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J Neurosurg. 2018 Dec 1;129(6):1562-1571. doi: 10.3171/2017.8.JNS1733.

Prediction of depression and anxiety via patient-assessed tremor severity, not physician-reported motor symptom severity, in patients with Parkinson's disease or essential tremor who have undergone deep brain stimulation.

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1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.
2Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania.
3Department of Neurosurgery, Neurological Institute.
4Department of Quantitative Health Science, Cleveland Clinic.
5Center for Neurological Restoration, Department of Neurosurgery, Neurological Institute.
6Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio; and.


OBJECTIVEDeep brain stimulation (DBS) is an effective therapy for movement disorders such as idiopathic Parkinson's disease (PD) and essential tremor (ET). However, some patients who demonstrate benefit on objective motor function tests do not experience postoperative improvement in depression or anxiety, 2 important components of quality of life (QOL). Thus, to examine other possible explanations for the lack of a post-DBS correlation between improved objective motor function and decreased depression or anxiety, the authors investigated whether patient perceptions of motor symptom severity might contribute to disease-associated depression and anxiety.METHODSThe authors performed a retrospective chart review of PD and ET patients who had undergone DBS at the Cleveland Clinic in the period from 2009 to 2013. Patient demographics, diagnosis (PD, ET), motor symptom severity, and QOL measures (Primary Care Evaluation of Mental Disorders 9-item Patient Health Questionnaire [PHQ-9] for depression, Generalized Anxiety Disorder 7-item Scale [GAD-7], and patient-assessed tremor scores) were collected at 4 time points: preoperatively, postoperatively, 1-year follow-up, and 2-year follow-up. Multivariable prediction models with solutions for fixed effects were constructed to assess the correlation of predictor variables with PHQ-9 and GAD-7 scores. Predictor variables included age, sex, visit time, diagnosis (PD vs ET), patient-assessed tremor, physician-reported tremor, Unified Parkinson's Disease Rating Scale part III (UPDRS-III) score, and patient-assessed tremor over time.RESULTSSeventy PD patients and 17 ET patients were included in this analysis. Mean postoperative and 1-year follow-up UPDRS-III and physician-reported tremor scores were significantly decreased compared with preoperative scores (p < 0.0001). Two-year follow-up physician-reported tremor was also significantly decreased from preoperative scores (p < 0.0001). Only a diagnosis of PD (p = 0.0047) and the patient-assessed tremor rating (p < 0.0001) were significantly predictive of depression. A greater time since surgery, in general, significantly decreased anxiety scores (p < 0.0001) except when a worsening of patient-assessed tremor was reported over the same time period (p < 0.0013).CONCLUSIONSPatient-assessed tremor severity alone was predictive of depression in PD and ET following DBS. This finding suggests that a patient's perception of illness plays a greater role in depression than objective physical disability regardless of the time since surgical intervention. In addition, while anxiety may be attenuated by DBS, patient-assessed return of tremor over time can increase anxiety, highlighting the importance of long-term follow-up for behavioral health features in chronic neurological disorders. Together, these data suggest that the patient experience of motor symptoms plays a role in depression and anxiety-a finding that warrants consideration when evaluating, treating, and following movement disorder patients who are candidates for DBS.


ADL = activity of daily living; DBS = deep brain stimulation; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; ET = essential tremor; FTM = Fahn-Tolosa-Marin tremor rating scale; GAD-7 = Generalized Anxiety Disorder 7-item Scale; PD = Parkinson’s disease; PHQ-9 = 9-item Patient Health Questionnaire; Parkinson’s disease; QOL = quality of life; UPDRS-III = Unified Parkinson’s Disease Rating Scale part III; anxiety; deep brain stimulation; depression; essential tremor; functional neurosurgery; patient-perceived tremor; quality of life


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