[Paleopsych] Boston Globe: Brain device offers hope for some mental disorders

[Premise Checker]

Brain device offers hope for some mental disorders
http://www.boston.com/news/local/articles/2004/08/04/brain_device_offers_hope_for_some_mental_disorders?mode=PF

    By Carey Goldberg, Globe Staff  |  4.8.4

    With its infamous history of crude ''icepick" lobotomies, psychiatric
    surgery has been widely shunned for decades. Now, it appears poised to
    make a careful comeback using a far gentler technology: a pacemaker
    for the brain that, once implanted, can be adjusted or turned off.

    Researchers at Butler Hospital in Providence are completing the
    largest study to date of the ''deep brain stimulation" device's
    potential to alleviate mental illness, involving 10 patients with
    severe, intractable obsessive compulsive disorder. The doctors say it
    looks promising, and they are beginning to test the device as a last
    resort for chronic depression.

    The brain stimulators, though widely used for Parkinson's disease, are
    still highly experimental for psychiatric disorders: Only a couple of
    dozen patients have received them worldwide. But they are generating
    high excitement among neurosurgeons, along with an equally acute sense
    of caution.

    ''Deep brain stimulation has and will revolutionize functional
    neurosurgery in the next decade," said Dr. G. Rees Cosgrove, a
    neurosurgeon at Massachusetts General Hospital, which is seeking to
    take part in the depression study.

    However, he said, surgeons must be supremely careful to ''avoid
    re-creating some of the mistakes of the past.

    This ''is a historical threshold," Cosgrove said. ''It needs to be
    done well and properly and be above reproach, or we'll never have
    another opportunity."

    The electrodes that deliver the stimulation are embedded in precise
    locations in the brain during an operation that lasts several hours.
    They are connected by wires to a pair of battery-powered pulse
    generators, each about 2 inches square, implanted in the patient's
    chest.

    It remains unclear why, exactly, the pulses work, but they appear to
    block or jam bad signals that travel through malfunctioning circuits
    in the brain. Patients generally cannot feel the pulses of
    high-frequency energy.

    The deep-brain stimulators have gained powerful momentum from their
    success in reducing symptoms in patients with Parkinson's disease.
    About 25,000 of the so-called Activa systems have been implanted
    worldwide since 1996, mainly in Parkinson's patients, according to
    Medtronic Inc. of Minneapolis, the only company that makes and sells
    them in the United States.

    The implants do not cure Parkinson's patients, but many people report
    major improvements that last for years. The downside: Between 1
    percent and 5 percent of patients have experienced serious
    complications such as bleeding or seizures, and infections have arisen
    in from 2 percent to 25 percent of cases. Between 5 percent and 15
    percent have had problems with the hardware that required repair.

    As the procedure has become more popular and familiar, neurosurgeons
    have begun trying it on a range of other illnesses, including
    epilepsy, in which the treatment of last resort had traditionally been
    ablative surgery: cutting or burning a lesion, or hole, in part of the
    brain.

    In tiny numbers, psychiatric patients have undergone sophisticated
    ablative psychosurgery in recent years, and because the surgery often
    helped, researchers reasoned that deep brain stimulation could bring
    similar results.

    Thus far, researchers report, the stimulation appears to work about as
    well in psychiatric patients as the ablative techniques. Those
    ablative operations have brought significantly reduced symptoms for 25
    percent to 45 percent of psychiatric patients in which everything else
    had failed, Cosgrove said.

    Deep brain stimulation probably ''will recapitulate the whole history
    of ablative surgery in psychiatry, which fell into disrepute," said
    Dr. Daniel Tarsy, chief of the movement disorders center at Beth
    Israel Deaconess Medical Center, who has extensive experience with the
    stimulators.

    That disrepute stems from the mid-20th-century heyday of the lobotomy.
    Tens of thousands of mentally ill people underwent lobotomies, often
    without their consent, as illustrated by Jack Nicholson's character,
    R.P. McMurphy, in the movie ''One Flew Over The Cuckoo's Nest," based
    on the novel by Ken Kesey.

    The procedure's best-known proponent, Dr. Walter Freeman, traveled the
    country from state hospital to state hospital, lobotomizing patients
    by inserting an icepick-like instrument up through the socket of the
    eye, wiggling it around in the frontal lobes of the brain.

    The procedure began to lose favor only when effective psychiatric
    drugs began to appear in the mid-1950s, said Elliot S. Valenstein,
    author of ''Great and Desperate Cures," a history of psychosurgery.

    Valenstein, an emeritus professor at the University of Michigan,
    warned that the danger for abuse of a surgical procedure still exists,
    ''when you get the right combination of a strong need, plus no
    alternative, and some prestigious people pushing it, and the press
    talking about it being a breakthrough."

    It is a different era, however. In the studies at Butler Hospital,
    patients are protected by several levels of safeguards: an independent
    review board that includes community members and bioethicists; a
    prolonged process to make sure patients fully understand and agree to
    the procedure; and a ''consent monitor," a retired hospital chaplain
    who acts as a patient advocate.

    Dr. Benjamin Greenberg, the lead researcher and a Brown University
    associate professor of psychiatry, said that great care is also taken
    to ensure that patients have been correctly diagnosed and that they
    have exhausted all other possible treatments. In the depression study,
    that list must include electroshock treatments.

    The studies generally reject eight patients for every one they accept,
    he said, and patients must be referred by a psychiatrist.

    Psychosurgery using deep brain stimulation is expected to remain
    strictly a topic of research for the next several years before it
    could become clinically available at specialized centers, Greenberg
    said. Much remains to be perfected, including the brain locations for
    the electrodes and the settings of the stimulators.

    And ultimately only about 4,000 patients a year nationwide with
    obsessive compulsive disorder, and perhaps more with depression, would
    be good candidates for such last-ditch surgery, he estimated.

    Greenberg said he could not connect a reporter with a patient who has
    undergone the surgery; media contact can be difficult for them, he
    said. But in general, for the risk of surgery to be worthwhile, the
    patients must be severely disabled and in great suffering, he said.

    One patient operated on by Butler researchers endured obsessive
    thoughts and compulsive behaviors 14 to 16 hours a day, often waking
    at 4:30 in the morning to begin rituals of double-checking, arranging,
    counting, and rearranging things, Greenberg said. At one point, the
    patient withdrew $100 from a cash machine, then could not remember
    where $5 of it had gone, pulled over to the side of the road, and
    spent five hours trying to recall.

    The stimulator surgery holds appeal for patients in desperate need of
    better therapies. But, said Dr. Ken Duckworth, medical director for
    the National Alliance for the Mentally Ill, ''Nobody calls an election
    with 2 percent of the returns in." Better treatments are badly needed,
    he said, but so are better data on whether the stimulators are safe
    and effective.

    Medtronic, the company that makes the brain stimulator system, is
    ''cautious but very interested" in its potential for psychiatric
    disorders, said spokeswoman Kathleen Janasz. It is not sponsoring the
    initial clinical trials, she said, though Greenberg said it was
    helping to pay for them.

    Hundreds of surgeons are now capable of implanting the stimulator
    system, because of their experience with Parkinson's patients, and
    many have expressed interest in trying it.

    Dr. Alim Louis Benabid, the French neurosurgeon considered the father
    of deep brain stimulation for Parkinson's disease, said the
    stimulators hold great potential for transforming basic brain research
    into treatments.

    ''But," he wrote in an e-mail, ''I fear that this would become a
    medical (and worse, a surgical) market, which would push doctors as
    well as companies to overpractice." The stimulators, he said, ''may
    prove to be a wonderful new tool, or on the contrary a temptation for
    unjustified malpractice."

    Carey Goldberg is reachable at goldberg at globe.com.