“You are not alone! 10-15% of people suffer from depression. There is an effective treatment for depression available, even for severely depressed patients….
At Jaslok Hospital, we understand the weight that depression places on individuals and their loved ones. Our commitment to providing the best depression treatment in Mumbai stems from our dedication to improving lives and restoring hope.
Depression is a serious and incapacitating medical illness. MDD is a common condition that is widely frequent in population: community-based surveys conducted in several countries using ICD-10 criteria showed a lifetime prevalence ranging from 6-12%, with an annual prevalence of 3-11%. Current data show that MDD is an incapacitating condition: it is predicted that MDD will be the second cause of incapacitating disease in 2020. In addition, depression is a chronic, recurrent disorder, as nearly 80% of patients relapse after the treatment of an episode. Finally, about one third of patients have treatment-resistant depression (TRD), which is defined as the failure to achieve adequate response of symptoms after two or more antidepressant treatment trials. Various hypotheses propose that MDD is a disorder associated with dysfunction in critical areas related to mood regulation. In fact, two major pathways can be determined here: the cognitive-executive pathway, in which a hypoactive dorso-lateral prefrontal cortex fails to regulate areas related to executive functioning; and the affective-somatic pathway, in which a hyperactive Prefrontal cortex modulates erratically areas related to negative affect and self-awareness. The rationale in using different neurostimulator therapies is based on their mechanisms of inhibiting or enhancing activity in these pathways depending on the area stimulated. The other aspects are biochemical disturbances in certain brain chemicals called neurotransmitters that are thought to be the underlying cause of depressive disorders in general. Major depression is a major psychiatric disorder in which, the prominent symptom is a disturbance of mood which is a constant feeling that is experienced internally and that influences a person’s attitudes, thinking, behaviour and perception.
Depression is a mood disorder that influences the way a person thinks, feels, and handles daily activities. It goes beyond the typical ups and downs of life and becomes a persistent state of sadness, affecting one’s overall well-being. Often accompanied by feelings of worthlessness and guilt, depression can be a profound emotional struggle.
There are several types of depression, each with its unique characteristics and symptoms. It’s essential to note that depression is a complex mental health condition, and individuals may experience a combination of symptoms. Here are some common types of depression:
It’s a heavy burden that crushes the soul, making even the simplest tasks feel impossible to overcome. It’s like being trapped in a suffocating abyss, where hope seems to slip away from your grasp. Each day becomes an unyielding struggle, and the weight on your heart feels unbearable. According to Diagnostic and Statistic Manual of Mental disorder (DSM)-5, MDD is defined as low mood for more than 2 weeks associated with 5 or more depressive symptoms.
A constant shadow follows you everywhere, and PDD feels like an unending rain cloud hanging over your head. It’s like walking through an endless dark tunnel with no glimpse of light ahead. Joy becomes a distant memory, and the world loses its vibrant colors. According to DSM-5, PDD is defined as low mood associated with 2 or more depressive symptoms for more than 2 years.
With SAD, the changing seasons bring overwhelming sadness. It’s like being locked in a cage of sorrow during the cold and gloomy months. The lack of sunlight dampens your spirit, leaving you feeling hollow and disconnected from the world around you. Therefore, bright light therapy is the first line of treatment for SAD.
This type of depression brings a terrifying twist, where the mind becomes a battleground of delusions and hallucinations. It’s like living in a nightmarish world where the line between reality and fantasy blurs, leaving you isolated and terrified.
During the depressive phase of bipolar disorder, emotions swing like a pendulum from euphoria to despair. The darkness that engulfs you is suffocating, pulling you down into a state of desolation where hope seems out of reach. Even though depression is present, antidepressant medications are not given in order to avoid making mania worse. They are initially treated with mood stabilizers.
The joy of bringing new life into the world clashes with an overwhelming sense of emptiness and sadness. It’s like drowning in a sea of conflicting emotions, feeling guilty for not experiencing the happiness you think you should. This is more common in younger females and if not treated patient may develop psychotic symptoms.
Typically depression is associated with decrease appetite, weight loss and lack of interest. However, some patient start eating more and gain weight during depression. With atypical depression, you experience hypersensitivity to rejection and a constant state of heaviness in your limbs. It’s like carrying an invisible weight that drags you down at unexpected moments.
It’s a type of depression that is followed by some disturbing events (like death of loved ones or bankruptcy etc.). Sadness to some extent and duration is normal, however, when symptoms exaggerate or persist for longer duration, it may indicate depression. It feels like being stuck in a never-ending storm of despair, with circumstances beyond your control casting a dark cloud over your life.
Depression presents itself in various ways, and recognizing the symptoms is crucial for early intervention and treatment. Common signs include:
Overwhelming feelings of sadness or emptiness that linger for prolonged periods.
A constant lack of energy, leading to persistent fatigue even after adequate rest.
Insomnia or excessive sleeping are typical indicators of depression.
Disinterest or withdrawal from once-enjoyable activities or hobbies.
Drastic shifts in appetite, leading to noticeable weight loss or gain.
Struggling to focus, make decisions, or recall details.
Persistent self-blame and feelings of inadequacy.
In severe cases, individuals may experience thoughts of self-harm.
Depression is a complicated disorder that is influenced by a variety of factors, including:
Imbalances in brain neurotransmitters such as serotonin and dopamine can contribute to the incidence of depressive episodes.
Having a family history of depression can increase one’s vulnerability to the disorder.
Traumatic occurrences, the death of a loved one, or continuous stress can all function as depression triggers.
Certain personality types may be predisposed to depression.
Dealing with long-term health concerns can trigger depression.
Identifying the underlying causes is an essential step in tailoring effective treatment plans.
At Jaslok Hospital, we offer a range of cutting-edge and proven therapies to address depression effectively. Some of our prominent treatment options include:
Electroconvulsive therapy (ECT) is a procedure, done under general anesthesia, in which electric stimuli are used to induce seizures. ECT appears to cause changes in the brain that can quickly reverse symptoms of certain mental health conditions.
Several guidelines suggest the role of ECT as a first-line treatment of severe major depressive disorder, especially in psychotic and/or suicidal patients, or those with catatonia or treatment-resistant depression. Many people notice an improvement in their symptoms after about a few sessions with electroconvulsive therapy. No one knows for sure how ECT assist treating severe depression and other mental illnesses. However, it is known that many electrophysiological aspects of brain function are changed during and after seizure activity.
TMS uses the principle of electromagnetic induction to stimulate the neurons in the brain. Multiple sessions are required to get therapeutic benefit. It has proved its efficiency in various clinical trials on depression. Recent meta-analyses published in 2007 and 2008 showed that rTMS had the same efficacy of pharmacological drugs for MDD with also similar rates of response and remission rates for TRD (25% and 17%), respectively, which is similar to the STAR*D results of 19% and 13%. Therefore, TMS is rapidly getting approval as a mode of treatment for depression. Currently, rTMS has been approved for use in Brazil, Canada, Israel and some European countries and also in the US.
Vagus nerve stimulation (VNS) is helpful for treatment-resistant depression. It may be used when medicines, psychotherapy and ECT haven’t been effective for depression. It is an FDA approved treatment for such a resistant patient. Despite the short term studies failing to reflect effectiveness, beneficial effects of VNS at long-term in a large number of patients, together with its low number of unwanted side effects, make this method an attractive treatment for patients suffering from MDD.
One of the innovative treatments we offer is Deep Brain Stimulation (DBS). This groundbreaking procedure involves implanting a small device in the brain, which delivers carefully controlled electrical impulses. DBS has shown promising results in alleviating depression symptoms, especially in cases that have been resistant to other forms of treatment.
We believe that ongoing support is integral to the recovery journey. Our dedicated team of experienced counsellors and support staff are here to lend a listening ear and offer guidance throughout the treatment process. Regular follow-up sessions and progress evaluations ensure that each patient receives continuous care and assistance.
Jaslok Hospital stands at the forefront when it comes to depression treatment in Mumbai, with a team of dedicated professionals who prioritize patients’ well-being. Our commitment to providing personalized care and utilizing cutting-edge treatments ensures the best possible outcomes for those seeking relief from depression’s grasp.
Our state-of-the-art facilities, coupled with a team of compassionate and skilled professionals, have earned us the reputation as the best depression treatment clinic in Mumbai. We take immense pride in our patient-centric approach, focusing on individual needs and crafting personalized treatment plans.
Our team of depression treatment specialists comprises esteemed doctors including neurologists, neurosurgeons, psychiatrists, psychologists, and therapists.
The team is led by the best neurologist in India, Dr Paresh K Doshi. Their expertise, combined with their genuine empathy, ensures that you receive world-class care and support during your treatment at Jaslok Hospital.
It is beyond the scope of this team to offer you any advice on medical treatment. However, several other advanced interventional treatments are described below.
ECT is the first and most studied brain stimulation therapy to date. In fact, Cerletti and Bini, in 1938, conducted the first descriptions of using electric stimuli to induce therapeutic seizures. Although its mechanisms of action are still incompletely known, accumulated evidence points that its antidepressants effects are related to several mechanisms, such as restoring hemispheric balance, increasing BDNF serum levels, enhancing neurogenesis through a series of electrical shocks and, long-term up-regulation of serotonin activity and down-regulation of muscarinic activity. Nevertheless, several guidelines support the role of ECT as a first-line treatment of severe major depressive disorder, especially in psychotic and/or suicidal patients, or those with catatonia or treatment-resistant depression.
In recent years, several systematic reviews and meta-analyses of ECT efficacy have been published. The UK ECT Review Group reviewed the efficacy of ECT vs. (sham) ECT, drug therapy & other parameters. The pooled analysis of ECT comparisons against amitriptyline, imipramine, phenelzine or others favored ECT with a mean Hamilton difference of 5.2 (95% CI ranging between 1.4-8.9). Bilateral ECT was more effective than unilateral (mean Hamilton reduction of 3.6 points – 95% CI ranging between 2.2-5.2). Finally, treatment with high doses of ECT led to a greater reduction in depressive symptoms with a mean change of Hamilton scores of 4.1 (95% CI ranging between 2.4-5.9) when compared to placebo. They observed an important decrease in performance in almost all neuropsychological tests at post-ECT.
TMS uses the principle of electromagnetic induction to focus induced current in the brain. RTMS has been tested for several neurological and psychiatric conditions, but none has had the same number of studies and positive results than MDD. Recent meta-analyses published in 2007 and 2008 showed that rTMS had the same efficacy of pharmacological drugs for MDD with also similar rates of response and remission rates for TRD (25% and 17%), respectively, which interestingly is similar to the STAR*D results of 19% and 13%. Currently, rTMS has been approved for use in Brazil, Canada, Israel and some European countries and also in the US.
Long-term studies have proven the good clinical outcome of VNS for MDD while it is well tolerated; a successful response have been described in half of the patients, with complete remission in one third. Immediately postoperatively and at short-term follow-up, VNS has shown a low effectiveness. However, its beneficial effect at long-term in a substantial amount of patients, together with its low number of unwanted side effects, make this method an attractive treatment for patients suffering from MDD.
Lesion Surgery
Deep Brain Stimulation
The Deep Brain Stimulation surgery in India has shown successful results in a majority of patients suffering from advanced stages of the Parkinson’s disease and is now a well accepted treatment. While this surgery showed major improvements in Parkinson’s disease patients for controlling motor movements and the like, until recent time there was no substantial evidence that the same surgery could be used for patients suffering from depression. However, thanks to medical research on the matter, it has been proved that DBS can be a viable option for treatment resistant depression in patients, especially for unipolar major depressive disorder (MDD) or bipolar II disorder (BP). DBS for depression is now being talked about extensively.
While MDD is prone to being resistant to allopathic treatment and slowly immune to medication, bipolar II disorder patients are known to go into a hypo-manic or manic episode state when given antidepressant medications. These aspects make DBS an ideal solution for such patients. Deep Brain Stimulation uses high frequency electrical stimulation to target a specific area of the brain for a particular neuro-psychiatric disorder. While DBS has shown substantial improvement in many patients, most studies on the matter have shown mixed results.
Patient selection is crucial to the success of depression surgery. It is important that the patient be offered surgical evaluation at an appropriate center which has the expertise of evaluating such patients. At Jaslok hospital, such patients are evaluated by two psychiatrists and a neurosurgeon. They establish if the disease is indeed incurable with medical treatment and the patient has been offered adequate trial of best medical therapies. If they find it appropriate, he is referred to a committee to confirm the findings and only after such stringent evaluation surgery is offered. Remember that even though this depression surgery may help and show marked improvement in the patient, it may be recommended that the medication and other treatments like counselling, psychotherapy, rehabilitation, etc., be continued even after the depression surgery. There can be cases where DBS may not be the best option at hand, with such patients the conventional psychiatric or psychologist help with allopathic medication may be the only way for now, until there is another scientific breakthrough that can benefit them.
In view of the fact that depression surgery is a ray of hope for many, but still not the right treatment for every person caught in the anguish of this disorder, it is important to continue the research and clinical trials on the subject. Many hope that a close understanding of DBS and how it works on the brain can provide researchers with the insight they need to find a cure for depression and other psychopathic diseases.
Dr. Paresh Doshi, Director of the functional neurosurgical department at Jaslok Hospital, established this program in 1998 to treat movement disorders, epilepsy, spasticity, pain and psychiatric disorders. The first Deep brain stimulation (DBS) surgery in India was performed here. Dr. Doshi has performed over 250 DBS surgeries at Jaslok Hospital, which is the largest in India and is credited as the only Indian on the task force for “guidelines for psychiatric disorders surgery”.
Dr. Amit Desai has been a Consultant Psychiatrist at Jaslok Hospital for almost 13 years. He specializes in adult psychiatry. Psychiatric consultant on Jaslok Hospital’s Functional Neurosurgical Department panel for DBS related to Parkinson’s disease and Obsessive Compulsive Disease.
Surgery Procedure
The surgery is done under local anesthesia with stereotactic guidance keeping the patient completely awake during the procedure. First, a frame is applied to the patients head then a CT scan is done. These images are fused with the previous MRI images of brain using a special software program and the specific target in the brain i.e., subgenual cingulate gyrus area 25 is visualized. Dr. Doshi does the optimum target and trajectory planning for DBS. After that, the patient is brought to the operation theater. During surgery, Benjamin was tested by asking several questions relating to his mood and feelings. As the lead was inserted and the brain stimulated, Benjamin said he was feeling lighter than before, smiled during the procedure, felt relieved of stress and felt like talking to his old friend to whom he stopped talking for a long time, indicating improvement in feelings. The leads were connected to a pacemaker that delivers continuous stimulation to the brain. As days progress, the effect of stimulation builds up and we look forward to a greater improvement in his mood.
Results
In 2005, Mayberg et al. presented the first clinical study of DBS in depression. The hypothesis to stimulate this area was acquired from observations that showed hyperactivity of the subgenual cingulate cortex (Brodmann area 25; Cg25) in chronic depressed patients. It was thought that this area plays a primary role in processes like learning, memory, motivation, and reward—behaviors that change with depression. In this novel study by Mayberg et al., six patients were implanted and stimulated with parameters adjusted to the apparent optimal benefit. After 6 months, in 67% of patients, a reduction of more than 50% on the Hamilton depression rating scale (HDRS) was seen, with a total or partial remission in three patients. Clinically, improvement was referred as an increase in energy, interest, psychomotor speech and decrease of apathy and anhedonia. In addition, imaging studies showed normalization in the cerebral blood flow of Cg25 and other areas which appear to be related with depression. Schlaepfer et al. published the positive results of DBS of the nucleus accumbens for depression in three patients. The positive behavioral changes in these patients were supported by positron emission tomography imaging that correlated symptomatology with an augmentation of metabolism in the nucleus accumbens, amygdala, and dorsolateral and dorsomedial prefrontal cortex, and reduced metabolism in the ventral and ventrolateral medial prefrontal cortex .
We have performed three cases of DBS for drug resistant MDD. The first patient was a 25 years old man from Australia. He had the most severe form of depression which had been resistant to all forms of treatment including ECT. He underwent area Cg 25 DBS. At two years follow up, he did not require any medications, was also married and resumed his work.
Benjamin Ward
PATIENT UNDERGONE DBS FOR DEPRESSION
“Everything is going very well. I started working 3 weeks ago, it is going well. I am getting into a routine and it is a lot easier now, compared to when I was unwell. It’s good being able to work and to be able to support myself. I am now doing everything I used to do before I fell ill [work, church, friends, exercise, beach and motorbikes] which is amazing and I feel pretty much completely better. I am more than happy to do so because DBS has changed my life. I want people who were in my situation to hear that DBS is a treatment for depression and that it is possible to get. I was lucky that I found out about the treatment 2 years ago on the internet. Because if I had not found it myself, I still would probably not have heard about it, let alone had the surgery. Thanks again to you and all your team for all your help.
Ablative surgery to treat mental illnesses is one of the therapies that has expanded more rapidly and widely as a non-pharmacological therapy. Throughout the decades many targets, approaches and techniques have been tried, with diverse and sometimes contradictory outcomes. Although the effects on mood gained the attention of medical community, due to the growing prevalence and socioeconomic burden, often no objective measurement of the effects was performed and probably misdiagnosed patients were included into the studies.
Capsulotomy
Jean Talairach, based on the leucotomy work, got the idea to disconnect front thalamic fibers e.g. fibers running between the subgenual anterior cingulate cortex and the orbitofrontal cortex and the medial, anterior and dorsomedial thalamic nuclei. The procedure represented, in that way, a restricted lobotomy procedure and was performed stereo tactically by electrocoagulation between the anterior and mid third of the anterior limb of the internal capsule at the level of the interventricular foramen. Lars Leksell propagated this procedure in Sweden where the procedure also have been performed with the gamma knife.
During the course of years, the target got more refined. Additional information suggested that the ventral part of the internal capsule was surrounded by functionally active an important areas like bed nucleus of stria terminals, nucleus accumbens, ventral striatum etc. Nuttin et. al showed that the initial Capsulotomy target can be further modified to move posteriorly and ventrally to achieve better outcomes. The current strategy is to use stereotactic techniques to make a lesion in the VC/VS area.
Results There is no age limit for the surgery but Capsulotomy below the age of 20 has not been reported. The anterior Capsulotomy has been reported to be especially effective against obsessive compulsive disorder with a long lasting improvement among 48–78%. Side effects are generally few and shortlift consisting of headache, confusion, urinary incontinence and weight gain. The most prevalent side effect is tiredness and lack of initiative. This lethargia, although generally transient, has been reported to last for several weeks or months and at least in some case may result in a persistent mild apathy or dominant frontal lobe syndrome.
Cingulectomy (cingulotomy)
In 1967, Ballantine described the first stereotactic anterior cingulotomy for psychiatric disorders including depression, after the publication of reports by Foltz and White, who by that time had carried out stereotactic cingulotomies in patients with untreatable pain. The stereotactic neurosurgical technique was applied for the first time in patients by Spiegel and Wycis in 1947. It was a milestone in neurosurgery because specific deep targets could be reached through one burr-hole by using internal cerebral landmarks. Ballantine reported an improvement in 77% of operated patients with comorbid fear and depression. Other studies showed an improvement between 44% and 92% with personality changes, epilepsy, weight gain and urine incontinence as the most reported side effects. Cingulotomy is more commonly used for treating depression than OCD.
Surgery for psychiatric disorders has been always disfigured with controversies. In order to avoid the mistakes of the past, psychiatrists from all across India; from (academic and private practice) and functional neurosurgeons met in May 2009. Around 30 experts’s brain stormed and debated over the published literature and evidence. Guidelines for this were subsequently laid down and recommended for any center that desired to follow the surgical program. In 2011, World society of stereotactic and functional neurosurgery set up a “Psychiatric surgery task force” to evaluate the evidence and draw guidelines for the psychiatric disorders surgery. After two years of debate and data analysis, the guidelines were formed taking several aspects into consideration and published in 2013. This is an open source publication and can be reviewed by anyone. Some key parts of guidelines are reproduced below:
The scope of neurosurgical intervention for psychiatric disorders
Neurosurgical therapy for psychiatric disorder range from those that have been in routine use in specialist centers for several decades eg: anterior cingulotomy for MDD anterior Capsulotomy for OCD to those that remain highly experimental and have only had been tried very small number of patients eg: (DBS for anorexia nervosa). However, despite the lengthy history and the weight of publications associated with lesion procedures in particular. The collected evidence supporting the application of all neurosurgical treatments for psychiatric disorders requires to be strengthened. While certain procedures are considered to represent ‘established’ practice for severe treatment-refractory psychiatric disorders in some countries (eg: thermal anterior cingulotomy for MDD and OCD in the Scotland, USA, South Korea and elsewhere, radio-frequency anterior Capsulotomy for severe treatment-refractory OCD in Belgium.) the nature of these & many other procedures in neurosurgery, including DBS for psychiatric disorders, remains at a ‘proof-of-principle’ investigational stage of development. Current practiced stereotactic ablative procedures do not have level I evidence with randomized controlled trials, but their safety and efficacy are supported by level II evidence in treatment-refractory MDD and OCD. However, this degree of evidence is not yet available for ‘new’ lesioning methods such as gamma knife and stereotactic-focused ultrasound.”
The paper goes on to suggest that besides careful patient selection, till the therapies get fully established, they should be overseen by ethics committee or Institutional review board. The guidelines were endorsed by several world organizations, including, European Society for Stereotactic and Functional Neurosurgery (ESSFN), partnering with the Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’, along with the Psychiatric Neurosurgery Committee of the American Society for Stereotactic and Functional Neurosurgery (ASSFN), the Latin American Society for Stereotactic and Functional Neurosurgery (SLANFE), the Asian-Australasian Society for Stereotactic and Functional Neurosurgery (AASSFN) and the World Psychiatric Association (WPA).
At the Jaslok Hospital and Research Centre strict adherence is followed. Even before this paper all surgeries were scrutinized and overseen by the Ethics committee and scientific committee of the Jaslok Hospital to ensure patient’s safety.
First case of DBS for Depression in Asian and Australian continents
The following is the excerpt from one of the Media reports:
Mumbai, October 1st, 2013: Mr. Benjamin Ward, a 26 year old gentleman from Sydney, Australia, was suffering from severe depression with suicidal thoughts, has undergone ‘Deep Brain Stimulation’ a depression surgery at Jaslok Hospital, Mumbai on 25th September 2013. Dr Paresh Doshi, Director of Neurosurgery and Dr Amit Desai, Consultant Psychiatrist, shared their experience of this path breaking depression surgery.
Benjamin was born a healthy baby, was socially active and comes from a happy family.
Symptoms of Benjamin’s disease
His symptoms of depression first appeared after his return from China where he went along with a Church on a mission to built and maintain orphanages. While in China, he noticed that he became overly tired and tearful and had to return home earlier than planned. Following this, he was alright for one year, after which, he had frequent episodes of depression. He used to cry at work and had suicidal thoughts of crashing his car. He lost interest in work and quit his job. He felt like a robot. He also had increased worries and developed disturbances in sleep at night. Benjamin consulted a psychiatrist who is still treating him, tried several drugs at full dose and for sufficient periods of time but most showed only initial benefits [these drugs included Mirtazapine, Lithium, Quetiapine, Valdoxan and Methylphenidate]. He also suffered from side effects of some drugs. When drugs failed; he was advised electroconvulsive therapy (ECT). He took several cycles of ECT and even transcranial magnetic stimulation (TMS) and cognitive behavioral therapy (CBT), but all resulted in little benefits. Having failed medications and other alternate treatments for years, Benjamin was desperate for relief. After extensive research, he found that Dr. Paresh Doshi had successfully performed DBS for several treatment resistant conditions.
“On detailed review, we found that Benjamin was suffering from treatment resistant major depressive disorder. We felt that he was an ideal candidate for area 25 DBS which is presently being done only in a few selected centers all over the world. Benjamin’s reports revealed that he is suffering from severe grade depression”, said Dr Paresh Doshi, Director of Neurosurgery, Jaslok Hospital & Medical Research Centre.
Dr. Doshi discussed the case in a Joint Meeting attended by two psychiatrists, two neurosurgeons and a Neurologist. All of them opined that he is an ideal candidate for DBS as he had tried all the available medications and other therapies. The same was discussed with his relatives and they readily agreed.
He underwent the DBS surgery in awake condition. He had significant improvement on the operation table itself.
Postoperatively he was well and was discharged with significant improvement in his symptoms. Two years later he is now completely free of depression, has resumed back his work and has started socializing with friends. He also found his soul mate and got married.