Deep brain stimulation (DBS) has gained wide use in movement disorders and remains an area of active research in psychiatric disorders. Recent clinical trial setbacks may reflect clinicians’ trial-and-error approach to selecting stimulation parameters [1]. Newer studies focus on “closed-loop” approaches, where DBS settings are adjusted based on an objective, brain-based readout. Those studies divide roughly into “anatomical” approaches based on targeting stimulation to specific white matter (WM) bundles and “physiologic” approaches that focus on changing pathologic signatures in brain electrical activity. We argue that success in psychiatric applications may require a synthesis of both approaches: individualized anatomically guided electrode placement coupled with biomarker-responsive targeting of network dynamics.

The anatomical approach optimizes clinical response by tailoring electrode placement relative to individual brain anatomy. In subcallosal cingulate (SCC) DBS for depression, an open-label study prospectively targeted the intersection of four different tracts in peri-SCC WM using individualized probabilistic tractography. Out of 11, 9 patients responded, a substantial improvement over the same group’s prior results [2]. The same approach is now being expanded beyond SCC WM to optimize DBS placement in the ventral striatum/ventral capsule and medial forebrain bundle [1].

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