The

n e w e ng l a n d j o u r na l

of

m e dic i n e

c or r e sp ondence

Deep-Brain Stimulation for Parkinsons Disease

To the Editor: We are impressed by the favorable outcome of deep-brain stimulation, as compared with optimal medical management alone,
for levodopa-related motor complications of advanced Parkinsons disease in the study reported
by Deuschl et al. (Aug. 31 issue).1 However, we disagree with the conclusion that cognition, mood,
and overall psychiatric functioning were unchanged
by neurostimulation. One patient in the treatment
group but none in the control group committed
suicide; seven patients in the treatment group but
none in the control group had depressive symptoms or cognitive disturbances. The exact nature
or putative causes of these adverse events are not
mentioned. Second, the use of two psychiatric rating scales without formal clinical assessment by
a psychiatrist and only at two points, before and
after 6 months of treatment, is insufficient to detect and monitor psychiatric side effects. Given the
fact that deep-brain stimulation in different target areas is clearly associated with both psychiatric and other side effects,2,3 careful and comprehensive monitoring of all such effects is imperative
in future studies.
Klaus Lieb, M.D.
University Medical Center
79104 Freiburg, Germany

Thomas E. Schlaepfer, M.D.

University Hospital
53105 Bonn, Germany
schlaepf@jhmi.edu

this weeks letters

2256 Deep-Brain Stimulation for Parkinsons Disease
2257 Termination of Resuscitation in Out-of-Hospital
Cardiac Arrest
2260 Telithromycin and Acute Liver Failure
2261 Judging the Safety of Aprotinin

2256

n engl j med 355;21

Dr. Schlaepfer reports having served as principal investigator

on an investigator-initiated study partly sponsored by Medtronic.
1. Deuschl G, Schade-Brittinger C, Krack P, et al. A randomized
trial of deep-brain stimulation for Parkinsons disease. N Engl J
Med 2006;355:896-908. [Erratum, N Engl J Med 2006;355:1289.]
2. Schlaepfer T, Lieb K. Deep brain stimulation for treatment
of refractory depression. Lancet 2005;366:1420-2.
3. Piasecki SD, Jefferson JW. Psychiatric complications of deep
brain stimulation for Parkinsons disease. J Clin Psychiatry
2004;65:845-9.

The authors reply: All patients in our study

were assessed by a psychiatrist if psychiatric effects were reported. Individual patients certainly
had psychiatric complications, as reported in our
article, a finding that confirms earlier observations.1,2 However, the aim of the trial was to assess with the use of defined outcome variables
whether a decline in cognition, mood, or overall
psychiatric functioning in the group receiving
neurostimulation, as compared with the medication-only group, compromised the effect of motor improvements on the quality of life. This question can be answered only by comparing the groups
with the use of established and sensitive rating
scales for neuropsychological and psychiatric functioning, not by examining the incidence of psychiatric diagnoses on a case-by-case basis. Outcomes
according to these generally accepted scales did
not differ between the medically treated control
group and the neurostimulation group. Therefore,
neurostimulation neither exerts its effect through
influences on psychiatric functioning nor impairs
overall cognitive and emotional functioning.
Gnther Deuschl, M.D., Ph.D.
Jens Volkmann, M.D., Ph.D.
Universittsklinikum Schleswig-Holstein, Kiel
D-24105 Kiel, Germany
g.deuschl@neurologie.uni-kiel.de
1. Voon V, Kubu C, Krack P, Houeto JL, Troster AI. Deep brain

stimulation: neuropsychological and neuropsychiatric issues.

Mov Disord 2006;21:Suppl 14:S305-S327.
2. Deuschl G, Herzog J, Kleiner-Fisman G, et al. Deep brain
stimulation: postoperative issues. Mov Disord 2006;21:Suppl 14:
S219-S237.

www.nejm.org

november 23, 2006

The New England Journal of Medicine

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