after experience with a few patients. Six patients went even longer than the 52 weeks to achieve optimization.

Once optimization was achieved, patients were randomized to a crossover phase in which they received two blocks of six weeks of either continued active or sham treatment that involved simply turning off the stimulation. Outcomes were classified in terms of investigator-rated changes in the 17-item Hamilton Depression Rating Scale.

The outcome of the open-label phase of the study was the change of the investigator-rated HAM-D-17 score (range, 0-52) from baseline to T2. In addition, we classified patients as responders (≥50% reduction of HAM-D-17 score at T2 compared with baseline) or nonresponders (<50% reduction of HAM-D-17 score atT2 compared with baseline). Remission was defined as a HAM-D-17 score of 7 or less at T2. The primary outcome measure of the randomized, double-blind crossover trial was the difference in HAM-D-17 scores between the active and sham stimulation phases. In a post hoc analysis, we tested whether a subset of nonresponders showed a partial response (≥25% but <50% reduction of HAM-D-17 score at T2 compared with baseline).

Results

Clinical outcomes. The mean time to first response in responders was 53.6 (50.6) days (range, 6-154 days) after the start of treatment optimization. The mean HAM-D-17 scores decreased from 22.2 (95%CI, 20.3-24.1) at baseline to 15.9 (95% CI, 12.3-19.5) at T2.

An already small sample shrank further from initial assessment of eligibility until retention at the end of the cross over study. Of the 52 patients assessed for eligibility, 23 were in eligible and four refused. Once the optimization phase of the trial started, four patients withdrew for lack of effect. Another five could not be randomized in the crossover phase, three because of an unstable psychiatric status, one because of fear of worsening symptoms, and one because of their physical health. So, the randomized phase of the trial consisted of nine patients randomized to the active treatment and then the sham and another seven patients randomized to the sham and then active treatment.

The crossover to sham treatment did not go as planned. Of the nine (three responders and six nonresponders) randomized to the active-then-sham condition, all had to be crossed over early – one because the patient requested a crossover, two because of a gradual increase in symptoms, and three because of logistics. Of the seven patients assigned to sham- first (four responders and three nonresponders), all had to be crossed over within a day because of increases in symptoms.

I don’t want to get lost in the details here. But we are getting into small numbers with nonrandom attrition, imbalanced assignment of responders versus nonresponders in the randomization, and the breakdown of the planned sham treatment. From what I’ve read elsewhere about DBS, I don’t think that providers or patients were blinded to the sham treatment. Patients should be able to feel the shutting off of the stimulator.

Adverse events. DBS has safety issues. Serious adverse events included severe nausea during surgery (1 patient), suicide attempt (4 patients), and suicidal ideation (2 patients). Two nonresponders died several weeks after they withdrew from the study and DBS had been stopped (1 suicide, 1 euthanasia). Two patients developed full blown mania during treatment and another patient became hypomanic.

The article’s Discussion claims

We found a significant reduction of depressive symptoms following vALIC DBS, resulting in response in 10 patients (40%) and partial response in 6 (24%) patients with TRD.

Remission was achieved in 5 (20%) patients. The randomized active-sham phase study design indicates that reduction of depressive symptoms cannot be attributed to placebo effects…

Conclusions

This trial shows efficacy of DBS in patients with TRD and supports the possible benefits of DBS despite a previous disappointing randomized clinical trial. Further specification of targets and the most accurate setting optimization as well as larger randomized clinical trials are necessary.

A clinical trial with starting with 25 patients does not have much potential to shift our confidence in the efficacy of DBS. Any hope of doing so was further dashed when the sample was reduced to 17 patients who remained for the investigators’ attempted randomization to an active treatment versus sham comparison (seven responders and nine nonresponders). Then sham condition could not be maintained as planed in the protocol for any patients.

The authors interpreted the immediate effects of shifting to sham treatment as ruling out any placebo effect. However, it’s likely that shutting off the stimulator was noticeable to the patients and the immediacy of effects speaks to likelihood an effect due to the strong expectations of patients with intolerable depression having their hope taken away. Some of the immediate response could’ve been a nocebo response.

Helen Mayberg and colleagues’ invited commentary

The commentary attempted to discourage a pessimistic assessment of DBS based on the difficulties implementing the original plans for the study as described in the protocol.

A cynical reading of the study by Bergfeld et al1 might lead to the conclusion that the labor-intensive and expert-driven tuning of the DBS device required for treatment response makes this a nonviable clinical intervention for TRD. On the contrary, we see a tremendous opportunity to retrospectively characterize the various features that best define patients who responded well to this treatment. New studies could test these variables prospectively.

The substantial deviation from protocol that occurred after only two patients were entered into the trial was praised in terms of the authors’ “tenacious attempts to establish a stable response”:

We appreciate the reality of planning a protocol with seemingly conservative time points based on the initial patients, only to find these time points ultimately to be insufficient. The authors’ tenacious attempts to establish a stable response by extending the optimization period from the initial protocol using 3 to 6 months to a full year is commendable and provides critical information for future trials.

Maybe, but I think the need for this important change, along with the other difficulties that were encountered in implementing the study, speak to a randomized controlled trial of DBS being premature.

Conflict of Interest Disclosures: Dr Mayberg has a paid consulting agreement with St Jude Medical Inc, which licensed her intellectual property to develop deep brain stimulation for the treatment of severe depression (US 2005/0033379A1). The terms of this agreement have been reviewed and approved by Emory University in accordance with their conflict of interest policies. No other disclosures were reported.

Helen Mayberg’s declaration of interest clearly identifies her as someone who is not a detached observer, but who would benefit financially and professionally from any strengthening the claims for the efficacy of DBS. We are alerted by this declaration, but I think there were some things that were not mentioned in the article or editorial about Helen Mayberg’s work that would influence her credibility even more if they were known.

Helen Mayberg’s anecdotes and statistics about the success of DBS

Mayberg has been attracting attention for over a decade with her contagious exuberance for DBS. A 2006 article in the New York Times by David Dobbs started with a compelling anecdote of one of Mayberg’s patients being able to resume a normal life after previous ineffective treatments for severe depression. The story reported the success with 8 of12 patients treated with DBS:

They’ve re-engaged their families, resumed jobs and friendships, started businesses, taken up hobbies old and new, replanted dying gardens. They’ve regained the resilience that distinguishes the healthy from the depressed.

Director of NIMH Tom Insel chimed in:

“People often ask me about the significance of small first studies like this,” says Dr. Thomas Insel, who as director of the National Institute of Mental Health enjoys an unparalleled view of the discipline. “I usually tell them: ‘Don’t bother. We don’t know enough.’ But this is different. Here we know enough to say this is something significant. I really do believe this is the beginning of a new way of understanding depression.”

A 2015 press release from Emory University, Targeting depression with deep brain stimulation, gives another anecdote of a dramatic treatment success.

Okay, we know to be skeptical about University press releases, but then there are the dramatic anecdotes and even numbers in a news article in Science, Short-Circuiting Depression that borders on an infomercial for Mayberg’s work.

short-circuiting depression

Since 2003, Mayberg and others have used DBS in area 25 to treat depression in more than 100 patients. Between 30% and 40% of patients do “extremely well”—getting married, going back to work, and reclaiming their lives, says Sidney Kennedy, a psychiatrist at Toronto General Hospital in Canada who is now running a DBS study sponsored by the medical device company St. Jude Medical. Another 30% show modest improvement but still experience residual depression. Between 20% and 25% do not experience any benefit, he says. People contemplating brain surgery might want better odds, but patients with extreme, relentless depression often feel they have little to lose. “For me, it was a last resort,” Patterson says.

By making minute adjustments in the positions of the electrodes, Mayberg says, her team has gradually raised its long-term response rates to 75% to 80% in 24 patients now being treated at Emory University.

A chronically depressed person or someone who cares for someone who is depressed might be motivated to go on the Internet and try to find more information about Mayberg’s trial. A website for Mayberg’s BROADEN (BROdmann Area 25 DEep brain Neuromodulation) study once provided a description of the study, answers to frequently asked questions, and an opportunity to register for screening for the study. However, it’s no longer accessible through Google or other search engines. But you can reach an archived website with a link provided by Neurocritic, but the click links are no longer functional.

Neurocritic’s blog posts about Mayberg and DBS

If you are lucky, a Google search for Mayberg deep brain stimulation, might bring you to any of three blog posts by Neurocritic [1] [2] [3] that have rich links and provide a very different story of Mayberg and DBS.

One link takes you to the trial registration for Mayberg’s BROADEN study: A Clinical Evaluation of Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment-Resistant Depression. The updated file registration indicates that the study will end in September 2017, and that the study is ongoing but not recruiting participants.

This information should have been updated, as should other publicity about Mayberg’s BROADEN study. Namely, as Neurocritic documents, the company attempting to commercialize DBS by funding the study, St. Jude Medical terminated after futility analyses indicated that further enrollment of patients had only a 17% probability of achieving a significant effect. At the point of terminating the trial, 125 patients had been role.

Neurocritic also provides a link to an excellent, open access review paper:

Morishita T, Fayad SM, Higuchi MA, Nestor KA, Foote KD. Deep brain stimulation for treatment-resistant depression: systematic review of clinical outcomes. Neurotherapeutics. 2014 Jul 1;11(3):475-84.

The article reveals that although there are 22 published studies of DBS for treatment-resistant depression, only three are randomized trials, one of which was completed with null results. Two – including Mayberg’s BROADEN trial – were discontinued because futility analyses indicate that a finding of efficacy for the treatment was unlikely.

Finally, Neurocritic  also provides a link to a Neurotech Business Report, Depressing Innovation:

The news that St. Jude Medical failed a futility analysis of its BROADEN trial of DBS for treatment of depression cast a pall over an otherwise upbeat attendance at the 2013 NANS meeting [see Conference Report, p7]. Once again, the industry is left to pick up the pieces as a promising new technology gets set back by what could be many years.

It’s too early to assess blame for this failure. It’s tempting to wonder if St. Jude management was too eager to commence this trial, since that has been a culprit in other trial failures. But there’s clearly more involved here, not least the complexity of specifying the precise brain circuits involved with major depression. Indeed, Helen Mayberg’s own thinking on DBS targeting has evolved over the years since the seminal paper she and colleague Andres Lozano published in Neuron in 2005, which implicated Cg25 as a lucrative target for depression. Mayberg now believes that neuronal tracts emanating from Cg25 toward medial frontal areas may be more relevant [NBR Nov13 p1]. Research that she, Cameron McIntyre, and others are conducting on probabilistic tractography to identify the patient-specific brain regions most relevant to the particular form of depression the patient is suffering from will likely prove to be very fruitful in the years ahead.

So, we have a heavily hyped unproven treatment for which the only clinical trials have either been null or terminated following a futility analysis. Helen Mayberg, a patent holder associated with one of these trials was inappropriate to be recruited for commentary on another, more modestly sized trial that also ran into numerous difficulties that can be taken to suggest it was premature. However, I find it outrageous that so little effort has been made to correct the record concerning her BROADEN trial or even to acknowledge its closing in the JAMA: Psychiatry commentary.

Untold numbers of depressed patients who don’t get expected benefits from available treatments are being misled with false hope from anecdotes and statistics from a trial that was ultimately terminated.

I find troubling what my exercise showed might happen when someone who is motivated by the skepticism goes to the Internet and tries to get additional information about the JAMA: Psychiatry paper. They could be careful to rely on only seemingly credible sources – a trial registration and a Science article.  The Science article is not peer-reviewed but nonetheless has a credibility conveyed appearing in the premier and respected Science. The trial registration has not been updated with valuable information and the Science article gives no indication how it is contradicted by better quality evidence. So, they would be misled.

 

 



Leave a comment

Please note, comments must be approved before they are published