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Friday, July 22, 2011

Brain Surgery for Mental Illness?

In a recent post in the WebMD Depression Community, one person asked if there is brain surgery for depression as all medications and psychotherapy have failed to help. Another posted that brain surgery for depression is science fiction and doesn’t exist…

First, I have yet to meet someone that has truly tried all non-surgical options for depression. Second, we need to be careful that when we discuss surgery for psychiatric disorders, we do not make false claims about curing everyone definitively, or traveling down the road of excessive use without bona fide data and repeat our overuse of frontal lobotomies. Third, there are surgical procedures, some even FDA approved, to treat psychiatric disorders. Below are some brief descriptions:

  1. VNS (vagus nerve stimulation) is FDA approved for treatment resistant depression. A pacemaker is inserted into the chest wall by the arm pit just like a heart pace maker. A wire runs under the skin into the left neck near the carotid artery and is clipped onto the vagus nerve. This nerve is a large nerve that sends signals into the brain. It allows connections to areas of the brain that are felt to be involved in depression. About every 5 minutes a small electrical impulse travels from pacemaker, up the wire and into the brain. Not really brain surgery, but is arm pit and neck surgery that ultimately affects the brain. This approach also treats epilepsy.
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  3. DBS (deep brain stimulation) is FDA approved for compassionate use for refractory OCD. Currently it is experimental and being investigated for depression. A pacemaker is inserted similar to VNS but two wires are sent under the skin, behind the neck and onto the scalp near the top of the head. Two smaller wires (microelectrodes) are actually inserted into the brain (brain surgery) into areas also associated with depression. Again, electrical impulses travel from the pacemaker and into brain tissue. This is a type of brain surgery. This approach also treats certain forms of hand and arm tremors.
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  5. CST (cortical stimulation therapy) is even more experimental and in earlier stages of development compared to DBS or VNS. This involves a similar pacemaker in the chest wall and wires to the scalp, but surgery is needed to open part of the skull near the left frontal lobe area of the brain. A small, band-aid sized, flat electrode is placed over this brain area. Electrical impulses from the pacemaker and wires are sent to this flat electrode sitting on the surface of brain tissue and this is felt to restore brain functioning in this area which is dysfunctional in depression. This is brain surgery.

 

So there are brain surgeries and device based treatments for psychiatric disorders. These approaches are saved for those patients who often have failed to respond to almost everything. Patients have to be selected to match as closely to those who joined studies to get the same outcomes. This can be a lengthy process and I find that most insurance companies refuse to pay for these treatments which may run $20,000 or more. They are able to do this as the private insurance company is allowed to call these treatments experimental by their own internal definitions, despite some of these treatments being clearly FDA approved and not being experimental according to federal regulations.

Given that patient selection is tedious and specific and that most insurances will not pay for these treatments, it is unlikely that we will see thousands of patients walking around with computer chip pacemakers controlling brain function. Science fiction and conspiracy writers will have to wait many more years for this to become anywhere close to a reality.

Posted by: Thomas L. Schwartz, MD at 2:24 pm

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