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EpCS in Severe Treatment Resistant Depression

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details. Identifier: NCT04124341
Recruitment Status : Not yet recruiting
First Posted : October 11, 2019
Last Update Posted : October 30, 2019
Information provided by (Responsible Party):
University of Minnesota

Brief Summary:
Purpose: Treatment-resistant depression (TRD) is a leading cause of premature mortality and healthcare costs. Negative stimuli capture the attention of depressed patients. The more entrenched these core attentional processes are, the longer patients remain ill. The parietal Late Positive Potential (LPP) [an event-related potential (ERP) measured by electroencephalography (EEG)], reliably captures biased attention and early affective responses to environmental stimuli. LPP is top-down modulated by the prefrontal cortex (PFC), an important target for depression treatment. Using a combination of anatomical, functional and electric-field simulation localization methods, the investigators will stereotactically implant 15 TRD patients with bilateral EpCS in a 2-phase approach. The investigators will confirm target engagement, reduction of LPP response, as well as examine the relationship between reductions in LPP and changes in depressive symptoms in TRD patients.

Condition or disease Intervention/treatment Phase
Treatment Resistant Depression Device: Epidural Prefrontal Cortical Stimulation (EpCS) Not Applicable

Detailed Description:

Significance of Research Question: TRD patients present with the inability to disengage from negative perceptions and memories, which further dysregulates their mood and prevents them from engaging the outside world with flexibility. The investigators will demonstrate that LPP, a measure of early emotional processes, is a valid target for treating TRD. Intermittent bilateral EpCS will directly engage attention allocation networks, modulate LPP and decrease depressive symptoms. Using Bayesian optimization tools, the investigators can explore a larger number of settings than otherwise possible using classic parametric permutations, and reliably establish a sustained effective target engagement over time. Machine learning and an adaptive clinical trial design will offset the relatively small sample size, enable individualized treatments and help demonstrate that intermittent bilateral EpCS is an effective antidepressant treatment option for severe and chronic depression.

Objectives (confirm target engagement and demonstrate clinical relevance): To examine the relationship between reductions in LPP and clinical improvement. The investigators will define the optimal interval for adjusting EpCS settings over time and key design elements for a more definitive randomized control trial (RCT). This study also aims to explore other electrophysiology and behavioral measures that can add to the adaptive stimulation parameters adjustments method.

Hypothesis: Severe TRD patients with chronic intermittent EpCS therapy will show a sustained lowering of LPP (replication of target engagement) over a 6-month period, and this change will be related to decreases in Hamilton Rating Scale for Depression (HRSD24). This pattern will demonstrate that target engagement (lowering of LPP) is a key mechanism of antidepressant treatment with EpCS.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 15 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Epidural Prefrontal Cortical Stimulation (EpCS) in Severe Treatment Resistant Depression
Estimated Study Start Date : December 1, 2019
Estimated Primary Completion Date : December 31, 2021
Estimated Study Completion Date : December 31, 2021

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: Epidural Prefrontal Cortical Stimulation (EpCS)
Stereotactically implanted bilateral EpCS
Device: Epidural Prefrontal Cortical Stimulation (EpCS)
Prior to surgery, subjects will undergo a high resolution structural scan to identify anatomical landmarks for rostral anterior and lateral prefrontal cortex. Following identification of target areas, EpCS quad leads will be projected over the anterior and lateral prefrontal cortex.Subjects will be kept in the hospital for a minimum of 72 hours for observation during which the investigators will obtain a high resolution spiral CT scan without contrast to confirm lead placements post- operatively and rule out any intra-cranial bleeds. Patients will receive analgesics which they may continue as an outpatient on as needed basis. During this 2-3 weeks recovery period, the attention to pain control and mood is critical. The research team will contact patients at least twice per week to check on their status.

Primary Outcome Measures :
  1. Change in LPP Amplitude [ Time Frame: 6 months ]
    Change in late positive potential (LPP) amplitude as a result of Bayesian optimized bilateral EpCS. LPP is an event-related potential (ERP) measured by electroencephalography (EEG), which reliably captures biased attention and early affective responses to environmental stimuli.

Secondary Outcome Measures :
  1. Change in HRSD Scores [ Time Frame: 6 months ]
    In order to demonstrate that sustained lowering of LPP, as a result of Bayesian optimized bilateral EpCS, change in Hamilton Rating Scale for Depression (HRSD) scores will be calculated. HDRS is a 24-item interview-based tool measuring depression symptoms in the previous week. Scoring is based on only the first 17 items. Eight items are scored on a 5-point scale, ranging from 0 = not present to 4 = severe. Nine are scored from 0-2. Total scores are the sum of the 17 item scores and range from 0 (Normal functioning) to 22 (severe depression).

Information from the National Library of Medicine

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Ages Eligible for Study:   21 Years to 55 Years   (Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Participant has a diagnosis of chronic (greater than or equal to 2 years) depressive episode as defined by DSM V criteria
  • Participant has not had an adequate response to three or more adequate antidepressant treatments from at least two different antidepressant treatment categories in the current depressive episode according to the Antidepressant Treatment History Form (ATHF)
  • Participant must have had ECT or refused to undergo ECT if clinically indicated to them
  • Participant must have HRSD greater than or equal to 20
  • Participant must be able to complete the evaluations needed for this study including the functional imaging scans and the EEG Bayesian optimization sessions

Exclusion Criteria:

  • The EpCS would (in the investigator's judgment) pose an unacceptable surgical or medical risk for the participant
  • Participant is expected to require full body magnetic resonance imaging (MRI) during the clinical study
  • Participant is judged by the investigator to be acutely suicidal (e.g. within the 30 days prior to the EpCS implant the participant has made a suicide attempt or gesture or has made specific plans or preparation to commit suicide or scores 14 or higher on the SSI)
  • In addition to the acute suicidal risks mentioned above, participant meets any of the following:

    1. Has made a suicide attempt within the previous 12 months that required medical treatment
    2. Has made greater than or equal to two suicide attempts in the past 12 months
    3. Has a clear-cut plan for suicide that states that she/he cannot guarantee that she/he will call her/his regular psychiatrist or the Investigator if the impulse to implement the plan becomes substantial during the study
    4. Is likely to attempt suicide within the next six months, in the Investigator's opinion
  • Participant has a history of schizophrenia, schizoaffective disorder, or other psychotic disorder, or a current major depressive episode that includes psychotic features (commonly referred to as psychotic depression) according to the DSM V criteria
  • Participant with a diagnosis of dementia with a Mini-Mental State Exam (MMSE) less than or equal to 23
  • Female participant with a positive urine pregnancy test
  • Participant with a positive urine drug screen
  • Participant with DBS
  • Participant with VNS if the device was active in the last 6 months prior to study enrollment

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT04124341

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Contact: Ziad Nahas, MD, MSCR 612-273-9732
Contact: Maxwell Thorpe

Sponsors and Collaborators
University of Minnesota

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Responsible Party: University of Minnesota Identifier: NCT04124341     History of Changes
Other Study ID Numbers: STUDY00006945
First Posted: October 11, 2019    Key Record Dates
Last Update Posted: October 30, 2019
Last Verified: October 2019
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: Yes
Device Product Not Approved or Cleared by U.S. FDA: No
Pediatric Postmarket Surveillance of a Device Product: No
Additional relevant MeSH terms:
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Depressive Disorder
Depressive Disorder, Treatment-Resistant
Behavioral Symptoms
Mood Disorders
Mental Disorders