Deep Brain StimulationA New Treatment for

Treatment-Resistant Depression

Nothing worked …

Michael Lindsey suffered for years with severe, treatment-resistant depression

Tried every available fix 20 different

medications 16 electroshock

treatments Endless talk

therapy Nothing worked

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… until DBS

Underwent deep brain stimulation surgery in a final attempt to regain his life

Awake during the procedure, Michael laughed for the first time in years

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Deep Brain Stimulation (DBS)

Used successful on thousands with Parkinson’s disease

Fixes malfunctioning brain systems via direct electrical stimulation

Excites very specific targets Reversible and adjustable Not FDA-approved for

treatment-resistant depression yet but initial trials are promising

www.henryfordhealth.org

What is depression?

A disease of the brain Involves a person’s

physiology, biochemistry, mood, thoughts and behavior

Severe depressive symptoms without mania

a/k/a “major depression” or “major depressive disorder”

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Treatment-ResistantDepression (TRD)

“Major depressive disorder” that just won’t go away

Severe depressive symptoms Lasts months or years Resists all standard

treatments Antidepressants Talk Therapies ECT

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Grim Statistics

17% of the U.S. population will experience major depressive disorder in their lifetime

www.fims.uwo.ca

Grim Statistics

Only 37% of those that seek treatment achieve full remission from initial drug monotherapy

www.cbc.ca www.fims.uwo.ca

Grim Statistics

20% will show little or no response to multiple modes of aggressive treatment

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www.thelostboys.org www.fims.uwo.cawww.cbc.ca

Reason for Optimism

Rapid advances in brain imaging and genetic mapping isolate specific brain networks and neural pathways implicated in mental illness

http://brainatlas.org/aba/www.americanmonitoringphysicians.com

uk.news.yahoo.com

DBS Basics

www.npr.org

DBS directly excites specific targets in the brain via electrodes on surgically-implanted leads Electrical current interrupts “bad” brain impulses

www.us.oup.com

DBS Basics

www.henryfordhealth.org

Leads run to a generator implanted in the patient’s chest A sort of “pacemaker

for the brain”

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Dollars Well Spent?

$50,000 per patient per DBS procedure

Unknown amount of research dollars still needed to bring DBS to FDA approval stage

Are the effects costly enough to make funding DBS worthwhile?

Why not try more talk or drug therapies?

Treatment-Resistant Depression:

Cost to Sufferer

Exacerbates or raises risk for…Cancer, diabetes, heart disease,

obesity, et al.Substance abuse, suicide, death

Cost of human suffering

www.paigetropandweinstein.com

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www.nationalmssociety.org

Loss of companionship

Financial loss Emotional &

physical toll on primary caregiver(s)

Negative impact on next generation’s health and mortality rate

Treatment-Resistant Depression

Cost to Families

www.who.int

Treatment-Resistant Depression:

Cost to Society

Directly related healthcare costs $83 billion in 2002

Healthcare costs linked through comorbid conditions Diabetes patients with severe

depression 86% higher healthcare expenses

Increased homelessness, substance abuse, morbidity

http://www.sxc.hu/photo/524470

Treatment-Resistant Depression:

Costs to Economy

Decreased work productivity

Increased absenteeism 27.2 lost workdays per ill

worker per year A leading cause of

disability claims Will be second only to

cardiac disease by 2020 -- World Health Organization

www.sxc.hu

Criteria for DBS

DBS is exploratory and invasive To be considered for DBS, a patient

must meet certain criteria: Major depression at

least 5 years Current episode at

least 2 years Ability to comply with

monthly visits, prolonged testing visits, etc.

www.becomehealthynow.com

More Criteria

At least four failed antidepressants in two different classes while augmenting with two other therapies

Failure or intolerance to ECT therapy

news.bbc.co.uk

www.sxc.hu

www.freeimages.co.uk

www.cbc.ca

DBS Surgery

Steps taken in performing DBS surgery for depression are similar to those for Parkinson’s

disease

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Bill’s DBS Step-by-Step

Bill is a Parkinson’s disease patient effectively treated with DBS

Warning: what follows is an honest portrayal of brain surgery and is not recommended for the faint of stomach.

Here are the basic steps completed in order to implant Bill’s DBS electrical implants

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First, to the MRI

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Head Is Secured

Head is secured in a stereotaxic frame

“They assembled the stereotaxic

frame from a kit that looked like

a very expensive

erector set.” --Bill

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Awake but No Pain

Lidocaine for the skin and a lack of sensory nerves in the brain means pain-free surgery (except, of course, for the shot itself)

“I was approached with a

hypodermic that looked to me to be the size of a

caulking gun.” --Bill

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On the OR Table

Stereotaxic frame is bolted to operating room table for absolute stability

Another MRI is taken with Bill’s head firmly in place “Since the surgery

is all done relative to the

frame, this is a vitally important

step.”--Billmac2.innanen.com

Going In

After the incision, a hole about the size of a dime (3/4 inch or 18 mm) is cut through the skull

“Dr. Schlosser made the first

incision at 8:29 AM. I didn't feel a thing except a little pressure.

--Bill . mac2.innanen.com

Probe Is Inserted

The micro drive advances a microelectrode probe down a hollow tube called “the introducer”

Once proper placement is achieved, the probe is removed and the final stimulator lead is eased through the introducer

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On the OR Table

A stack of “listening” equipment stands ready and waiting for Bill’s brain waves

As the microelectrode is advanced, the signals it returns are monitored by listening to the speaker and watching the oscillograph

“When the signal changed for a particular movement it would be noted on ‘the

map’ … it was most important when the signal

was clearly associated with my tremor.”--Bill .

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Precise Location

The goal is to locate the probe in the precise locations needed to stop malfunctioning brainwaves

Once the location is found, leads are eased into place cms.clevelandclinic.org

Stimulator Programming

Once Bill has healed from surgery, his stimulator is turned on and adjusted

http://mac2.innanen.com/~bill/parkinsons/DBSsurgery/index.php?p=21 http://mac2.innanen.com/~bill/parkinsons/DBSsurgery/index.php?p=22

Results of DBS for Depression

Dr. Helen Mayberg, et al., 2005 Treated six TRD patients

Remember, all previous treatments failed

Four out of the six experienced near immediate relief

Within 6 months of treatment, near remission