Deep Brain Stimulation
A New Treatment for
Treatment-Resistant Depression
Nothing worked …
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Michael Lindsey suffered
for years with severe,
treatment-resistant
depression
Tried every available fix
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20 different medications
16 electroshock
treatments
Endless talk therapy
Nothing worked
www.dispatch.com
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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
www.dispatch.com
… until DBS
Deep Brain Stimulation (DBS)
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Used successful on thousands
with Parkinson’s disease
Fixes malfunctioning brain
systems via direct electrical
stimulation
Excites very specific targets
Reversible and adjustable
Not FDA-approved for
treatment-resistant depression
yet but initial trials are promising
www.henryfordhealth.org
What is depression?
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www.dreamstime.com
A disease of the brain
Involves a person’s
physiology, biochemistry,
mood, thoughts and behavior
Severe depressive symptoms
without mania
a/k/a “major depression” or
“major depressive disorder”
Treatment-Resistant
Depression (TRD)
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http://www.neptunecowboy.com
“Major depressive disorder” that just won’t
go away
Severe depressive symptoms
Lasts months or years
Resists all standard
treatments
 Antidepressants
 Talk Therapies
 ECT
Grim Statistics
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17% of the U.S.
population will
experience major
depressive disorder in
their lifetime
www.fims.uwo.ca
Grim Statistics

Only 37% of those
that seek treatment
achieve full remission
from initial drug
monotherapy
www.cbc.ca
www.fims.uwo.ca
Grim Statistics
www.bbc.co.uk

20% will show little or
no response to
multiple modes of
aggressive treatment
www.thelostboys.org
www.cbc.ca
www.fims.uwo.ca
Reason for Optimism

Rapid advances in brain imaging and
genetic mapping isolate specific brain
networks and neural
pathways implicated in
mental illness
uk.news.yahoo.com
www.americanmonitoringphysicians.com
http://brainatlas.org/aba/
DBS Basics
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DBS directly excites specific targets in the brain
via electrodes on surgically-implanted leads
Electrical current
interrupts “bad” brain
impulses
www.npr.org
www.us.oup.com
DBS Basics
Leads run to a generator implanted in the
patient’s chest
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mac2.innanen.com
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A sort of “pacemaker
for the brain”
www.henryfordhealth.org
Dollars Well Spent?
$50,000 per patient per DBS
procedure
 Unknown amount of research dollars
still needed to bring DBS to FDA
approval stage
 Are the effects costly enough to make
funding DBS worthwhile?
 Why not try more talk or drug
therapies?
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Treatment-Resistant Depression:
Cost to Sufferer
 Exacerbates
or raises risk for…
 Cancer,
diabetes, heart disease,
obesity, et al.
 Substance abuse, suicide, death
 Cost
gallery.hd.org
of human suffering
www.paigetropandweinstein.com
www.nationalmssociety.org
Treatment-Resistant Depression
Cost to Families
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Loss of companionship
Financial loss
Emotional & physical
toll on primary
caregiver(s)
Negative impact on
next generation’s
health and mortality
rate
www.who.int
Treatment-Resistant Depression:
Cost to Society
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Directly related healthcare costs
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Healthcare costs linked through
comorbid conditions
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http://www.sxc.hu/photo/524470
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$83 billion in 2002
Diabetes patients with severe
depression 86% higher healthcare
expenses
Increased homelessness,
substance abuse, morbidity
Treatment-Resistant Depression:
Costs to Economy
Decreased work
productivity
 Increased absenteeism
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www.sxc.hu
27.2 lost workdays per ill
worker per year
A leading cause of
disability claims
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Will be second only to
cardiac disease by 2020
-- World Health Organization
Criteria for DBS
DBS is exploratory and invasive
 To be considered for DBS, a patient must
meet certain criteria:
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Major depression at
least 5 years
 Current episode at least
2 years
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Ability to comply with
monthly visits, prolonged
testing visits, etc.
www.becomehealthynow.com
More Criteria
At least four failed antidepressants in two
different classes while augmenting with two
other therapies
 Failure or intolerance to ECT therapy
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www.sxc.hu
www.freeimages.co.uk
news.bbc.co.uk
www.cbc.ca
http://mac2.innanen.com/~bill/parkinsons/DBSsurgery/
DBS Surgery
Steps taken in performing DBS surgery for depression
are similar to those for Parkinson’s disease
Bill’s DBS Step-by-Step
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Bill is a Parkinson’s disease patient effectively
treated with DBS
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Here are the basic steps
completed in order to implant
Bill’s DBS electrical implants
Warning: what follows is
an honest portrayal of brain
surgery and is not
recommended for the faint
of stomach.
http://mac2.innanen.com/~bill/
First, to the MRI
mac2.innanen.com
mac2.innanen.com
mediabyran.kib.ki.se
Head Is Secured
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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
Awake but No Pain
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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
On the OR Table
Stereotaxic frame is bolted to operating
room table for absolute stability
 Another MRI is taken with Bill’s head firmly
in place
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“Since the surgery is
all done relative to
the frame, this is a
vitally important
step.”--Bill
mac2.innanen.com
Going In
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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.
mac2.innanen.com
--Bill .
Probe Is Inserted
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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
mac2.innanen.com
On the OR Table
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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
mac2.innanen.com
“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 .
Precise Location
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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
cms.clevelandclinic.org
Stimulator Programming
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Once Bill has healed from surgery, his
stimulator is turned on and adjusted
http://mac2.innanen.com/~bill/parkinsons/DBSsurgery/index.php?p=21
http://mac2.innanen.com/~bill/parkinsons/DBSsurgery/index.php?p=22
Results of DBS for
Depression
Dr. Helen Mayberg, et al., 2005
 Treated six TRD patients
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Remember, all previous treatments failed
Four out of the six experienced near
immediate relief
 Within 6 months of treatment, near
remission
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