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.
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.
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.