Sheila Cook, a 62-year old grandmother, has been suffering from deep depression for more than ten years (1). She underwent many courses of antidepressants, as well as electric shock therapy (ECT) in attempt to improve her distress and disability. But the disease seemed to be resistant to any forms of psychiatric help. When scientists from Bristol had offered Mrs. Cook a completely novel and radical treatment, she didn’t suspect that her life would change that much. British woman is the first patient to benefit from the most advanced method of stereotactic ablative neurosurgery.
The patient, whose condition ceased to respond to any regular intervention, was firstly offered deep brain stimulation (DBS). This method has been performed in over 75,000 people worldwide. It is approved by the US Food and Drug Administration (FDA) as a treatment for Parkinson’s disease, essential tremor, dystonia and obsessive compulsive disorder. Other indications such as epilepsy, chronic pain or depression are thought to be rather experimental, but in many studies they proved effective (2).DBS involves surgical placement of a three-piece set. It consists of an implanted pulse generator (IPG), that is most commonly put subcutaneously into the clavicle area, next an extension and a lead. The latter is placed in a proper part of the brain.
As far as depression is concerned the main target area of the brain is subcallosal cingulate gyrus (SCG), to be precise Brodmann’s area 25 (3). Imaging studies show a pathological SCG metabolism in patients with depression, a pattern that is to be reversed by different antidepressant therapies. During a trial it was observed that when only in local anaesthesia, switching on a current for electrodes resulted in patients feeling instantly less upset, more alert and interested in the environment. The molecular basis of this extraordinary phenomenon is unknown, yet recently thoroughly examined (4). But somehow the procedure was not enough for Sheila. Although her condition improved a little, all in all she ended up making a suicide attempt.
This is when the scientists created a completely novel method of stereotactic neurosurgery and offered it to the patient. Stereotaxy refers to the type of procedure which is carried out with help of special three-dimensional coordinates system to specifically localise small targets in the human body. It is usually applied for neurosurgery, but also for example for radiotherapy in neoplasm treatment. As opposed to DBS, stereotactic neurosurgery does not include neuromodulation, but it involves irreversible lesioning. As we know the history of psychosurgery is very controversial, but only now has it become possible to perform anterior cingulotomy with as little invasiveness as possible. It is estimated that 75% of patients suffering from treatment resistant depression (TRD) received partial or substantial benefit from stereotactic ablative procedures (5). Anterior cingulotomy (ACING) is one of the most promising means of combating depression. The Bristol novel method is said to be based on performing ablation with help of special guide tubes, but for now the details remain a secret.
The example of Sheila Cook shows that there is more to depression than just drugs or ECT. It turns out that the future of fighting psychiatric diseases lays in neurosurgeonsˈ hands. With deep brain stimulation or ablative stereotactic neurosurgery it may become possible to reverse the pathology that creeps on various parts of brain. Let us hope that more and more patients will be able to say the words Mrs Cook has spoken: “I cannot thank the clinicians and researchers who worked with me enough – they have given me my life back.”
1.University of Bristol, Bristol Neuroscience, News http://www.bristol.ac.uk/neuroscience/bn-news/2011/110125dbs-depression.html
2.Deep Brain Stimulation: Technology at the Cutting Edge Rahul S. Shah, Su-Youne Chang, Hoon-Ki Min, Zang-Hee Cho, Charles D. Blaha and Kendall H. Lee
3.Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up After 3 to 6 Years. Kennedy SH, Giacobbe P, Rizvi SJ, Placenza FM, Nishikawa Y, Mayberg HS, Lozano AM. http://www.ncbi.nlm.nih.gov/pubmed/21285143
4.The subcallosal cingulate gyrus in the context of major depression. Hamani C, Mayberg H, Stone S, Laxton A, Haber S, Lozano AM. http://www.ncbi.nlm.nih.gov/pubmed/21145043
5.Prospective assessment of stereotactic ablative surgery for intractable major depression. Shields DC, Asaad W, Eskandar EN, Jain FA, Cosgrove GR, Flaherty AW, Cassem EH, Price BH, Rauch SL, Dougherty DD. http://www.ncbi.nlm.nih.gov/pubmed/18486107