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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by pseudoname on April 2, 2006, at 12:06:30
There's a long article about deep brain stimulation for treatment-resistant depression in today's New York Times Magazine: http://www.nytimes.com/2006/04/02/magazine/02depression.html
It features a 41-year-old TRD woman named Deanna Cole-Benjamin, whose depression was “resistant to every class of antidepressant, numerous combinations of antidepressants and anti-anxiety drugs, intensive psychotherapy and about a hundred [!!] sessions of electroconvulsive therapy. Patients who have failed that many treatments usually don't emerge from their depressions.”
From that cheery note it goes on to describe an experimental procedure “called deep brain stimulation, or D.B.S., which is used to treat Parkinson's. It involves planting electrodes in a region near the center of the brain called Area 25 and sending in a steady stream of low voltage from a pacemaker in the chest.” (Different from vagus nerve stimulation, which zaps nerves in the neck.)
“As it turned out, 8 of the 12 patients he operated on, including Deanna, felt their depressions lift while suffering minimal side effects — an incredible rate of effectiveness in patients so immovably depressed. Nor did they just vaguely recover. Their scores on the Hamilton depression scale, a standard used to measure the severity of depression, fell from the soul-deadening high 20's to the single digits — essentially normal.”
The article talks about how neurologist Helen Mayberg and neurosurgeon Andres Lozano adapted the technique from Parkinsonism treatment, where over 30,000 people have had the surgery, although targeting a different area.
“The D.B.S. operation involves an intrusion that is delicate but brutal. The patients are kept awake so they can describe any changes, and the only drug administered is a local anesthetic. The surgical team shaves much of the patient's head and attaches to the skull, with four screws drilled through skin into bone, the stereotactic frame that will hold the head steady against the operating table and serve as a navigational aid. Mounting the frame takes only about 10 minutes.” Then they drill a hole in the top of the patient's skull and thread a guide tube down to Area 25.
In Deanna's case, Mayberg [who was running the procedure], wasn't going to tell her when the device was activated. When they switched it on, Deanna said, “It's very strange. I know you've been with me in the operating room this whole time. I know you care about me. But it's not that. I don't know what you just did. But I'm looking at you, and it's like I just feel suddenly more connected to you.”
Then they shut it off and Deanna said, “God, it's just so odd. You just went away again. I guess it wasn't really anything.”
“It was subtle like a brick,” Mayberg said. On, she felt emotionally connected to people; off, she was severely depressed as usual.
After Deanna went home (with it on), “Not all was light and flowers. On a purely biological level, the improvement made by D.B.S. sometimes amplified the side effects of the high doses of medication the patients had been taking. Doctors don't quite understand this phenomenon, but they see it happen in other instances too; it is as if the patient, deadened, is again made sensate. Deanna broke out in hives and felt nauseated; her hands shook. These symptoms eased when she (as several of the patients have done) reduced her meds — slowly, so as not to introduce new variables. She now takes standard doses of Effexor, an antidepressant, and Seroquel, an anti-psychotic drug.”
The doctor said, “We're just fixing the circuit. The patient's life still needs work. It's like fixing a knee. They need that high-quality physical and supportive therapy afterward if they're really going to move around again.” ... The transition is not back to a former self and family but to a new one.
Apparently Deanna's improvement has persisted since 2004, though.
Much talk of “paradigm shift” and “the beginning of a new way of understanding” and a common denominator of depression, which we've heard before. The article notes “Other treatments have started this well and fizzled.”
Posted by bassman on April 2, 2006, at 18:48:31
In reply to deep brain stimulation in N.Y.Times, posted by pseudoname on April 2, 2006, at 12:06:30
I'm gonna have to be lots more depressed before I let someone attach my head to a metal plate with four screws.:>}
Seriously, though, maybe it's the beginning of more basic understanding of depression and why it "hurts"-that would be great.
Posted by Maxime on April 3, 2006, at 10:52:05
In reply to deep brain stimulation in N.Y.Times, posted by pseudoname on April 2, 2006, at 12:06:30
They were doing trial studies in Toronto and I tried to get in on it. I really think DBS is the answer for me.
Maxime
Posted by honeybee on April 4, 2006, at 8:56:57
In reply to Re: deep brain stimulation in N.Y.Times » pseudoname, posted by Maxime on April 3, 2006, at 10:52:05
Really, a new theory of depression is so long overdue, what with the scattershot way that antidepressants *work* (for about half the people who take them). I had a long, healthy run on Effexor before I decided to go off of it, and while I muddle on to the next treatment, I'm trying to find something whose actions are more precise.
Does anyone know anything more about Area 25 and what treating its dysfunction entails? I'm not quite ready to hop on the nearest plane to Toronto to sign up for the study (though you'd better believe I thought about it!), but I'd like to keep tabs on it and see if any babblers have done it and how it's worked.
hb
Posted by honeybee on April 4, 2006, at 9:00:03
In reply to Re: deep brain stimulation in N.Y.Times, posted by honeybee on April 4, 2006, at 8:56:57
Mayberg (the lead of the DBS study) mentions the importance of finding ways to better classify the kinds of depression that people have. Isn't this already available? Doesn't rTMS do that very thing?
Posted by pseudoname on April 4, 2006, at 12:36:23
In reply to Re: deep brain stimulation in N.Y.Times, posted by honeybee on April 4, 2006, at 8:56:57
This article is from 2 years ago, when the study just reported had just begun, but it tells a little more about the “network theory” and how Area 25 may fit in.
http://www.neuropsychiatryreviews.com/may04/npr_may04_pathway.html (NeuroPsychiatry Reviews, May 2004, vol 5(3))
Despite other studies showing similar brain response from both psychotherapy and drugs, this article says there are *different* responses in depressed brains that respond to CBT and those that respond to medication. “These treatment findings stress the complex interactions of a distributed set of both limbic and cortical brain regions [in depression],” suggesting there's a network of brain sites involved that respond differently in different people.
-snip-
A last set of studies was presented to emphasize this point, using a Structural Equation modeling and path analysis to look for predictive markers in scans taken prior to treatment that might differentiate patients who went on to do well on cognitive therapy from those who did well on paroxetine and those who benefited from neither approach. In the first group [CBT responders], the state of the network reflected the cross-talk among the orbital frontal, medial frontal, and cingulate regions, Dr. Mayberg explained. “In contrast, the paroxetine group model was uninfluenced by activity in the medial frontal and orbital frontal regions,” she said. “The state of the brain in these patients was dependent on variation in the hippocampus, area 25, and lateral prefrontal regions. If we look at the patients who were medication nonresponders, the network state was distinct from the other groups, with an emphasis on inputs to area 25 without modulation by cortex.
-snip-> Isn't this already available? Doesn't rTMS do that very thing?
Hi, honeybee. Other than the study that found first-week changes in depressed brains that would respond to Prozac (which I hadn't realized was also by Mayberg) and Daniel Amen's clinic reports (which I *think* have not been replicated by other researchers – anybody know?), I don't know of *any* tests that divide depressed people into different treatment categories in general use.
Also, rTMS targets the cortex, not the deep brain.
Posted by SLS on April 4, 2006, at 13:08:56
In reply to Area 25, “network theory” – more, posted by pseudoname on April 4, 2006, at 12:36:23
> This article is from 2 years ago, when the study just reported had just begun, but it tells a little more about the “network theory” and how Area 25 may fit in.
>
> http://www.neuropsychiatryreviews.com/may04/npr_may04_pathway.html (NeuroPsychiatry Reviews, May 2004, vol 5(3))
>
> Despite other studies showing similar brain response from both psychotherapy and drugs, this article says there are *different* responses in depressed brains that respond to CBT and those that respond to medication.I have also seen studies reporting oppositional differences in the way medication and CBT alter brain function.
- Scott
Posted by honeybee on April 4, 2006, at 13:28:12
In reply to Re: Area 25, “network theory” – more, posted by SLS on April 4, 2006, at 13:08:56
First, thanks to you both. I was confused about rTMS. I meant to say rEEG, which I had understood to somehow analyze brain wave patterns and predict what medications would work best depending on those patterns.
Scott, what exactly do you mean by "oppositional" by the way. That medication responders will not be CBT responders and vice versa? Just curious.
Posted by SLS on April 4, 2006, at 15:29:25
In reply to Re: Area 25, “network theory” – more, posted by honeybee on April 4, 2006, at 13:28:12
> Scott, what exactly do you mean by "oppositional" by the way. That medication responders will not be CBT responders and vice versa? Just curious.
Hi.
Sorry for the ambiguity.
I wish I could remember where I encountered the literature. It said that the two treatments produced opposite effects in a particular region of the brain. There was nothing mentioned regarding the treatability of different subtypes of depressive disorder.
- Scott
Posted by honeybee on April 4, 2006, at 15:31:54
In reply to Re: Area 25, “network theory” – more » honeybee, posted by SLS on April 4, 2006, at 15:29:25
Which have you found more success with?
Posted by pseudoname on April 4, 2006, at 16:08:22
In reply to Re: Area 25, “network theory” – more, posted by honeybee on April 4, 2006, at 13:28:12
Googling just now, it looks like there's still only a handful of clinics advertising rEEG, and it's not covered by insurance.
But EEG would't show anything about how things like the lymbic system or Area 25 were involved, anyway, would it? Just cortical activity, I think.
Also, no articles came up for rEEG in depression treatment on Google Scholar. That's a little disappointing. I can't find that any of the clinic web sites say how many people are actually in their data base. It also sounds like their main measure of efficacy was physician self-report. And the unpublished studies they conducted on rEEG apparently had no control groups, so they don't say much, unfortunately.
So I guess rEEG isn't (yet) filling that diagnostic hole that Mayberg was talking about. A lot more good research is needed.
Posted by pseudoname on April 4, 2006, at 18:01:47
In reply to rEEG » honeybee, posted by pseudoname on April 4, 2006, at 16:08:22
I guess they've got about 2,000 people in their private database, but that includes people with drug addiction, bulimia, OCD, ADHD, headaches, and fibromyalgia, not just depressives. They don't say how many from each group.
They did a controlled study of 11 treatment-resistant depressives in 1996-97. They say the study is “submitted for publication”, but they don't say when or where, and it was finished 9 years ago.
In the study, 5 patients got regularly-selected drugs and 6 patients got rEEG-selected drugs. After 6 weeks at therapeutic doses, none of the 5 regular patients had better than modest improvement, but 3 of the 6 rEEG patients had scores near remission.
Interestingly, the rEEG didn't advise *which* antidepressant to use, just very broad categories: (1) Antidepressant, (2) Anticonvulsant/lithium, and (3) Stimulant.
Thing is, I've tried EVERY possible combination of those broad categories over the years, so if rEEG hasn't gotten more specific by now, there's no way it could benefit me.
• Suffin, Stephen C; W Hamlin Emory; et al. (Submitted). “A QEEG Method for Predicting Pharmacotherapeutic Outcome in Refractory Major Depressive Disorder: A Pilot Study”. http://www.cnsresponse.com/Documents/Prospstudyfull.pdf
Posted by gibber on April 4, 2006, at 18:48:54
In reply to Re: deep brain stimulation in N.Y.Times, posted by honeybee on April 4, 2006, at 8:56:57
This is a great topic. This appears to be more promising than VNS. After digging a little deeper into the study I found an interesting sentence which seems to indicate that for those who responded to DBS, they had brain scans similar to both people who responded to medication and CBT. Sounds like a very thorough treatment.
"The observation that the changes with DBS seen here features both the antidepressant medication and the CBT- induced changes suggests that Cg25WM DBS acts at a critical node of a distributed mood-regulatory network involved in major depression "
Also I'm curious as to why in their follow up study they are excluding atypical depressives. That's me! I'm too young for the study anyway but I wonder if its not as effective for atypicals?
Gibber
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