Turning down the sadness
Brain surgery for depression shows promise
It was a gloomy, rainy October day in 2007 when Kathryn began to see in colour again. This day marked the moment she started to recover — from a 19-year battle with a profoundly disabling treatment-resistant depression.
Kathryn had gone shopping early that morning. When she left the mall and walked outside, all she saw were the colours of the leaves on the trees.
“Seeing these blazing reds, intense yellows and oranges in a way that I hadn’t seen in years,” said Kathryn. “I started to sob right in that parking lot.”
Severe depression is insidious. Kathryn describes it not as an intense sadness, but as a numbness — the inability to feel anything at all. According to the WHO, depression is the leading cause of disability worldwide. And research on treatment-resistant depression shows that one-third of people don’t respond to trials of multiple medications and treatment, such as psychotherapy and electroconvulsive therapy.
The day Kathryn’s senses came “back online” was two years, two months and five days after undergoing an experimental brain surgery — known as deep brain stimulation (DBS).
But before the U.S. Food and Drug Administration can approve DBS, clinical trials must show that it is safe and can effectively fight chronic cases of treatmentresistant depression.
Physicians started experimenting with DBS in 2003. In this procedure, a surgeon drills a small hole into the skull and directs an electrode down into a region called Brodmann area 25 — what Dr. Andres Lozano, a neurosurgeon at Toronto Western Hospital and leader in the field of DBS, has referred to as the “sadness centre of the brain.”
The other end of the electrode is tunnelled down under the skin to a battery, or pacemaker-like device, in the chest. Doctors then use a remote control to turn up or down — like the volume on a speaker — the amount of electricity delivered to that area of the brain.
While DBS refers to “stimulation,” it is actually an inhibitory effect that is at work. The current from the electrodes are turning down sadness, pumping the brakes. In people with treatmentresistant depression this area of the brain is very active and medication or psychotherapy can’t quieten it down.
However, DBS is not a cure. If stimulation stops, the depression will return.
“This is not a pill, it’s a surgical procedure,” said Lozano, “so there’s much more variability in the surgical procedure than there is in taking a simple medicine.”
The real story is the one that comes after surgery. Life continues for the patients.
Kathryn, a patient of neurologist Dr. Helen Mayberg of Emory University in Atlanta, is one of those for whom DBS has worked. Her road to recovery hasn’t been easy. Prior to her DBS surgery, she had tried over 40 medications, electroconvulsive therapy and psychotherapy. Kathryn had very real plans of suicide.
“Recovery is actually a very long process. It’s not like you just wake up one morning and your depression is gone and your life is wonderful,” said Kathryn. It’s been 10 years now since that momentous October morning when the grey lifted. Today, Kathryn doesn’t take medication and has no residual symptoms of depression. She so far has had no adverse effects to DBS.
Her case is unusual. Most patients need some form of medication. Kathryn wants others considering this road to have realistic expectations.
Just as after any surgery, there is rehab after DBS. When someone has their hip replaced they must learn to walk again, said Dr. Peter Giacobbe, a Toronto psychiatrist at the University Health Network who works with DBS patients and worked closely with Kathryn.
It’s the same with surgery for depression, “these people need to learn how to rebuild their lives and undo past ways of connecting with others,” he said. “The people who successfully do that, you can see that they’re able to go back to work. Their remission rates creep up over one to three years.”
As for Kathryn, today she lives a very full life. She works, volunteers, sits on a number of committees and is involved with patient-engagement related to mental health. It’s quite a change for someone who once struggled to leave her bed.
“DBS is a long-term prospect,” said Giacobbe. “We work with these people for 15 years — or more. You get married to them in some ways it’s ’til device or death do you part.”
For now, DBS remains experimental. While it is reserved for the most severe cases of depression, Kathryn refers to the power that comes from just knowing that something like DBS is out there, and that other potential new solutions are emerging, such as genetic testing and new medications inspired by the drug ketamine.