[Paleopsych] Boston Globe: Brain device offers hope for some mental disorders
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Thu Aug 5 22:32:27 UTC 2004
Brain device offers hope for some mental disorders
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
''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
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
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
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
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
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
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
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
''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
Carey Goldberg is reachable at goldberg at globe.com.
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