Dr. Williams is an Assistant Professor within the Department of Psychiatry and Behavioral Sciences and the Director of the Stanford Brain Stimulation Lab. Dr. Williams has a broad background in clinical neuroscience and is triple board-certified in general neurology, general psychiatry, as well as behavioral neurology & neuropsychiatry. In addition, he has specific training and clinical expertise in the development of brain stimulation methodologies under Mark George, MD. Themes of his work include (a) examining the use of spaced learning theory in the application of neurostimulation techniques, (b) development and mechanistic understanding of rapid-acting antidepressants, and (c) identifying objective biomarkers that predict neuromodulation responses in treatment-resistant neuropsychiatric conditions. He has published papers in high impact peer-reviewed journals including Brain, American Journal of Psychiatry, and the Proceedings of the National Academy of Science. Results from his studies have gained widespread attention in journals such as Science and New England Journal of Medicine Journal Watch as well as in the popular press and have been featured in various news sources including Time, Smithsonian, and Newsweek. Dr. Williams received two NARSAD Young Investigator Awards in 2016 and 2018 along with the 2019 Gerald R. Klerman Award. Dr. Williams received the National Institute of Mental Health Biobehavioral Research Award for Innovative New Scientists in 2020.
- Interventional Psychiatry
- Behavioral Neurology
Director, Stanford Interventional Psychiatry Clinical Research (2019 - Present)
Director, Stanford Brain Stimulation Laboratory (2015 - Present)
Chief Resident of Neuropsychiatry, Medical University of South Carolina (2011 - 2014)
Chief Resident of Neurology, Medical University of South Carolina (2011 - 2012)
Honors & Awards
Leading Research Achievements, Brain & Behavior Research Foundation (2021)
Biobehavioral Research Award for Innovative New Scientists, National Institute of Mental Health (2020)
Bipolar Research Award, One Mind (2020)
Leading Research Achievements, Brain & Behavior Research Foundation (2020)
Chairman's Award for Advancing Science, Stanford University (2019)
Gerald R. Klerman Award, Brain & Behavior Research Foundation (2019)
NARSAD Young Investigator Award, Brain & Behavior Research Foundation (2018-2020)
NARSAD Young Investigator Award, Brain & Behavior Research Foundation (2016-2018)
Boards, Advisory Committees, Professional Organizations
Director, Board of Directors, Clinical TMS Society (2021 - Present)
Member, American Neuropsychiatric Association Committee on Research (2016 - Present)
Diplomate, American Board of Psychiatry and Neurology (2014 - Present)
Board Certification, United Council for Neurologic Subspecialties, Behavioral Neurology & Neuropsychiatry (2020)
Board Certification: American Board of Psychiatry and Neurology, Neurology (2019)
Board Certification: American Board of Psychiatry and Neurology, Psychiatry (2014)
NIH R25 Research Fellowship, Medical University of South Carolina (Mentor: Mark George, MD), Human Neuroscience (2014)
Clinical Fellowship, Medical University of South Carolina, Invasive and Non-Invasive Neuromodulation (2014)
Residency, Medical University of South Carolina, Psychiatry (2014)
Residency, Medical University of South Carolina, Neurology (2014)
Intership, Medical University of South Carolina, Internal Medicine (2009)
MD, Medical University of South Carolina, Medicine (2008)
Accelerated Theta Burst in Treatment-Resistant Depression: A Dose Finding and Biomarker Study
This study evaluates the effectiveness of re-treatment using accelerated schedule of intermittent theta-burst stimulation for treatment-resistant depression. This is an open label study.
Establishing a Dose-response Relationship With Accelerated Transcranial Magnetic Stimulation
This study evaluates an accelerated schedule of theta-burst stimulation using a transcranial magnetic stimulation device for treatment-resistant depression. In a double-blind, randomized, sham-controlled fashion, half the participants will receive accelerated theta-burst stimulation while half will receive sham treatment.
Establishing Functional Biomarkers for Spaced Theta-Burst Stimulation
The investigators plan to use functional magnetic resonance imaging (fMRI) methods to assess brain changes following spaced theta burst stimulation (TBS), a new form of repetitive transcranial magnetic stimulation (rTMS), in 10 healthy participants. The investigators will measure the effects of both excitatory (intermittent, iTBS) and inhibitory (continuous, cTBS) TBS applied to the motor cortex, a system that when stimulated produces a readily observable behavioral response (e.g., movement of a given body regions). In addition to brain activity, we will assess the effects of TBS on motor responses and pain perception. The goal is to determine how brain activity and blood flow during tasks and at rest change following the applications of spaced cTBS and iTBS. Additionally, the aim is to determine the duration of the spaced TBS effects on brain activity and behavior. This study will provide an understanding of the functional brain and behavioral changes that occur following spaced TBS to the motor cortex and has implications for reducing the long treatment schedules associated with classical rTMS protocols.
Neuroimaging Biomarkers for Predicting rTMS Response in OCD
This study evaluates an accelerated schedule of theta-burst stimulation using a Transcranial Magnetic Stimulation (TMS) device for treatment-resistant Obsessive Compulsive Disorder (OCD). In a randomized fashion, half the participants will receive accelerated theta-burst stimulation at the dorsomedial prefrontal cortex (DMPFC), while half will receive accelerated theta-burst stimulation at the right orbitofrontal (rOFC) site.
rTMS for Orthopaedic Trauma Patients
This study evaluates an accelerated schedule of theta-burst stimulation using a transcranial magnetic stimulation device for orthopaedic trauma patients. In this open label study, all participants will receive accelerated theta-burst stimulation. This study will examine whether symptoms of psychiatric distress and opioid use in orthopaedic trauma patients can be mitigated with rTMS to improve post-injury recovery.
aTBS for Treatment of Depression in AUD
This study evaluates an accelerated schedule of theta-burst stimulation using a transcranial magnetic stimulation device for improvement of depressive symptoms and drinking behavior in individuals with alcohol dependence. In this open label study, all participants will receive accelerated theta-burst stimulation.
Stanford is currently not accepting patients for this trial. For more information, please contact Romina Nejad, MSc, 650-497-3933.
Bilateral Accelerated Theta Burst in Treatment-Resistant Bipolar Depression
This study evaluates an accelerated schedule of theta-burst stimulation using a transcranial magnetic stimulation device for treatment-resistant bipolar depression. In this open-label study, all participants will receive accelerated theta-burst stimulation.
Stanford is currently not accepting patients for this trial. For more information, please contact Nolan Williams, MD, 650-497-3933.
iTBS in Refractory Pediatric Depression
This work will mark the first step in understanding the neural targets for rTMS in youth with difficult to treat depressive symptoms, creating benchmarks for optimizing the safety and efficacy of rTMS for pediatric populations through precision targeting, and encourage funding applications for larger sham- controlled randomized clinical studies.
Stanford is currently not accepting patients for this trial. For more information, please contact Romina Nejad, BS, 650-497-3933.
Rapid Non-Invasive Brain Stimulation for OCD (oTMS)
The purpose of this study is to understand how cortical stimulation affects Obsessive-Compulsive Disorder (OCD) symptoms.
Stanford is currently not accepting patients for this trial. For more information, please contact Andrea Varias, MSHS, 650-724-8912.
SAINT for Treatment of Preoperative Depression to Reduce Opioid Use Following Arthroplasty
This study evaluates an accelerated schedule of theta-burst stimulation using a transcranial magnetic stimulation device for treatment-resistant depression. In a double-blind fashion, half the participants will receive accelerated theta-burst stimulation while half will receive sham treatment.
Stanford is currently not accepting patients for this trial. For more information, please contact Romina Nejad, MSc, 650-736-4850.
The Effects of Stanford Accelerated Intelligent Neuromodulation Therapy on Explicit and Implicit Suicidal Cognition
This study evaluates the effects of an accelerated schedule of theta-burst stimulation, termed Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT), on the neural networks underlying explicit and implicit suicidal cognition in inpatients with major depressive disorder.
Stanford is currently not accepting patients for this trial.
Use of Repetitive Transcranial Magnetic Stimulation to Augment Hypnotic Analgesia
The investigators plan to use functional neuroimaging (fMRI) to understand the brain systems affected when hypnosis and hypnotic analgesia are augmented with repetitive transcranial magnetic stimulation (rTMS), a form of non-invasive brain stimulation to 100 people with fibromyalgia, a chronic pain condition. The investigators will measure the effect of rTMS-augmentation on the brain networks underlying hypnotizability, as well as the effect of rTMS-augmentation on hypnotic analgesia networks. The investigators hope to demonstrate that a combination of these psychological and neuromodulatory treatments will be more effective than hypnosis alone, thereby enhancing the depth of hypnosis, range of hypnosis and the efficacy of hypnotic analgesia and hopefully creating a new treatment modality for individuals suffering from pain syndromes such as fibromyalgia pain.
Stanford is currently not accepting patients for this trial. For more information, please contact Merve Gulser, BS, 650-736-2233.
Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial.
The American journal of psychiatry
OBJECTIVE: Depression is the leading cause of disability worldwide, and half of patients with depression have treatment-resistant depression. Intermittent theta-burst stimulation (iTBS) is approved by the U.S. Food and Drug Administration for the treatment of treatment-resistant depression but is limited by suboptimal efficacy and a 6-week duration. The authors addressed these limitations by developing a neuroscience-informed accelerated iTBS protocol, Stanford neuromodulation therapy (SNT; previously referred to as Stanford accelerated intelligent neuromodulation therapy, or SAINT). This protocol was associated with a remission rate of 90% after 5 days of open-label treatment. Here, the authors report the results of a sham-controlled double-blind trial of SNT for treatment-resistant depression.METHODS: Participants with treatment-resistant depression currently experiencing moderate to severe depressive episodes were randomly assigned to receive active or sham SNT. Resting-state functional MRI was used to individually target the region of the left dorsolateral prefrontal cortex most functionally anticorrelated with the subgenual anterior cingulate cortex. The primary outcome was score on the Montgomery-Asberg Depression Rating Scale (MADRS) 4 weeks after treatment.RESULTS: At the planned interim analysis, 32 participants with treatment-resistant depression had been enrolled, and 29 participants who continued to meet inclusion criteria received either active (N=14) or sham (N=15) SNT. The mean percent reduction from baseline in MADRS score 4 weeks after treatment was 52.5% in the active treatment group and 11.1% in the sham treatment group.CONCLUSIONS: SNT, a high-dose iTBS protocol with functional-connectivity-guided targeting, was more effective than sham stimulation for treatment-resistant depression. Further trials are needed to determine SNT's durability and to compare it with other treatments.
View details for DOI 10.1176/appi.ajp.2021.20101429
View details for PubMedID 34711062
Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression.
The American journal of psychiatry
New antidepressant treatments are needed that are effective, rapid acting, safe, and tolerable. Intermittent theta-burst stimulation (iTBS) is a noninvasive brain stimulation treatment that has been approved by the U.S. Food and Drug Administration for treatment-resistant depression. Recent methodological advances suggest that the current iTBS protocol might be improved through 1) treating patients with multiple sessions per day at optimally spaced intervals, 2) applying a higher overall pulse dose of stimulation, and 3) precision targeting of the left dorsolateral prefrontal cortex (DLPFC) to subgenual anterior cingulate cortex (sgACC) circuit. The authors examined the feasibility, tolerability, and preliminary efficacy of Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT), an accelerated, high-dose resting-state functional connectivity MRI (fcMRI)-guided iTBS protocol for treatment-resistant depression.Twenty-two participants with treatment-resistant depression received open-label SAINT. fcMRI was used to individually target the region of the left DLPFC most anticorrelated with sgACC in each participant. Fifty iTBS sessions (1,800 pulses per session, 50-minute intersession interval) were delivered as 10 daily sessions over 5 consecutive days at 90% resting motor threshold (adjusted for cortical depth). Neuropsychological testing was conducted before and after SAINT.One participant withdrew, leaving a sample size of 21. Nineteen of 21 participants (90.5%) met remission criteria (defined as a score <11 on the Montgomery-Åsberg Depression Rating Scale). In the intent-to-treat analysis, 19 of 22 participants (86.4%) met remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects.SAINT, an accelerated, high-dose, iTBS protocol with fcMRI-guided targeting, was well tolerated and safe. Double-blinded sham-controlled trials are needed to confirm the remission rate observed in this initial study.
View details for DOI 10.1176/appi.ajp.2019.19070720
View details for PubMedID 32252538
Attenuation of antidepressant and antisuicidal effects of ketamine by opioid receptor antagonism.
We recently reported that naltrexone blocks antidepressant effects of ketamine in humans, indicating that antidepressant effects of ketamine require opioid receptor activation. However, it is unknown if opioid receptors are also involved in ketamine's antisuicidality effects. Here, in a secondary analysis of our recent clinical trial, we test whether naltrexone attenuates antisuicidality effects of ketamine. Participants were pretreated with naltrexone or placebo prior to intravenous ketamine in a double-blinded crossover design. Suicidality was measured with the Hamilton Depression Rating Scale item 3, Montgomery-Åsberg Depression Rating Scale item 10, and Columbia Suicide Severity Rating Scale. In the 12 participants who completed naltrexone and placebo conditions, naltrexone attenuated the antisuicidality effects of ketamine on all three suicidality scales/subscales (linear mixed model, fixed pretreatment effect, p < 0.01). Results indicate that opioid receptor activation plays a significant role in the antisuicidality effects of ketamine.
View details for DOI 10.1038/s41380-019-0503-4
View details for PubMedID 31467392
Attenuation of Antidepressant Effects of Ketamine by Opioid Receptor Antagonism.
The American journal of psychiatry
OBJECTIVE: In addition to N-methyl-d-aspartate receptor antagonism, ketamine produces opioid system activation. The objective of this study was to determine whether opioid receptor antagonism prior to administration of intravenous ketamine attenuates its acute antidepressant or dissociative effects.METHOD: In a proposed double-blind crossover study of 30 adults with treatment-resistant depression, the authors performed a planned interim analysis after studying 14 participants, 12 of whom completed both conditions in randomized order: placebo or 50 mg of naltrexone preceding intravenous infusion of 0.5 mg/kg of ketamine. Response was defined as a reduction ≥50% in score on the 17-item Hamilton Depression Rating Scale (HAM-D) score on postinfusion day 1.RESULTS: In the interim analysis, seven of 12 adults with treatment-resistant depression met the response criterion during the ketamine plus placebo condition. Reductions in 6-item and 17-item HAM-D scores among participants in the ketamine plus naltrexone condition were significantly lower than those of participants in the ketamine plus placebo condition on postinfusion days 1 and 3. Secondary analysis of all participants who completed the placebo and naltrexone conditions, regardless of the robustness of response to ketamine, showed similar results. There were no differences in ketamine-induced dissociation between conditions. Because naltrexone dramatically blocked the antidepressant but not the dissociative effects of ketamine, the trial was halted at the interim analysis.CONCLUSIONS: The findings suggest that ketamine's acute antidepressant effect requires opioid system activation. The dissociative effects of ketamine are not mediated by the opioid system, and they do not appear sufficient without the opioid effect to produce the acute antidepressant effects of ketamine in adults with treatment-resistant depression.
View details for PubMedID 30153752
High-dose spaced theta-burst TMS as a rapid-acting antidepressant in highly refractory depression.
Brain : a journal of neurology
View details for PubMedID 29415152
Five Year Follow-Up of Bilateral Epidural Prefrontal Cortical Stimulation for Treatment-Resistant Depression
2016; 9 (6): 897-904
Epidural prefrontal cortical stimulation (EpCS) represents a novel therapeutic approach with many unique benefits that can be used for treatment-resistant depression (TRD).To examine the long-term safety and efficacy of EpCS of the frontopolar cortex (FPC) and dorsolateral prefrontal cortex (DLPFC) for treatment of TRD.Adults (N = 5) who were 21-80 years old with severe TRD [failure to respond to adequate courses of at least 4 antidepressant medications, psychotherapy and ≥20 on the Hamilton Rating Scale for Depression (HRSD24)] were recruited. Participants were implanted with bilateral EpCS over the FPC and DLPFC and received constant, chronic stimulation throughout the five years with Medtronic IPGs. They were followed for 5 years (2/1/2008-10/14/2013). Efficacy of EpCS was assessed with the HRSD24 in an open-label design as the primary outcome measure at five years.All 5 patients continued to tolerate the therapy. The mean improvements from pre-implant baseline on the HRSD24 were [7 months] 54.9% (±37.7), [1 year] 41.2% (±36.6), [2 years] 53.8% (±21.7), and [5 years] 45% (±47). Three of 5 (60%) subjects continued to be in remission at 5 years. There were 5 serious adverse events: 1 electrode 'paddle' infection and 4 device malfunctions, all resulting in suicidal ideation and/or hospitalization.These results suggest that chronic bilateral EpCS over the FPC and DLPFC is a promising and potentially durable new technology for treating TRD, both acutely and over 5 years.
View details for DOI 10.1016/j.brs.2016.06.054
View details for Web of Science ID 000387197500013
View details for PubMedID 27443912
Deep brain stimulation (DBS) at the interface of neurology and psychiatry
JOURNAL OF CLINICAL INVESTIGATION
2013; 123 (11): 4546-4556
Deep brain stimulation (DBS) is an emerging interventional therapy for well-screened patients with specific treatment-resistant neuropsychiatric diseases. Some neuropsychiatric conditions, such as Parkinson disease, have available and reasonable guideline and efficacy data, while other conditions, such as major depressive disorder and Tourette syndrome, have more limited, but promising results. This review summarizes both the efficacy and the neuroanatomical targets for DBS in four common neuropsychiatric conditions: Parkinson disease, Tourette syndrome, major depressive disorder, and obsessive-compulsive disorder. Based on emerging new research, we summarize novel approaches to optimization of stimulation for each neuropsychiatric disease and we review the potential positive and negative effects that may be observed following DBS. Finally, we summarize the likely future innovations in the field of electrical neural-network modulation.
View details for DOI 10.1172/JCI68341
View details for Web of Science ID 000326611900002
View details for PubMedID 24177464
Hypnotic predictors of agency: Responsiveness to specific suggestions in hypnosis is associated with involuntariness in fibromyalgia.
Consciousness and cognition
2021; 96: 103221
Hypnosis is associated with alterations in the sense of agency which can play a role in its utilization as a nonpharmacological option for pain management. The goal of the current study was to examine the relationships between responsiveness to suggestions in hypnosis and alterations of the sense of agency among patients with fibromyalgia. Ninety-eight participants with fibromyalgia underwent two hypnotizability assessments followed by the Sense of Agency Rating Scale. Clinical pain measures were also collected. Involuntariness was predicted by responsiveness to control, ideomotor, and dissociation suggestions. Effortlessness was predicted by responsiveness to control and ideomotor suggestions, and age. Hypnotizability was associated with main clinical pain outcomes, but agency alterations were not. Results suggest a shared mechanism between responsiveness to specific suggestions and the sense of agency in hypnosis. We discuss theoretical and clinical implications for pain management and the need for further research.
View details for DOI 10.1016/j.concog.2021.103221
View details for PubMedID 34695719
- Unraveling the opioid actions of S-ketamine and R-ketamine: comment on Bonaventura et al. Molecular psychiatry 2021
Accelerated Neuromodulation Therapy for Obsessive-Compulsive Disorder.
The open-label trial of Williams, Sudheimer, Cole, et al., suggests safety, feasibility, and high efficacy for treatment-refractory OCD of an accelerated, fMRI-guided, high-dose, cTBSmod protocol targeting the right frontal pole. Larger, randomized, controlled trials are needed to test the promising results of this pilot study. CLINICALTRIALS.GOV REGISTRY NUMBERS: NCT03404609.
View details for DOI 10.1016/j.brs.2021.02.013
View details for PubMedID 33631349
- The Future of Training and Practice in Neuromodulation: An Interventional Psychiatry Perspective. Frontiers in psychiatry 2021; 12: 734487
- Lather, Rinse, Repeat? Breaking Repetitive Behaviors With Repetitive Stimulation. The American journal of psychiatry 2021; 178 (5): 378–80
- Synchronized Cervical VNS With Accelerated Theta Burst TMS For Treatment Resistant Depression. Brain stimulation 2020
- Transcranial Magnetic Stimulation Parameter Space: Wide Open for Exploration. Biological psychiatry 2020; 87 (5): 384–85
Deep Brain Stimulation Results in Greater Symptomatic Improvement in Tourette Syndrome than Conservative Measures: A Meta-Analysis.
Stereotactic and functional neurosurgery
Deep brain stimulation (DBS) has emerged as a safe and effective therapy for refractory Tourette syndrome (TS). Recent studies have identified several neural targets as effective in reducing TS symptoms with DBS, but, to our knowledge, none has compared the effectiveness of DBS with conservative therapy.A literature review was performed to identify studies investigating adult patient outcomes reported as Yale Global Tic Severity Scale (YGTSS) scores after DBS surgery, pharmacotherapy, and psychotherapy. Data were pooled using a random-effects model of inverse variance-weighted meta-analysis (n = 168 for DBS, n = 131 for medications, and n = 154 for behavioral therapy).DBS resulted in a significantly greater reduction in YGTSS total score (49.9 ± 17.5%) than pharmacotherapy (22.5 ± 15.2%, p = 0.001) or psychotherapy (20.0 ± 11.3%, p < 0.001), with a complication (adverse effect) rate of 0.15/case, 1.13/case, and 0.60/case, respectively.Our data suggest that adult patients with refractory TS undergoing DBS experience greater symptomatic improvement with surprisingly low morbidity than can be obtained with pharmacotherapy or psychotherapy.
View details for DOI 10.1159/000507059
View details for PubMedID 32434201
Evidence for the role of the dorsal ventral lateral posterior thalamic nucleus connectivity in deep brain stimulation for Gilles de la Tourette syndrome.
Journal of psychiatric research
2020; 132: 60–64
Gilles de la Tourette syndrome (GTS) can manifest as debilitating, medically-refractory tics for which deep brain stimulation (DBS) of the centromedian-parafascicular complex (CM) can provide effective treatment. However, patients have reported benefit with activation of contacts dorsal to the CM and likely in the ventro-lateral thalamus (VL). At our institution, a case of a robust and durable response in a GTS patient required stimulation in the CM and more dorsally. We explore the structural connectivity of thalamic subregions associated with GTS using diffusion MRI tractography. Diffusion weighted images from 40 healthy Human Connectome Project (HCP) subjects and our GTS patient were analyzed. The VL posterior nucleus (VLp) and the CM were used as seeds for whole-brain probabilistic tractography. Leads were localized via linear registration of pre-/post-operative imaging and cross-referenced with the DBS Intrinsic Template Atlas. Tractography revealed high streamline probability from the CM and VLp to the superior frontal gyrus, rostral middle frontal gyrus, brainstem, and ventral diencephalon. Given reported variable responses to DBS along the thalamus, we segmented the VLp based on its connectivity profile. Ventral and dorsal subdivisions emerged, with streamline probability patterns differing between the dorsal VLp and CM. The CM, the most reported DBS target for GTS, and the dorsal VLp have different but seemingly complimentary connectivity profiles as evidenced by our patient who, at 1-year post-operatively, had significant therapeutic benefit. Stimulation of both regions may better target reward and motor circuits, resulting in enhanced symptom control for GTS.
View details for DOI 10.1016/j.jpsychires.2020.09.024
View details for PubMedID 33045620
Brain-Responsive Neurostimulation for Loss of Control Eating: Early Feasibility Study.
Loss of control (LOC) is a pervasive feature of binge eating, which contributes significantly to the growing epidemic of obesity; approximately 80 million US adults are obese. Brain-responsive neurostimulation guided by the delta band was previously found to block binge-eating behavior in mice. Following novel preclinical work and a human case study demonstrating an association between the delta band and reward anticipation, the US Food and Drug Administration approved an Investigational Device Exemption for a first-in-human study.To assess feasibility, safety, and nonfutility of brain-responsive neurostimulation for LOC eating in treatment-refractory obesity.This is a single-site, early feasibility study with a randomized, single-blinded, staggered-onset design. Six subjects will undergo bilateral brain-responsive neurostimulation of the nucleus accumbens for LOC eating using the RNS® System (NeuroPace Inc). Eligible participants must have treatment-refractory obesity with body mass index ≥ 45 kg/m2. Electrophysiological signals of LOC will be characterized using real-time recording capabilities coupled with synchronized video monitoring. Effects on other eating disorder pathology, mood, neuropsychological profile, metabolic syndrome, and nutrition will also be assessed.Safety/feasibility of brain-responsive neurostimulation of the nucleus accumbens will be examined. The primary success criterion is a decrease of ≥1 LOC eating episode/week based on a 28-d average in ≥50% of subjects after 6 mo of responsive neurostimulation.This study is the first to use brain-responsive neurostimulation for obesity; this approach represents a paradigm shift for intractable mental health disorders.
View details for DOI 10.1093/neuros/nyaa300
View details for PubMedID 32717033
- Multimodal characterization of the human nucleus accumbens NEUROIMAGE 2019; 198: 137–49
- Rigorous Trial Design Is Essential to Understand the Role of Opioid Receptors in Ketamine's Antidepressant Effect JAMA PSYCHIATRY 2019; 76 (6): 657–58
- Attenuation of Anti-Suicidal Effects of Ketamine by Opioid Receptor Antagonism ELSEVIER SCIENCE INC. 2019: S113
- Stanford Accelerated Intelligent Neuromodulation Therapy for Suicidal Ideation (SAINT-SI) ELSEVIER SCIENCE INC. 2019: S28
- The Effects of Cortisol Administration on Emotion, Stress Reactivity, and Brain Activity in Depression ELSEVIER SCIENCE INC. 2019: S267
Rigorous Trial Design Is Essential to Understand the Role of Opioid Receptors in Ketamine's Antidepressant Effect.
View details for PubMedID 31042274
- Rigorous Translational Models Are Key to Studying Ketamine's Antidepressant Mechanism: Response to Wang and Kaplin AMERICAN JOURNAL OF PSYCHIATRY 2019; 176 (5): 412
- Robust clinical benefit of multi-target deep brain stimulation for treatment of Gilles de la Tourette syndrome and its comorbidities BRAIN STIMULATION 2019; 12 (3): 816–18
Rigorous Translational Models Are Key to Studying Ketamine's Antidepressant Mechanism: Response to Wang and Kaplin.
The American journal of psychiatry
2019; 176 (5): 412
View details for PubMedID 31039633
Case Studies in Neuroscience: The electrophysiology of a human obsession in nucleus accumbens.
Journal of neurophysiology
Microelectrode recordings were performed during awake deep brain stimulation surgery for obsessive-compulsive disorder, revealing robust brain oscillations that were plainly visible throughout the ventral striatum. There was an elegant topological correspondence between each oscillation and the underlying brain anatomy, most prominently a ~35Hz gamma-oscillation specific to the nucleus accumbens. Direct provocation of the patient's contamination obsession modulated both firing rate and gamma-oscillation amplitude within the nucleus accumbens.
View details for DOI 10.1152/jn.00096.2019
View details for PubMedID 31017846
- Comparative effectiveness of neuroablation and deep brain stimulation for treatment-resistant obsessive-compulsive disorder: a meta-analytic study JOURNAL OF NEUROLOGY NEUROSURGERY AND PSYCHIATRY 2019; 90 (4): 469–73
Robust clinical benefit of multi-target deep brain stimulation for treatment of Gilles de la Tourette syndrome and its comorbidities.
View details for PubMedID 30878341
- Interpreting Ketamine's Opioid Receptor Dependent Effect: Response to Sanacora AMERICAN JOURNAL OF PSYCHIATRY 2019; 176 (3): 249–50
Target Population, Dose, and Timing Considerations for Understanding Naltrexone's Subjective Effect: Response to Amiaz.
The American journal of psychiatry
2019; 176 (3): 251–52
View details for PubMedID 30818989
Interpreting Ketamine's Opioid Receptor Dependent Effect: Response to Sanacora.
The American journal of psychiatry
2019; 176 (3): 249–50
View details for PubMedID 30818991
- Target Population, Dose, and Timing Considerations for Understanding Naltrexone's Subjective Effect: Response to Amiaz AMERICAN JOURNAL OF PSYCHIATRY 2019; 176 (3): 251–52
Multimodal characterization of the human nucleus accumbens.
Dysregulation of the nucleus accumbens (NAc) is implicated in numerous neuropsychiatric disorders. Treatments targeting this area directly (e.g. deep brain stimulation) demonstrate variable efficacy, perhaps owing to non-specific targeting of a functionally heterogeneous nucleus. Here we provide support for this notion, first observing disparate behavioral effects in response to direct simulation of different locations within the NAc in a human patient. These observations motivate a segmentation of the NAc into subregions, which we produce from a diffusion-tractography based analysis of 245 young, unrelated healthy subjects. We further explore the mechanism of these stimulation-induced behavioral responses by identifying the most probable subset of axons activated using a patient-specific computational model. We validate our diffusion-based segmentation using evidence from several modalities, including MRI-based measures of function and microstructure, human post-mortem immunohistochemical staining, and cross-species comparison of cortical-NAc projections that are known to be conserved. Finally, we visualize the passage of individual axon bundles through one NAc subregion in a post-mortem human sample using CLARITY 3D histology corroborated by 7T tractography. Collectively, these findings extensively characterize human NAc subregions and provide insight into their structural and functional distinctions with implications for stereotactic treatments targeting this region.
View details for PubMedID 31077843
- Adjunctive repetitive transcranial magnetic stimulation delivers superior quality of life for focal epilepsy compared to anti-epileptic drugs: A meta-analytic utility prediction study. Brain stimulation 2019
Comparative effectiveness of neuroablation and deep brain stimulation for treatment-resistant obsessive-compulsive disorder: a meta-analytic study.
Journal of neurology, neurosurgery, and psychiatry
The safety and efficacy of neuroablation (ABL) and deep brain stimulation (DBS) for treatment refractory obsessive-compulsive disorder (OCD) has not been examined. This study sought to generate a definitive comparative effectiveness model of these therapies.A EMBASE/PubMed search of English-language, peer-reviewed articles reporting ABL and DBS for OCD was performed in January 2018. Change in quality of life (QOL) was quantified based on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the impact of complications on QOL was assessed. Mean response of Y-BOCS was determined using random-effects, inverse-variance weighted meta-analysis of observational data.Across 56 studies, totalling 681 cases (367 ABL; 314 DBS), ABL exhibited greater overall utility than DBS. Pooled ability to reduce Y-BOCS scores was 50.4% (±22.7%) for ABL and was 40.9% (±13.7%) for DBS. Meta-regression revealed no significant change in per cent improvement in Y-BOCS scores over the length of follow-up for either ABL or DBS. Adverse events occurred in 43.6% (±4.2%) of ABL cases and 64.6% (±4.1%) of DBS cases (p<0.001). Complications reduced ABL utility by 72.6% (±4.0%) and DBS utility by 71.7% (±4.3%). ABL utility (0.189±0.03) was superior to DBS (0.167±0.04) (p<0.001).Overall, ABL utility was greater than DBS, with ABL showing a greater per cent improvement in Y-BOCS than DBS. These findings help guide success thresholds in future clinical trials for treatment refractory OCD.
View details for PubMedID 30679237
- Attenuation of Antidepressant Effects of Ketamine by Opioid Receptor Antagonism AMER PSYCHIATRIC PUBLISHING, INC. 2018: 1205–15
KETAMINE'S ANTIDEPRESSANT EFFECT IS BLOCKED BY A MU-OPIOID RECEPTOR ANTAGONIST IN HUMANS AND MICE
LIPPINCOTT WILLIAMS & WILKINS. 2018: 343
View details for Web of Science ID 000460106500197
Closing the loop on impulsivity via nucleus accumbens delta-band activity in mice and man.
Proceedings of the National Academy of Sciences of the United States of America
2018; 115 (1): 192–97
Reward hypersensitization is a common feature of neuropsychiatric disorders, manifesting as impulsivity for anticipated incentives. Temporally specific changes in activity within the nucleus accumbens (NAc), which occur during anticipatory periods preceding consummatory behavior, represent a critical opportunity for intervention. However, no available therapy is capable of automatically sensing and therapeutically responding to this vulnerable moment in time when anticipation-related neural signals may be present. To identify translatable biomarkers for an off-the-shelf responsive neurostimulation system, we record local field potentials from the NAc of mice and a human anticipating conventional rewards. We find increased power in 1- to 4-Hz oscillations predominate during reward anticipation, which can effectively trigger neurostimulation that reduces consummatory behavior in mice sensitized to highly palatable food. Similar oscillations are present in human NAc during reward anticipation, highlighting the translational potential of our findings in the development of a treatment for a major unmet need.
View details for PubMedID 29255043
Transcranial Magnetic Stimulation for Disorders Other Than Depression
TRANSCRANIAL MAGNETIC STIMULATION: CLINICAL APPLICATIONS FOR PSYCHIATRIC PRACTICE
View details for Web of Science ID 000549755600010
Influence of gender on inpatient treatment for bipolar disorder: An analysis of 60,607 hospitalisations
JOURNAL OF AFFECTIVE DISORDERS
2018; 225: 104–7
The influence of gender on inpatient treatment patterns in bipolar patients is unclear. The aim of this study is to examine whether differences in length of stay and frequency of inpatient episodes, according to ICD-10 bipolar disorder (BD)-subgroups, exist between men and women.All episodes of a manic (F31.0-2), depressive (F31.3-5) or mixed (F31.6) subtype of BD during an inpatient stay in an Austrian hospital in the period of 2001-2014 were included in this study. Data on episodes was provided by the national statistics agency. Weekly admission rates per 100,000 people were calculated by directly age-standardized rates.The database comprised 60,607 admissions (35.8% men). The number of inpatient episodes was significantly higher (p < 0.001) in women in all BD subgroups. Average length of stay in manic (p < 0.001) and depressive (p < 0.001) episodes was shorter in women compared to men. No difference could be found for mixed episodes.Only aggregated patient data and no single case histories were available for this study.The current study reveals relevant gender differences regarding inpatient treatment patterns, as women were overrepresented in all BD-subgroups. Despite equal life time prevalence, severe mood episodes lead more often to hospitalisations in women. There is a high necessity to further research the underlying causes of these findings.
View details for PubMedID 28810176
Modulation of the Neural Circuitry Underlying Trait Hypnotizability With Spaced Continuous Theta-Burst Stimulation
NATURE PUBLISHING GROUP. 2017: S508–S509
View details for Web of Science ID 000416846303052
- It takes time to tune ANNALS OF TRANSLATIONAL MEDICINE 2017; 5 (7): 171
Neuroversion: using electroconvulsive therapy as a bridge to deep brain stimulation implantation
2017; 23 (1): 26-30
Parkinson's disease (PD) is a movement disorder with significant neuropsychiatric comorbidities. Electroconvulsive therapy (ECT) is effective in treating these neuropsychiatric symptoms; however, clinicians are reluctant to use ECT in patients with deep brain stimulation (DBS) implantations for fear of damaging the device, as well as potential cognitive side effects. Right unilateral ultra-brief pulse (RUL UBP) ECT has a more favorable cognitive side-effect profile yet has never been reported in PD patients with DBS implants. We present a case series of three patients with a history of PD that all presented with psychiatric decompensation immediately prior to planned DBS surgery. All three patients had DBS electrode(s) in place at the time and an acute course of ECT was utilized in a novel method to "bridge" these individuals to neurosurgery. The patients all experienced symptom resolution (psychosis and/or depression and/or anxiety) without apparent cognitive side effects. This case series not only illustrates that right unilateral ultra-brief pulse can be utilized in patients with DBS electrodes but also illustrates that this intervention can be utilized as a neuromodulatory "bridge", where nonoperative surgical candidates with unstable psychiatric symptoms can be converted to operative candidates in a manner similar to electrical cardioversion.
View details for DOI 10.1080/13554794.2016.1276605
View details for Web of Science ID 000399644200005
View details for PubMedID 28376692
- It Takes Time to Tune Annals of Translational Medicine 2017; In Press
Optimization of epidural cortical stimulation for treatment-resistant depression.
View details for PubMedID 28918944
- Description of a Novel, Surgically Implanted Neuromodulatory Technique Known as Bilateral Epidural Prefrontal Cortical Stimulation (EpCS) for Treatment-Resistant Depression (TRD) Journal of Visualized Experiments 2017; In Press
Unilateral ultra-brief pulse electroconvulsive therapy for depression in Parkinson's disease.
Acta neurologica Scandinavica
Electroconvulsive therapy (ECT) has demonstrated efficacy in treating core symptoms of Parkinson's disease (PD); however, widespread use of ECT in PD has been limited due to concern over cognitive burden. We investigated the use of a newer ECT technology known to have fewer cognitive side effects (right unilateral [RUL] ultra-brief pulse [UBP]) for the treatment of medically refractory psychiatric dysfunction in PD.This open-label pilot study included 6 patients who were assessed in the motoric, cognitive, and neuropsychiatric domains prior to and after RUL UBP ECT. Primary endpoints were changes in total score on the HAM-D-17 and GDS-30 rating scales.Patients were found to improve in motoric and psychiatric domains following RUL UBP ECT without cognitive side effects, both immediately following ECT and at 1-month follow-up.This study demonstrates that RUL UBP ECT is safe, feasible, and potentially efficacious in treating multiple domains of PD, including motor and mood, without clear cognitive side effects.
View details for DOI 10.1111/ane.12614
View details for PubMedID 27241213
View details for PubMedCentralID PMC5133197
Stimulating Across the Frontostriatal Circuitry to Treat Parkinson's Disease
ELSEVIER SCIENCE INC. 2016: 402S–403S
View details for Web of Science ID 000432440805134
Neuroversion: Using Electroconvulsive Therapy as a Bridge to Deep Brain Stimulation Implantation
ELSEVIER SCIENCE INC. 2016: 127S–128S
View details for Web of Science ID 000432440801153
Reward circuit DBS improves Parkinson's gait along with severe depression and OCD
2016; 22 (2): 201-204
A 59-year-old Caucasian man with a past history of Parkinson's disease (PD) status post-bilateral subthalamic nucleus (STN) deep brain stimulation (DBS), who also had treatment-resistant (TR) obsessive-compulsive disorder (OCD), and treatment-resistant depression (TRD), presented for further evaluation and management of his TR OCD. After an unsuccessful attempt to treat his OCD by reprogramming his existing STN DBS, he was offered bilateral ventral capsule/ventral striatum (VC/VS) DBS surgery. In addition to the expected improvement in OCD symptoms, he experienced significant improvement in both PD-related apathy and depression along with resolution of suicidal ideation. Furthermore, the patient's festinating gait dramatically improved. This case demonstrates that DBS of both the STN and VC/VS appears to have an initial signal of safety and tolerability. This is the first instance where both the STN and the VC/VS DBS targets have been implanted in an individual and the first case where a patient with PD has received additional DBS in mood-regulatory circuitry.
View details for DOI 10.1080/13554794.2015.1112019
View details for Web of Science ID 000369770400011
View details for PubMedID 26644268
NMDA antagonist treatment of depression.
Current opinion in neurobiology
2016; 36: 112-117
Ketamine is a psychoactive anesthetic agent, which has been approved and utilized for various forms of anesthesia over decades. Recently, ketamine has been demonstrated to have robust and rapid antidepressant effects in individuals with treatment-resistant depression. After more than a decade of research, it is unclear what the mechanisms underlying the novel antidepressant effect are. The consensus has centered on NMDA properties of ketamine as a potential factor in the mechanism for antidepressant action. However, this may be a true but partial explanation of the effects of ketamine as a novel antidepressant. It appears that ketamine influences synaptic plasticity and may promote new synapse formation. From a neurocircuitry perspective, ketamine may exert some of its effects on the anterior cingulate.
View details for DOI 10.1016/j.conb.2015.11.001
View details for PubMedID 26687375
Beyond Neural Cubism: Promoting a Multidimensional View of Brain Disorders by Enhancing the Integration of Neurology and Psychiatry in Education
2015; 90 (5): 581-586
Cubism was an influential early-20th-century art movement characterized by angular, disjointed imagery. The two-dimensional appearance of Cubist figures and objects is created through juxtaposition of angles. The authors posit that the constrained perspectives found in Cubism may also be found in the clinical classification of brain disorders. Neurological disorders are often separated from psychiatric disorders as if they stemmed from different organ systems. Maintaining two isolated clinical disciplines fractionalizes the brain in the same way that Pablo Picasso fractionalized figures and objects in his Cubist art. This Neural Cubism perpetuates a clinical divide that does not reflect the scope and depth of neuroscience. All brain disorders are complex and multidimensional, with aberrant circuitry and resultant psychopharmacology manifesting as altered behavior, affect, mood, or cognition. Trainees should receive a multidimensional education based on modern neuroscience, not a partial education based on clinical precedent. The authors briefly outline the rationale for increasing the integration of neurology and psychiatry and discuss a nested model with which clinical neuroscientists (neurologists and psychiatrists) can approach and treat brain disorders.
View details for DOI 10.1097/ACM.0000000000000530
View details for Web of Science ID 000353879700016
View details for PubMedID 25340364
View details for PubMedCentralID PMC4405399
Oscillating Square Wave Transcranial Direct Current Stimulation (tDCS) Delivered During Slow Wave Sleep Does Not Improve Declarative Memory More Than Sham: A Randomized Sham Controlled Crossover Study
2015; 8 (3): 528-534
A 2006 trial in healthy medical students found that anodal slow oscillating tDCS delivered bi-frontally during slow wave sleep had an enhancing effect in declarative, but not procedural memory. Although there have been supporting animal studies, and similar findings in pathological groups, this study has not been replicated, or refuted, in the intervening years. We therefore tested these earlier results for replication using similar methods with the exception of current waveform (square in our study, nearly sinusoidal in the original).Our objective was to test the findings of a 2006 trial suggesting bi-frontal anodal tDCS during slow wave sleep enhances declarative memory.Twelve students (mean age 25, 9 women) free of medical problems underwent two testing conditions (active, sham) in a randomized counterbalanced fashion. Active stimulation consisted of oscillating square wave tDCS delivered during early Non-Rapid Eye Movement (NREM) sleep. The sham condition consisted of setting-up the tDCS device and electrodes, but not turning it on during sleep. tDCS was delivered bi-frontally with anodes placed at F3/F4, and cathodes placed at mastoids. Current density was 0.517 mA/cm(2), and oscillated between zero and maximal current at a frequency of 0.75 Hz. Stimulation occurred during five-five minute blocks with 1-min inter-block intervals (25 min total stimulation). The primary outcomes were both declarative memory consolidation measured by a paired word association test (PWA), and non-declarative memory, measured by a non-dominant finger-tapping test (FTT). We also recorded and analyzed sleep EEG.There was no difference in the number of paired word associations remembered before compared to after sleep [(active = 3.1 ± 3.0 SD more associations) (sham = 3.8 ± 3.1 SD more associations)]. Finger tapping improved, (non-significantly) following active stimulation [(3.6 ± 2.7 SD correctly typed sequences) compared to sham stimulation (2.3 ± 2.2 SD correctly typed sequences)].In this study, we failed to find improvements in declarative or performance memory and could not replicate an earlier study using nearly identical settings. Specifically we failed to find a beneficial effect on either overnight declarative or non-declarative memory consolidation via square-wave oscillating tDCS intervention applied bi-frontally during early NREM sleep. It is unclear if the morphology of the tDCS pulse is critical in any memory related improvements.
View details for DOI 10.1016/j.brs.2015.01.414
View details for Web of Science ID 000355772300013
View details for PubMedID 25795621
View details for PubMedCentralID PMC4598642
Adjunctive triple chronotherapy (combined total sleep deprivation, sleep phase advance, and bright light therapy) rapidly improves mood and suicidality in suicidal depressed inpatients: An open label pilot study
JOURNAL OF PSYCHIATRIC RESEARCH
2014; 59: 101-107
Previous studies have demonstrated that combined total sleep deprivation (Wake therapy), sleep phase advance, and bright light therapy (Triple Chronotherapy) produce a rapid and sustained antidepressant effect in acutely depressed individuals. To date no studies have explored the impact of the intervention on unipolar depressed individuals with acute concurrent suicidality. Participants were suicidal inpatients (N = 10, Mean age = 44 ± 16.4 SD, 6F) with unipolar depression. In addition to standard of care, they received open label Triple Chronotherapy. Participants underwent one night of total sleep deprivation (33-36 h), followed by a three-night sleep phase advance along with four 30-min sessions of bright light therapy (10,000 lux) each morning. Primary outcome measures included the 17 item Hamilton depression scale (HAM17), and the Columbia Suicide Severity Rating Scale (CSSRS), which were recorded at baseline prior to total sleep deprivation, and at protocol completion on day five. Both HAM17, and CSSRS scores were greatly reduced at the conclusion of the protocol. HAM17 scores dropped from a mean of 24.7 ± 4.2 SD at baseline to a mean of 9.4 ± 7.3 SD on day five (p = .002) with six of the ten individuals meeting criteria for remission. CSSRS scores dropped from a mean of 19.5 ± 8.5 SD at baseline to a mean of 7.2 ± 5.5 SD on day five (p = .01). The results of this small pilot trial demonstrate that adjunctive Triple Chronotherapy is feasible and tolerable in acutely suicidal and depressed inpatients. Limitations include a small number of participants, an open label design, and the lack of a comparison group. Randomized controlled studies are needed.
View details for DOI 10.1016/j.jpsychires.2014.08.015
View details for Web of Science ID 000344205700014
View details for PubMedID 25231629
View details for PubMedCentralID PMC4252537
Role of functional imaging in the development and refinement of invasive neuromodulation for psychiatric disorders.
World journal of radiology
2014; 6 (10): 756-778
Deep brain stimulation (DBS) is emerging as a powerful tool for the alleviation of targeted symptoms in treatment-resistant neuropsychiatric disorders. Despite the expanding use of neuropsychiatric DBS, the mechanisms responsible for its effects are only starting to be elucidated. Several modalities such as quantitative electroencephalography as well a intraoperative recordings have been utilized to attempt to understand the underpinnings of this new treatment modality, but functional imaging appears to offer several unique advantages. Functional imaging techniques like positron emission tomography, single photon emission computed tomography and functional magnetic resonance imaging have been used to examine the effects of focal DBS on activity in a distributed neural network. These investigations are critical for advancing the field of invasive neuromodulation in a safe and effective manner, particularly in terms of defining the neuroanatomical targets and refining the stimulation protocols. The purpose of this review is to summarize the current functional neuroimaging findings from neuropsychiatric DBS implantation for three disorders: treatment-resistant depression, obsessive-compulsive disorder, and Tourette syndrome. All of the major targets will be discussed (Nucleus accumbens, anterior limb of internal capsule, subcallosal cingulate, Subthalamic nucleus, Centromedial nucleus of the thalamus-Parafasicular complex, frontal pole, and dorsolateral prefrontal cortex). We will also address some apparent inconsistencies within this literature, and suggest potential future directions for this promising area.
View details for DOI 10.4329/wjr.v6.i10.756
View details for PubMedID 25349661
Interventional Psychiatry: Why Now?
JOURNAL OF CLINICAL PSYCHIATRY
2014; 75 (8): 895-897
Interventional psychiatry offers substantial therapeutic benefits in some neuropsychiatric disorders and enormous potential in treating others. However, as interventional diagnostics and therapeutics require specialized knowledge and skill foreign to many psychiatrists, the emerging subspecialty of interventional psychiatry must be more formally integrated into the continuum of psychiatric training to ensure both safe application and continued growth. By establishing training paradigms for interventional psychiatry, academic medical centers can help fill this knowledge gap. The cultivation of a properly trained cohort of interventional psychiatrists will better meet the challenges of treatment-resistant psychiatric illness through safe and ethical practice, while facilitating a more informed development and integration of novel neuromodulation techniques.
View details for DOI 10.4088/JCP.13l08745
View details for Web of Science ID 000345530300019
View details for PubMedID 25191910
Interventional Psychiatry: How Should Psychiatric Educators Incorporate Neuromodulation into Training?
2014; 38 (2): 168-176
Interventional psychiatry is an emerging subspecialty that uses a variety of procedural neuromodulation techniques in the context of an electrocircuit-based view of mental dysfunction as proximal causes for psychiatric diseases.The authors propose the development of an interventional psychiatry-training paradigm analogous to those found in cardiology and neurology.The proposed comprehensive training in interventional psychiatry would include didactics in the theory, proposed mechanisms, and delivery of invasive and noninvasive brain stimulation.The development and refinement of this subspecialty would facilitate safe, effective growth in the field of brain stimulation by certified and credentialed practitioners within the field of psychiatry while also potentially improving the efficacy of current treatments.
View details for DOI 10.1007/s40596-014-0050-x
View details for Web of Science ID 000334414300012
View details for PubMedID 24554501
View details for PubMedCentralID PMC4021584
STN vs. GPi Deep Brain Stimulation: Translating the Rematch into Clinical Practice.
Movement disorders clinical practice
2014; 1 (1): 24–35
When formulating a deep brain stimulation (DBS) treatment plan for a patient with Parkinson's disease (PD), two critical questions should be addressed: 1- Which brain target should be chosen to optimize this patient's outcome? and 2- Should this patient's DBS operation be unilateral or bilateral? Over the past two decades, two targets have emerged as leading contenders for PD DBS; the subthalamic nucleus (STN) and the globus pallidus internus (GPi). While the GPi target does have a following, most centers have uniformly employed bilateral STN DBS for all Parkinson's disease cases (Figure 1). This bilateral STN "one-size-fits-all" approach was challenged by an editorial entitled "STN vs. GPi: The Rematch," which appeared in the Archives of Neurology in 2005. Since 2005, a series of well designed clinical trials and follow-up studies have addressed the question as to whether a more tailored approach to DBS therapy might improve overall outcomes. Such a tailored approach would include the options of targeting the GPi, or choosing a unilateral operation. The results of the STN vs. GPi 'rematch' studies support the conclusion that bilateral STN DBS may not be the best option for every Parkinson's disease surgical patient. Off period motor symptoms and tremor improve in both targets, and with either unilateral or bilateral stimulation. Advantages of the STN target include more medication reduction, less frequent battery changes, and a more favorable economic profile. Advantages of GPi include more robust dyskinesia suppression, easier programming, and greater flexibility in adjusting medications. In cases where unilateral stimulation is anticipated, the data favor GPi DBS. This review summarizes the accumulated evidence regarding the use of bilateral vs. unilateral DBS and the selection of STN vs. GPi DBS, including definite and possible advantages of different targets and approaches. Based on this evidence, a more patient-tailored, symptom specific approach will be proposed to optimize outcomes of PD DBS therapy. Finally, the importance of an interdisciplinary care team for screening and effective management of DBS patients will be reaffirmed. Interdisciplinary teams can facilitate the proposed patient-specific DBS treatment planning and provide a more thorough analysis of the risk-benefit ratio for each patient.
View details for DOI 10.1002/mdc3.12004
View details for PubMedID 24779023
View details for PubMedCentralID PMC4000041
Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study
ANNALS OF EPIDEMIOLOGY
2013; 23 (12): 750-756
Few studies of sport-related traumatic brain injury (TBI) are population-based or rely on directly observed data on cause, demographic characteristics, and severity. This study addresses the epidemiology of sport-related TBI in a large population.Data on all South Carolina hospital and emergency department encounters for TBI, 1998-2011, were analyzed. Annual incidence rate of sport-related TBI was calculated, and rates were compared across demographic groups. Sport-related TBI severity was modeled as a function of demographic and TBI characteristics using logistic regression.A total of 16,642 individuals with sport-related TBI yielded an average annual incidence rate of 31.5/100,000 population with a steady increase from 19.7 in 1998 to 45.6 in 2011. The most common mechanisms of sport-related TBI were kicked in football (38.1%), followed by fall injuries in sports (20.3%). Incidence rate was greatest in adolescents ages 12-18 (120.6/100,000/persons). Severe sport-related TBI was strongly associated with off-road vehicular sport (odds ratio [OR], 4.73; 95% confidence interval [95% CI], 2.92-7.67); repeated head trauma (OR, 4.36; 95% CI, 3.69-5.15); equestrian sport (OR, 2.73; 95% CI, 1.64-4.51); and falls during sport activities (OR, 2.72; 95% CI, 1.67-4.46).The high incidence of sport-related TBI in youth, potential for repetitive mild TBI, and its long-term consequences on learning warrants coordinated surveillance activities and population-based outcome studies.
View details for DOI 10.1016/j.annepidem.2013.07.022
View details for Web of Science ID 000327926100002
View details for PubMedID 24060276
Unique Case of "Post-Lumbar Puncture Headache"
2013; 53 (9): 1479-1481
Lumbar puncture (LP) is associated with complications that include post-LP orthostatic headache, local bleeding, and subdural hematoma. We report a unique case of a spontaneous frontal epidural hematoma following a therapeutic lumbar puncture in a patient with a history of idiopathic intracranial hypertension. This case highlights the importance of symptomatology in patients following LPs by revealing a rare intracranial presentation that would be devastating if not discovered promptly and appropriately managed.
View details for DOI 10.1111/head.12005
View details for Web of Science ID 000325156600008
View details for PubMedID 23298181
PEDIATRIC EMERGENCY CARE
2012; 28 (9): 926-935
During the past decade, awareness of concussions has exploded as both the media and the medical literature have given more focus to this common problem. Concussions after recreational activities, especially athletics, are a frequent complaint in the emergency department. In the past few years, care of these patients has been simplified as grading systems and classifications have been abandoned. However, questions remain as to the best way to rehabilitate these patients to avoid long-term sequelae, especially in children and adolescents. The purpose of this review is to discuss the demographic characteristics, the pathophysiology, definition, clinical characteristics, and management of concussions in children and adolescents.
View details for DOI 10.1097/PEC.0b013e318267f674
View details for Web of Science ID 000308673600023
View details for PubMedID 22940896
High school coaches perceptions of physicians' role in the assessment and management of sports-related concussive injury.
Frontiers in neurology
2012; 3: 130-?
Sports concussions are an increasingly recognized common type of mild traumatic brain injury (TBI) that affect athletes of all ages. The need for an increased involvement of trained physicians in the diagnosis and treatment of concussion has become more obvious as the pathophysiology and long-term sequelae of sports concussion are better understood. To date, there has been great variability in the athletic community about the recognition of symptoms, diagnosis, management, and physician role in concussion care. An awareness assessment survey administered to 96 high school coaches in a large metropolitan city demonstrated that 37.5% of responders refer their concussed players to an emergency department after the incident, only 39.5% of responders have a physician available to evaluate their players after a concussion, 71.6% of those who had a physician available sent their players to a sports medicine physician, and none of the responders had their player's concussion evaluated by a neurologist. Interestingly, 71.8% of responders stated that their players returned to the team with "return to play" guidelines from their physician. This survey has highlighted two important areas where the medical community can better serve the athletic community. Because a concussion is a sport-inflicted injury to the nervous system, it is optimally evaluated and managed by a clinician with relevant training in both clinical neuroscience and sports medicine. Furthermore, all physicians who see patients suffering concussion should be educated in the current recommendations from the Consensus Statement on Concussion and provide return to play instructions that outline a graduated return to play, allowing the athlete to return to the field safely.
View details for DOI 10.3389/fneur.2012.00130
View details for PubMedID 23060851
Diagnosis, Treatment, and Long-Term Outcomes of Late-Onset (Type III) Multiple Acyl-CoA Dehydrogenase Deficiency
JOURNAL OF CHILD NEUROLOGY
2010; 25 (8): 954-960
We report 4 children with late-onset (type III) multiple acyl-CoA dehydrogenase deficiency, also known as glutaric aciduria type II, which is an autosomal recessive disorder of fatty acid and amino acid metabolism. The underlying deficiency is in the electron transfer flavoprotein or electron flavoprotein dehydrogenase. Clinical presentations include fatal acute neonatal metabolic encephalopathies with/without organ system anomalies (types I and II) and late-onset acute metabolic crises, myopathy, or neurodevelopmental delays (type III). Two patients were identified in childhood following a metabolic crisis and/or neurodevelopmental delay, and 2 were identified by newborn metabolic screening. Our cases will illustrate the difficulty in making a biochemical diagnosis of late-onset (type III) multiple acyl-CoA dehydrogenase deficiency from plasma acylcarnitines and urine organic acids in both symptomatic and asymptomatic children. However, they emphasize the need for timely diagnosis to urgently implement prophylactic treatment for life-threatening metabolic crises with low protein/fat diets supplemented with riboflavin and carnitine.
View details for DOI 10.1177/0883073809351984
View details for Web of Science ID 000279908100003
View details for PubMedID 20023066
Relapse rates with long-term antidepressant drug therapy: a meta-analysis
HUMAN PSYCHOPHARMACOLOGY-CLINICAL AND EXPERIMENTAL
2009; 24 (5): 401-408
Several long-term double-blind placebo controlled trials have shown prophylactic antidepressant therapy in unipolar depression. The goal of this work was to conduct a meta-analysis that would incorporate the most recent trials and evaluate their overall level of efficacy and relapse prevention over time.We performed a comprehensive literature search. The extracted data from selected studies were used to construct a regression model and evaluate the effect of treatment, time on medication, severity of illness, age, gender, and number of previous episodes.Across 11 maintenance treatment studies, the relapse rate was significantly different at 1 year for active drug (23%) versus placebo (51%). In addition, time on medication significantly affected the relapse rate.Prophylactic antidepressant drug therapy appears efficacious in preventing future relapses across a range of illness severity as well as age. More studies are needed to explore the effects of various acute antidepressant strategies and the direct influence of treatment resistance on relapse outcomes.
View details for DOI 10.1002/hup.1033
View details for Web of Science ID 000268116900004
View details for PubMedID 19526453