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Deep Brain Stimulation A New Treatment for Treatment-Resistant Depression.

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Presentation on theme: "Deep Brain Stimulation A New Treatment for Treatment-Resistant Depression."— Presentation transcript:

1 Deep Brain Stimulation A New Treatment for Treatment-Resistant Depression

2 Nothing worked … Michael Lindsey suffered for years with severe, treatment-resistant depression Michael Lindsey suffered for years with severe, treatment-resistant depression Tried every available fix Tried every available fix 20 different medications 20 different medications 16 electroshock treatments 16 electroshock treatments Endless talk therapy Endless talk therapy Nothing worked Nothing worked

3 … until DBS Underwent deep brain stimulation surgery in a final attempt to regain his life 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 Awake during the procedure, Michael laughed for the first time in years

4 Deep Brain Stimulation (DBS) Used successful on thousands with Parkinson’s disease Used successful on thousands with Parkinson’s disease Fixes malfunctioning brain systems via direct electrical stimulation Fixes malfunctioning brain systems via direct electrical stimulation Excites very specific targets Excites very specific targets Reversible and adjustable Reversible and adjustable Not FDA-approved for treatment-resistant depression yet but initial trials are promising Not FDA-approved for treatment-resistant depression yet but initial trials are promising

5 What is depression? A disease of the brain A disease of the brain Involves a person’s physiology, biochemistry, mood, thoughts and behavior Involves a person’s physiology, biochemistry, mood, thoughts and behavior Severe depressive symptoms without mania Severe depressive symptoms without mania a/k/a “major depression” or “major depressive disorder” a/k/a “major depression” or “major depressive disorder”

6 Treatment-Resistant Depression (TRD) “Major depressive disorder” that just won’t go away “Major depressive disorder” that just won’t go away Severe depressive symptoms Severe depressive symptoms Lasts months or years Lasts months or years Resists all standard treatments Resists all standard treatments Antidepressants Antidepressants Talk Therapies Talk Therapies ECT ECT

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

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

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

10 Reason for Optimism Rapid advances in brain imaging and genetic mapping isolate specific brain networks and neural pathways implicated in mental illness Rapid advances in brain imaging and genetic mapping isolate specific brain networks and neural pathways implicated in mental illness uk.news.yahoo.com

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

12 DBS Basics Leads run to a generator implanted in the patient’s chest Leads run to a generator implanted in the patient’s chest A sort of “pacemaker for the brain” A sort of “pacemaker for the brain” mac2.innanen.com

13 Dollars Well Spent? $50,000 per patient per DBS procedure $50,000 per patient per DBS procedure Unknown amount of research dollars still needed to bring DBS to FDA approval stage Unknown amount of research dollars still needed to bring DBS to FDA approval stage Are the effects costly enough to make funding DBS worthwhile? Are the effects costly enough to make funding DBS worthwhile? Why not try more talk or drug therapies? Why not try more talk or drug therapies?

14 Treatment-Resistant Depression: Cost to Sufferer Exacerbates or raises risk for… Exacerbates or raises risk for… Cancer, diabetes, heart disease, obesity, et al. Cancer, diabetes, heart disease, obesity, et al. Substance abuse, suicide, death Substance abuse, suicide, death Cost of human suffering Cost of human suffering gallery.hd.org

15 Loss of companionship Loss of companionship Financial loss Financial loss Emotional & physical toll on primary caregiver(s) Emotional & physical toll on primary caregiver(s) Negative impact on next generation’s health and mortality rate Negative impact on next generation’s health and mortality rate Treatment-Resistant Depression Cost to Families

16 Treatment-Resistant Depression: Cost to Society Directly related healthcare costs Directly related healthcare costs $83 billion in 2002 $83 billion in 2002 Healthcare costs linked through comorbid conditions Healthcare costs linked through comorbid conditions Diabetes patients with severe depression 86% higher healthcare expenses Diabetes patients with severe depression 86% higher healthcare expenses Increased homelessness, substance abuse, morbidity Increased homelessness, substance abuse, morbidity

17 Treatment-Resistant Depression: Costs to Economy Decreased work productivity Decreased work productivity Increased absenteeism Increased absenteeism 27.2 lost workdays per ill worker per year 27.2 lost workdays per ill worker per year A leading cause of disability claims A leading cause of disability claims Will be second only to cardiac disease by 2020 Will be second only to cardiac disease by World Health Organization -- World Health Organization

18 Criteria for DBS DBS is exploratory and invasive DBS is exploratory and invasive To be considered for DBS, a patient must meet certain criteria: To be considered for DBS, a patient must meet certain criteria: Major depression at least 5 years Major depression at least 5 years Current episode at least 2 years Current episode at least 2 years Ability to comply with monthly visits, prolonged testing visits, etc. Ability to comply with monthly visits, prolonged testing visits, etc.

19 More Criteria At least four failed antidepressants in two different classes while augmenting with two other therapies At least four failed antidepressants in two different classes while augmenting with two other therapies Failure or intolerance to ECT therapy Failure or intolerance to ECT therapy news.bbc.co.uk

20 DBS Surgery Steps taken in performing DBS surgery for depression are similar to those for Parkinson’s disease mac2.innanen.com /~bill/parkinsons/DBSsurgery/

21 Bill’s DBS Step-by-Step Bill is a Parkinson’s disease patient effectively treated with DBS 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. 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 Here are the basic steps completed in order to implant Bill’s DBS electrical implants

22 First, to the MRI mediabyran.kib.ki.se mac2.innanen.com

23 Head Is Secured Head is secured in a stereotaxic frame Head is secured in a stereotaxic frame “They assembled the stereotaxic frame from a kit that looked like a very expensive erector set.” --Bill mac2.innanen.com

24 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) 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 mac2.innanen.com

25 On the OR Table Stereotaxic frame is bolted to operating room table for absolute stability Stereotaxic frame is bolted to operating room table for absolute stability Another MRI is taken with Bill’s head firmly in place 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.”--Bill mac2.innanen.com

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

27 Probe Is Inserted The micro drive advances a microelectrode probe down a hollow tube called “the introducer” 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 Once proper placement is achieved, the probe is removed and the final stimulator lead is eased through the introducer mac2.innanen.com

28 On the OR Table A stack of “listening” equipment stands ready and waiting for Bill’s brain waves 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 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. mac2.innanen.com

29 Precise Location The goal is to locate the probe in the precise locations needed to stop malfunctioning brainwaves 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 Once the location is found, leads are eased into place cms.clevelandclinic.org

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

31 Results of DBS for Depression Dr. Helen Mayberg, et al., 2005 Dr. Helen Mayberg, et al., 2005 Treated six TRD patients Treated six TRD patients Remember, all previous treatments failed Remember, all previous treatments failed Four out of the six experienced near immediate relief Four out of the six experienced near immediate relief Within 6 months of treatment, near remission Within 6 months of treatment, near remission


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