The operation is Wednesday. Patient 005 is having a deep brain stimulation device implanted on Wednesday, give him some support, here: DBS Trial
Deep Brain Stimulation
Recently I found a hands on experience blog for someone undergoing deep brain stimulation for parkinson’s disease. Now another blogger who blogs about the participation in a trial: 278-005 DBS Trial. This trial is done in St. Jude’s. It’s the DBS study for TRD (treatment resistant depression). Surgery is scheduled for next week.
The trial is a blind study – which means I won’t know if the gizmo they give me is turned on or not. At least for 6 months I won’t know. from what I understand 2 out of 3 of the gizmos implanted will be turned on. The other 1/3 won’t be turned on for 6 months and NONE of us will know which one we are.
There is a new blog with the written hands on experience of undergoing deep brain stimulation surgery: Focus on a Cure’s Deep Brain Stimulation (DBS) Journal
This blog is created in the hopes that my experiences will give others inspiration to take a risk and have the courage to face the unknown in order to accomplish the impossible as others have done for me.
Incredible good insight and information about the whole procedure, especially the whole process before deciding to undergo the procedure.
One thing I was surprised about that after all my research and all my conversations with other DBS patients and doctors no one mentioned the steel ball ear plug portion of the halo/frame procedure. During this portion I asked the surgeon why no one ever mentioned this part he told me it was because most people do not remember it. Well let me be truthful I remember ever second of it and I told him I was going blog about it and let the secret out.
On this blog plenty of posts about the use and indications for Deep Brain Stimulation and on Mind Hacks a short list of things that deep brain stimulation has been used to treat.
Thanks Jan at Medblog.nl
In Deep Brain Stimulation for treatment resistant depression with stimulation of Broadman area 25 (Cg 25) no consistent declines in memory for either verbal or visual material were noted after onset or maintenance of DBS over baseline. This makes DBS a procedure with out apparent cognitive side effects in treatment resistant depression. In a recent publication with DBS in the Subthalamic Nucleus for treatment resistant Obsessive Compulsive Disorder (OCD) no cognitive decline was found. The ratings of neuropsychological measures were not modified by stimulation.
In 17 patients participating in this 10-month, crossover, double-blind, multicenter study assessing the efficacy and safety of stimulation of the subthalamic nucleus one patient had a parenchymal brain hemorrhage (bleeding) resulting in a permanent finger palsy. Two patients had an infection leading to removal of the pulse generator. Seven transient motor and psychiatric symptoms induced by active stimulation occurred in the first month of stimulation and resolved spontaneously or rapidly after adjustment of the setting. Ten other patients also had serious but transient side-effects.Three patients became hypomanic, three suffered from anxiety, two of depressive symptomps the others suffered from transient neurological side-effects such as dyskinesia, trouble walking, dysarthria, dysphagia and facial asymmetry.
Deep Brain Stimulation of the subthalamic nucleus significantly reduced the symptoms of severe forms of OCD.
In conclusion, findings from this 3-month crossover study suggest that stimulation of the subthalamic nucleus may lessen the severity of obsessive–compulsive symptoms and improve global functioning in patients with refractory, severe OCD. Serious adverse events occurred in 11 of the 17 patients in whom stimulators were implanted. The occurrence of severe adverse events, the small number of patients, and the short duration of the study highlight the risks of stimulation of the subthalamic nucleus and the need for larger studies with longer follow-up. In addition to assessment in a larger number of patients, a comparison with other stimulation targets and surgical procedures would be desirable, as would an evaluation of the long-term benefits of stimulation of the subthalamic nucleus in patients with OCD, notably with respect to their quality of life and their ability to function in social and work environments.
Deep brain stimulation has shown promise in the treatment of treatment resistant depression(TRD) in some small series and case reports. The definition of TRD is still a matter of debate. There isn’t one clear classification scheme of TRD. TRD shouldn’t be mixed up with pseudoresistant depression . The recent research with deep brain stimulation showed some promising results and in the future might add this treatment to the 9 steps for treatment resistant depression.
Since this treatment for TRD is in it’s infancy
The most appropriate target, optimal stimulation parameters, and long-term effects and efficacy remain uncertain.
About the targets for deep brain stimulation in treatment resistant depression some options are available:
- The reward circuitry of the ventral striatum and Nucleus Accumbens has been associated with drug addiction and depression for many years. Some case reports showed some partial effect on TRD. One case report with obsessive-compulsive disorder and concomitant major
depression and three cases with TRD.
- Subgenual Cingulate Cortex: Area 25. Helen Mayberg found the switch that lifts depression in area 25, a spot deep in the cortex. This area is the key conduit of neural traffic between the thinking frontal cortex or forebrain and the central limbic region that plays a role in emotions and which appeared earlier in our evolutionary development. This area is overactive during depression or sadness. This form of DBS was doen in a Randomized Controlled Trial with 6 patients with overall response of 60%.
- Inferior Thalamic Peduncle. The ITP has proven to be hyperactive in depression, a phenomenon that reverses with effective pharmacological treatment. Successful use of this target in DBS stimulation has been published in one case report. One initial case report indicates promise, large-scale trials of implantation are necessary to determine the efficacy and safety of this target.
- Rostral Cingulate Cortex: Area 24a. No electrode has yet been implanted in the rostral cingulate cortex in humans; however, stereotactic lesioning of this area has shown beneficial effects.
- Lateral Habenula. Only used in animal models with some suggestion that functional inhibition of this area using high-frequency DBS may have therapeutic benefit
These localizations have been described on this blog in another posts: 5 different locations for deep brain stimulation in depression, but now it appears in a peer reviewed article with excelent graphics.
Only three have been tried with patients with TRD or obsessive-compulsive disorder and concomitant major depression. The other anatomical targets are tentative. The most impressive results done with a proper study design was with Broadman area 25 by Helen Mayberg.
I think the following quote by Dr. Cosgrove sums it up as far as the progress and future of DBS is concerned:
“deep brain stimulation may provide a unique opportunity to help patients who suffer horribly from the consequences of severe depression…. early efforts must go forward only with the highest ethical, moral, and scientific standards to ensure that this historic opportunity is not wasted…. much is at stake.”
What do you think?
Jason S. Hauptman, Antonio A. F. DeSalles, Randall Espinoza, Mark Sedrak, Warren Ishida (2008). Potential surgical targets for deep brain stimulation in treatment-resistant depression Neurosurgical FOCUS, 25 (1) DOI: 10.3171/FOC/2008/25/7/E3
CNN’s Dr. Sanjay Gupta reports on new research showing deep brain stimulation may ease severe depression.
In a very short video a short introduction to Deep Brain Stimulation with nice animation. It is explained as a pacemaker to the brain. The pacemaker regulates mood circuits, potentially easing deep depression no other treatments can touch. Also about who are candidates for this treatment. Answer: When all else fails.
Alas the video is not always available or other technical problems exist.
The current study is the largest clinical trial to date of the efficacy of DBS as a treatment for severe depression. Between May 2003 and November 2006, Andrez M. Lozano and his colleagues implanted electrodes into the brains of a total of 20 patients (9 men and 11 women) with major depressive disorder, all of whom were referred to the researchers from hospitals or community psychiatrists, after failing to respond to antidepressants, psychotherapy or electroconvulsive therapy.
On Neurophilosophy a post about this new trial with this new treatment for treatment resistant depression.
12 out of the 20 patients reported significant long-term improvements in their condition. This was corroborated by neuropsychological assessments which measured, among other things, the patients’ mood, anxiety levels and sleeping patterns. These improvements were observed within 1 month and, importantly, persisted for at least 12 months after the treatment, by which time 7 of the patients had gone into full remission.
Time for some randomized controlled trial with switching on and off?
Related posts on this blog about Deep Brain Stimulation
Apart from a transient mild decline in manual motor speed, there seems to be no
adverse cognitive effects associated with chronic Deep Brain Stimulation (DBS) in Cg25 for Treatment Resistant Depression (TRD) in this sample of 6 patients with a follow-up of 12 months.
Another important conclusion from this research:
Several areas of cognition that were below average or impaired at baseline improved over follow-up, and these changes were not correlated with improvements in mood.
Broadman Area 25 as target for deep brain stimulation in treatment resistant depression. This area in the brain is from the most important publication about DBS and depression in Neuron march 2005 by Helen Mayberg. This is the location used in the largest trial with DBS in TRD. Other locations for DBS in TRD appear as well but these publications concern individual cases.
Functional neuroimaging as well as antidepressant treatment effects suggest that this area plays an important role in modulating negative mood states. Clinical response was demonstrated in 4 of 6 patients using standardized psychiatric end points. These results suggest that modulation of pathological activity in specific limbic-cortical circuits by electrical stimulation of Cg25 can effectively reverse symptoms in previously TRD patients.
Comparison to ECT
Moreover, in contrast to the memory deficits consistently reported with
ECT, no consistent declines in memory for either verbal or visual material were noted after onset or maintenance of DBS over baseline.
- small sample size (n=6)
- the lack of a matched control group
- the lack of control (on-off) conditions for stimulation
- impact of repeat testing or regression toward the mean may have nonetheless affected the results
- patients were not free of psychopharmacological drugs
Other indications for DBS:
McNeely, H.E., Mayberg, H.S., Lozano, A.M., Kennedy, S.H. (2008). Neuropsychological Impact of Cg25 Deep Brain Stimulation for Treatment-Resistant Depression. The Journal of Nervous and Mental Disease, 196(5), 405-410. DOI: 10.1097/NMD.0b013e3181710927
When other treatments fail, deep-brain stimulation (DBS) may offer hope to patients suffering from chronic and severe depression, according to a study presented here at the 76th Annual Meeting of the American Association of Neurological Surgeons (AANS).