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Related Topics
Deep Brain StimulationReview - Deep Brain Stimulation
A New Treatment Shows Promise in the Most Difficult Cases
by Jamie Talan
Dana Press, 2009
Review by Roy Sugarman, Ph.D.
Dec 1st 2009 (Volume 13, Issue 49)

Anyone who keeps up with any of the literature in mental health settings is aware of the dismal prognosis (if the STAR-D study is anything to go by, and its pedigree is sound), for getting to remission of the depression symptoms that affect depressed individuals, using just the one medication. The best SSRI of the times is not the major cure that we were all led to believe when Prozac first surfaced, and if the recent research is correct, from Irving Kirsch and colleagues, much of the effect is placebo anyway. We all also know that beating the placebo response is the heart of most pharma research, hard to do when those on the active medication realize that the side effects are real, and hence so is the drug they are on.

Studies have examined the warmth of the therapeutic relationship, CBT is great, but only against drugs or usual care, but few studies taken head to head with other therapies show it to be superior, and certainly in the complex multi-axial settings in which I worked, you needed more in your toolbox than just one big hammer.

And when all you have is a hammer, everything is a nail. Researchers into Parkinson's suddenly discovered some time ago that flicking the wrong switch brought sudden suicidality to a patient, flicking it back, and they regathered their equanimity instantly.  And then there is the tenth cranial nerve, the darling cranial nerve collaborator of the Autonomic Nervous System.

This lead Helen Mayberg of Emory to begin DBS as a means of treating refractory depression.  And led Edgar award winning science writer, Jamie Talan, to write this book, looking at depression, Parkinson's, OCD and dystonia.

As mentioned before, some 40 000 patients, mostly Parkinson sufferers, have undergone DBS. The rationale is that of implanting a mechanism similar in concept to a pacemaker that regularly delivers a stimulus to a nervous system element, and by inserting a stimulus into a homeostatically regulated brain system, creates a perturbation that elicits an effect on the target activity, eg the tremor.

Talan thus begins writing about Parkinson's, the mother lode in the author's words, and the 100 years of research that led to this application. She continues to expand and outline on what I have commented on above, and the French Connection.  Part two describes how DBS emerged from the investigations of the value of stimulus in dystonia, and other pioneering efforts, such as in Obsessive Compulsive Disorder in psychiatry, as well as depression, Tourette's and Epilepsy. Two unlikely candidates for sharing something in common are pain, and minimal consciousness: yet they are similar, given they are both just about impossible to objectively measure in terms of the patient's experience, the work now of Rezai and Llinas.

With this done, Talan looks to the future, and to the ethics of meddling in brain in this intrusive but oh so promising fashion.

The problem as Talan will show, is the need, like any other surgery, to get it just right, with the failures of individual specialists often showing up at the mainstream clinic's doors.  Damasio tells of a patient undergoing some procedure for their Parkinson's only to have an immediate and overwhelming suicidality commence when the wrong area is stimulated by accident.  Getting it just right in terms of where and how much to stimulate is an individual goal, and hence, can take months to get right.  It's not just the surgery, Talan points out, but the programming of the stimulation, and the entire program beyond the immediate evaluation and surgery.  Voltage, amplitude, frequency and duration are not only the parameters that need control, but the observations of others, such as a psychiatrist, in depression.  The effects can be paradoxical, bringing on a host of autonomic responses, each to be mapped and programmed, perhaps taking 3-6months.  Batteries run out, electrodes break, other hardware problems are common, and require regular visits to the DBS team.  There is little training available.

Clearly, and especially in psychiatry, this is not a job for beginners or dilettantes.  Informed assessment, training, programming and follow up are all critical.

Talan is a great writer, as her awards suggest, and each chapter has discussions around the guru's who lead the charge in each field, and of these, psychiatry is the most exciting. Each case history is terse and confronting, as Talan is not invested in any of these treatments, and so an honest appraisal of how difficult DBS is, is given in each case.  She does not tout this as a miracle, but her excitement is obvious.  Clearly, the field is a mass of human experimentation, hence her closing look at the ethics. It's a lucrative field, hence her references to the need for the guru's to fix the mess left by the dilettantes. 

There are no diagrams, this is not a "how-to" book, and very few anatomical references are made.  This is a book for someone who is curious about the field, a rather large, informative and well written news article, if you will.  But like a news item, a compelling read, and a great introduction to the history and progress of DBS, complete with a warning guide, to not try this at home.

Underneath all this of course is the fact that DBS is invasive brain surgery, and hence meant for the most resilient and troubling of human conditions, but at least, a ray of hope, for those worst afflicted.

 

© 2009 Roy Sugarman

 

Roy Sugarman Ph.D., Human Performance Institute, Sydney, Australia.


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