Thursday, November 08, 2007

Guest Blogger Dr. Peter Rabins on Deep Brain Stimulation

A while back we were talking about treatments for depression and some of our commenters asked about the newer, non-pharmacologic treatments out there. It was on my list, or maybe I was hoping Roy would jump in with some answers-- he likes gadgets and gizmos. We'd moved on and I forgot about this, but then we got an emailed request from JCAT in South Africa, asking for our thoughts on surgical treatments for depression, specifically Deep Brain Stimulation and Vagal Nerve Stimulation. I can't say I've ever recommended these treatments for any of my patients, I've never met anyone who has had them, and I don't have an opinion. I did, however, hear Dr. Peter Rabins talk about DBS as a treatment for depression last year, and so I thought I'd ask his opinion.

Dr. Rabins is a Professor of Psychiatry at Johns Hopkins Hospital where he is co-director of the division of Geriatric Psychiatry and Neuropsychiatry. He is the author of The 36-Hour Day, and more recently of Getting Old Without Getting Anxious.

Dr. Rabins writes:

There has been an amazing amount written in the popular
press about the potential for Deep Brain Stimulation
(DBS) to be usedto treat certain psychiatric syndromes.
Right now, there are preliminary and promising results
for severe, treatment-resistant major depression and
OCD but very little information has been published in
the peer-reviewed literature.

In Europe, DBS has also been used to treat anorexia 
nervosa,various substance abuse disorders, and even
aggressive behavior. Given what happened with
'lobotomy' surgery 60 years ago, I believe it is
incumbent upon the mental health community and
especially psychiatry to publicly and persistently
urge that the topic be approached from a scientific
point of view, that carefully designed studies with
long-term follow up data bemade publicly available,
and that very ill and vulnerable individuals be
protected from the harm and abuse that can result
from inappropriate claims, unnecessary and
non-beneficial surgery, and being taken advantage
of financially.

Many ethical and careful researchers have begun to
study DBS for psychiatric illness but it will take
time before results can tell us whether it is helpful
and worthwhile. In the meantime, it is best to keep
expectations down, to remind people that this is a
very expensive treatment that will likely only be
used for severe disease that has not responded to other
less invasive and less expensive approaches, and
that the treatments we have now for major depression,
including ECT,help the majority of very ill individuals.


Aqua said...

This strengthens my resolve to fight against my insurance company. If you can believe it about 6 months ago they sent a letter to my pdoc "suggesting" he refer me to have this procedure (DBS) done.

My pdoc was incredulous, as was I. He told me they cannot force me to have it done. After reading this I have to wonder how they could even think it was proper to suggest a procedure that had not been satisfactorily studied and reviewed in a scientific manner. Unless of course their wishes for me were more nefarious than healing my depression. Truly frightening.

Carrie said...

Interesting post. As I have said before, DBS is also being studied to treat chronic, refractory cluster headaches, and also possibly for other headache types, although clusters are where the studies are at right now. To my knowledge, there have been 2 major studies done, one of which was pretty promising. In the other, 2 patients died, although it wasn't as a direct result of the stimulator, but rather due to other complications.

When I went to the neurosurgeon in early 2005 regarding a consult for an occipital nerve stimulator implant, the neurosurgeon felt that at the time the ONSI wouldn't help me, but that I should come back in a few years when they had started doing DBS more commonly and had really built up a protocol and technique. I wrote about this on my new anonymous blog recently, but I am going for another ONSI consult in December, as information has changed that may mean I am a good candidate for ONSI. My mom is very very nervous about this as she feels that I have been through so much already and have experienced a lot of negative effects of various treatments, that she worries about jumping into surgery. I understand what she is saying, but with all the pain I have lived with, I am more willing to put myself through it personally, although still obviously nervous about it.

When I go for the consult, I want to ask him what their plans are for DBS for headache. They are doing it at a couple locations in the United States, but it is mostly being done in Europe. I'm wondering if our university will get involved in DBS for headache. Don't know if they do it for depression or any psychiatric disorders at our hospital. The studies I have printed on the ONSI to take to the neurosurgeon say that it may not be as effective as DBS, but it is much safer at this point.

For depression/other psychiatric disorders, what area of the brain do they stimulate? From this post, it sounds as though they may have more promising results for things like OCD/anorexia/other compulsive/neurotic disorders, which I didn't know they were trying the stimulator for. That's cool. For headache, they are only looking to stimulate the hypothalamus at this point, but I don't know if they have ever looked into stimulating other areas for various other headache types. Clusters are believed to be caused by a faulty hypothalamus, which is why they've targeted that area.

For me, my headaches are so refractory to every available treatment that we truly are considering some type of surgery. However, at my last consult, the neurosurgeon advised against ever doing any type of surgery where they cut through the nerves, causing possible permanent damage to my face/little or no headache relief. I'm referring to things like trigeminal rhizotomy and other surgeries where they destroy nerves and the like to relieve pain.

Glad to read this post - I certainly don't believe that any surgery should be jumped into without exhausting all other possibilities first.

Take care,
Carrie :)

ClinkShrink said...

Dinah wanted me to comment on the DBS post, and somebody else wanted to know if we have DBS in prison. (We don't.) There was a 1973 case (unreported), Kaimowitz v Michigan, that held that prisoners were inherently incompetent to consent to experimental brain surgery due to the coercive nature of the correctional environment. Goodness knows how a case like that would be decided today, but that's what we've got so far as regards brain surgery and prisoners.

jcat said...

Thanks! Pdoc and I are both interested, but more at a watch and wait level. Just frustrating that studies seem to take so long. First reputable-sounding trials go back as far as 2003 - although I guess 4 years is not that long - with good results from about 2005.
Aqua - the University of Toronto has been investigating DBS for quite a long time. They seem to have one of the larger study pools, and some positive feedback. Presumably the insurance would be prepared to pay for it? Here they would roll around laughing if it was even suggested!

Aqua said...

From what I understand the U of T studies were only done on a small group of people (6 people I think) I'm not willing to my brain on the line based on a study that small.

Also, I did look into the inclusion/exclusion criteria and I would not qualify. One of the exclusion criteria was atypical depression (which I definately have), and, if I remember correctly, people with anxiety disorders were excluded ...which I have too. So darn I'm out of luck.

Anonymous said...

Clink: It was very nice of you to comment on Dinah's post especially after she was so nice to you.

FooFoo5 said...

There is significantly more research regarding DBS for the treatment of movement disorders. I remember reading a very disturbing article in the journal Neurology last year that reported a suicide rate of nearly 5% for patients with, ironically, successful outcomes for movement disorder, but who also had pre-morbid depression. The article suggested excluding patients with a hx of depression, SA, and multiple DBS procedures.

For the moment Vagus Nerve Stimulation seems a whole lot more promising, and significantly safer.

dinah said...

How did the formatting get messed up again???

Ladyak47 said...

Yikes! My brother had brain surgery, actually. For Epilepsy. It was scary. He was altered a bit for a few months after the surgery...more emotional and talkative. But he returned to normal. He went back to work shortly after. I worried about him for a while, worried he was going to bump his head. It's been a couple of years, and he is doing pretty good. His vision is a little wacked.

Off topic, but related. Brain surgery is serious. Just scary stuff.

My brother has always been a bit odd...but after brain surgery...
He is a statistician for the DOD.

Jayme said...

I have nothing against DBS except the potential for abuse. Psychiatry has already proven itself to be coercive and forceful toward the most vulnerable of patients when it comes to ECT, and even today people are getting ECT against their will. Most of it is coerced but some is outright forced. I shudder to think of DBS following suit, despite the precautions being taken now. Soon DBS will be so accepted in the psychiatric system that patients will not know what hit them. We have always been the guinea pigs in psychiatry. How is this new, innovative procedure going to be any different? Is the outcry loud enough? Have people actually learned from history? Why is ECT still being forcced?

Midwife with a Knife said...

Does DBS have side effects? Obviously, there's always SOME risk of complications with any surgery (I'm sure brain surgery is no exception!).

But if it doesn't really have side effects, I would argue that it's not really in the same class as lobotomy, etc.

Jayme said...

It's only in the same class as lobotomy if it involves force. No one should ever be forced or cerced into brain surgery no matter how benign it appears to be.

Anonymous said...

A year or two ago a couple of people who had had this done were interviewed on a local television show. Apparently they were doing clinical trials in my area or something.

One person who had had this done really concerned me. She was sitting on stage with her hair in pigtails and clutching a stuffed animal. Keep in mind this an adult we're talking about, not a child. She was portrayed as a success story. My first question was her mental capacity to consent to this treatment. I definitely questioned it considering her behavior. Secondly, I felt concern that the psychiatrist on stage considered it successful in her case. To me, how she was acting was not exactly a ringing endorsement for the procedure. One person that they interviewed who had it done seemed okay, but she didn't seem okay at all. Granted, I didn't see how she was before but I wasn't impressed with the outcome in her case.


Carlo said...

Good Job! :)