A Depression Switch?


By DAVID DOBBS
Published: April 2, 2006

Deanna Cole-Benjamin never figured to be a test case for a radical new brain surgery for depression. Her youth contained no traumas; her adult life, as she describes it, was blessed. At 22 she joined Gary Benjamin, a career financial officer in the Canadian Army, in a marriage that brought her happiness and, in the 1990's, three children. They lived in a comfortable house in Kingston, a pleasant university town on Lake Ontario's north shore, and Deanna, a public-health nurse, loved her work. But in the last months of 2000, apropos of nothing — no life changes, no losses — she slid into a depression of extraordinary depth and duration.

"It began with a feeling of not really feeling as connected to things as usual," she told me one evening at the family's dining-room table. "Then it was like this wall fell around me. I felt sadder and sadder and then just numb."

Her doctor prescribed progressively stronger antidepressants, but they scarcely touched her. A couple of weeks before Christmas, she stopped going to work. The simplest acts — deciding what to wear, making breakfast — required immense will. Then one day, alone in the house after Gary had taken the kids to school and gone to work, she felt so desperate to escape her pain that she drove to her doctor's office and told him she didn't think she could go on anymore.

"He took one look," she told me later, "and said that he wanted me to stay right there in the office. Then he called Gary, and Gary came to the office, and he told us he wanted Gary to take me straight to the hospital."

They drove to the Providence Continuing Care Center's mental-health hospital, still known locally as the Kingston Psychiatric Hospital, or K.P.H., its name when it was built in the 1950's. "It's a dingy, archaic place," Deanna said, "typical of older mental hospitals." There, in the locked ward that also contained psychotic patients, she would spend the next 10 months straight and about 85 percent of the three years after that. Her depression would prove 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.

Finally, in the spring of 2004, Deanna's psychiatrist at the hospital, Dr. Gebrehiwot Abraham, received a fax from a University of Toronto research team asking if he had an appropriate candidate for a clinical trial of a new, experimental surgery for treatment-resistant depression. The operation borrowed a 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. One of the study's leaders, Dr. Helen Mayberg, a neurologist, had detected in depressed patients what she suspected was a crucial dysfunction in Area 25's activity. She hypothesized that the electrodes might modulate the area and ease the depression.

The procedure, Dr. Abraham told Deanna and Gary, had worked safely in thousands of Parkinson's patients. But it would carry some risk of neural complications (it was, after all, brain surgery), it would be uncomfortable and it might not work.

"We were in tears," said Deanna, who is now 41. "We felt we'd tried everything and nothing worked. But we talked about it and decided, 'Well, what have we got to lose?"'

What she hoped to lose, of course, was her depression. But depression, which 5 to 10 percent of Americans suffer in any given year and about 15 percent will suffer in their lifetimes, can be hard to lose. Drugs, as shown in a comprehensive study released last month by the National Institute of Mental Health, are effective in only half of patients with major depression. Psychotherapy does no better. For those people who are not helped by therapy or drugs, electroconvulsive therapy, or ECT, can bring relief. But few of those cures are complete. These therapies usually ease rather than cure depression while sometimes bringing side effects like insomnia or memory loss, and their potency often proves fleeting; as many as half to two-thirds of those successfully treated relapse within two years. Neither neuroscientists nor psychiatrists can say exactly what depression is. Neurologically and psychologically, what Hippocrates called the "black bile" and Susan Sontag "melancholy minus its charms" presents an almost impossibly complicated puzzle.


http://www.nytimes.com/2006/04/02/magazine...r=1&oref=slogin

There's much, much more.

some more:

"The expectations for the Toronto team's D.B.S. study were accordingly modest. When I later asked Mayberg's collaborator Dr. Andres Lozano, the neurosurgeon who performed the operations, what he had expected, he replied, "Nothing."

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. They've re-engaged their families, resumed jobs and friendships, started businesses, taken up hobbies old and new, replanted dying gardens. They've regained the resilience that distinguishes the healthy from the depressed.

These results brought a marvelous surprise to both the patients and the doctors involved — and nervous anticipation about whether their luck will hold. Though a few of the patients are more than two years out from the surgery, none completely trust their cure. No one can tell them for sure that it will last, and they worry. The study doctors and the wider medical community, meanwhile, are guarded about whether D.B.S. will prove so effective in larger trials. "I can't emphasize enough that we need a large, randomized study to confirm this as a treatment," says Valerie Voon, a University of Toronto psychiatrist who was with the team for the first six patients and who is now a research fellow at the National Institutes of Health.

Those caveats notwithstanding, many scientists following the trial say they believe it will change how psychiatrists define and treat mood disorders. Mayberg, who speaks of a "paradigm shift," notes that she developed the trial to evaluate not a treatment but a hypothesis. In that sense the trial succeeded. Mayberg's focus on Area 25 tests the emerging "network" model of mood disorders, a new way of looking at psychiatric conditions that isn't restricted by the neurochemical model of mood that has dominated over the past quarter century or so. Rather, it incorporates neurochemistry into the concept of the brain as a circuit board or wiring diagram. The network model carries profound implications for research and, ultimately, treatment. The Prozac revolution showed everyone that tweaking neurochemistry can dampen and sometimes extinguish depression — but only through a generalized approach, hitting the entire brain. ("Carpet-bombing," one neuroscientist calls it.) And the 50 percent success rate of antidepressant drugs suggests that they aren't hitting depression's central mechanism. The network approach, on the other hand, focuses on specific nodes, pathways and gateways that might be approached with various treatments — electrical, surgical or pharmacological. This small trial appears to confirm this model so emphatically that it's already changing the neuropsychiatric view of the brain and the direction of research." ....

(bold is my emphasis)

I watched a show a few weeks ago, that used this DBS to help a girl with Tourettes. They were very sucessful, though the FDA has not given it's approval yet.

From what I remember the Dr's doing the most cutting edge work with DBS here in the United States are at the Tulane University Hospital and Clinic in NOLA.