This blog is the last in a series of guest posts on technology and the brain to celebrate Scientific American Mind’s 10-year anniversary. The magazine’s special November/December issue similarly highlights the interface between code and thought in profiling a future, more digital YOU.
I have been a practicing psychiatrist at the Cleveland Clinic since 1989. Back in 1999, my colleagues and I began looking into a technology called deep brain stimulation (DBS) as a treatment for psychiatric disorders. Initially we wanted to see if DBS, in which surgeons implant a 1-milllimeter thin electrode through the skull to stimulate a specific region of the brain, could help people with very severe obsessive compulsive disorder.
These patients needed serious help. Many of them couldn’t leave the house; they spent many hours per day on rituals and compulsive behaviors, and were completely disabled. Placed in a specific area of the brain, a DBS electrode delivers constant low intensity stimulation designed to interrupt neural circuits thought to be involved in the particular disorder. Obsessive compulsive disorder is thought to involve too much activity in a brain circuit involving the orbitofrontal cortex, striatum and thalamus. Studies had shown that surgically removing parts of this circuit improved symptoms of the illness so we wanted to see if implanting an electrode in this circuit–we would aim for the ventral striatum–could improve their condition as well.
Indeed, we found that about half of the severely afflicted individuals we treated did get significant better after the electrode implantation. In addition, however, we noticed that the depression often present in these patients also improved significantly–leading us to consider using DBS in the same region for patients with severe intractable depression. In the following years, open-label studies in which researchers implanted electrodes in the ventral striatum and other brain regions showed that more than half of these very seriously affected patients get significantly better after the procedure.
That success rate does not tell the whole story, however. In studies of DBS in depression, success is generally measured by the lessening or lifting of symptoms such as sadness, low energy, insomnia, poor appetite, poor concentration and suicidal thinking. But declines in those signs do not necessarily provide a full measure of recovery, if by that we mean a smooth reintegration into life. To me, the most amazing part of watching these patients get over severe depression after DBS is that some would re-engage in life quickly upon improvement of their mood while others would sometimes take years to achieve a relatively normal quality of life. After years of living with severe depression, it appeared that a period of “relearning to live normally” was required. In addition, the patient was not the only one who had to adjust to a “new normal;” family and friends did, too. For these patients, fixing an abnormal biological circuit using the latest medical technology is just the start. They also have to rebuild their relationships and their place in the world… often struggling with the confidence required to perform typical activities of daily life. Returning to work, re-engaging in relationships, or even cooking on a regular basis requires a certain resilience and mental stamina that was long absent during their depression.
For example, one patient of mine, a 46-year-old whom I will call Mary, had more than a 20-year history of severe depression with her most recent episode lasting over six years. She had to quit her job as a school teacher, and instead simply stayed home spending most hours ruminating about how badly she felt. Married with two children, she went from being the primary caretaker of the family to depending on the family to take care of themselves while she existed in increasing isolation. She had frequent thoughts of suicide and tried to take her own life several times with medication overdoses. To reduce her suicidal thoughts, she received electroconvulsive therapy (ECT) on repeated occasions. ECT induces seizures and can be an effective treatment for severe depression. Mary was initially helped by the treatments, but they eventually waned in their effectiveness. She also experienced some short-term memory loss, likely as a result of ECT. Thus, she was left without many options to treat her illness.
Mary’s psychiatrist referred her to the Cleveland Clinic for possible treatment with DBS. Within three months of her surgery, she felt a significant improvement in her mood, energy, interest in favorite activities and concentration. She was able to re-engage with friends and family to a significant degree. Once again, she began traveling, engaging in crafts and socializing. When I saw her, it seemed obvious that she was a different person.
Still, Mary was plagued by worries that her depression would return, causing her to be afraid to re-engage fully with friends or return to work. Certain mildly stressful life events such as an illness in her child or a minor financial issue would paralyze her with fear that the depression was coming back. All individuals have a bad day once in a while. For Mary, a bad day could send her spiraling into ruminative worry. She lacked confidence in a sustained recovery. One of these events led to a recurrence of her depressive symptoms and required a brief hospital stay.
Only three to five years after her surgery did she finally feel free of the depression. Her work with a therapist during those years gradually brought about the confidence and resilience necessary to maintain recovery. She now frequently travels and is quite active with her family. Others in her life note a return of her upbeat and confident personality. Although she seemed like a totally different person within a few months of starting DBS to me, she only felt comfortable as a different person after several years.
Another patient, a 45-year-old mother of three, had severe depression for about 10 years. This woman, whom I will call Joanne, would enter the hospital many times a year, often for weeks at a time, because of pervasive suicidal thinking involving a desire to overdose on medication. When not in the hospital, she would spend most waking hours in her bed, due to ever-present despair, low energy and suicidal thinking. She was unable to care for her children, clean her house or go to her job as an administrative assistant. Her husband and children took over the cooking, cleaning and washing.
After many years on various medications, in psychotherapy, and attempts at ECT, Joanne’s psychiatrist referred her for DBS. Within several weeks of starting stimulation, her mood improved noticeably. Joanne smiled more and more often ventured out of her bedroom. Yet she seemed to resist a return to a normal life replete with a variety of tasks, conversations and activities. She would say it felt overwhelming to have to function again. It was easier in some ways to remain immobile and removed from much of life. She also feared a return of her illness. “What if I start to do well and the depression comes back again? I don’t think I could take it,” she said.
Her family had also learned to live essentially without her. After 10 years, you can’t just turn back the clock and pretend depression never happened. In different family members there were elements of anger, guilt and resentment. Children who spent most of their formative years without a functional mother could not easily let that go. Certainly, Joanne felt guilty about not having been there for her kids or husband for a good part of her life.
Over the next nine years the wounds began to heal. Her husband began to believe that her return to normal would be sustained. The fear of her committing suicide gradually went away. Trust in her returned.
Now, Joanne is very active in the lives of her grandchildren, providing them with a loving environment and a solid role model. They spend weekends and vacations with her. The anger and resentment have dwindled away. Although psychotherapy probably sped the process of recovery, my sense is that the process just took time. Time to feel that mom was stable enough to trust her. Time to heal some of the emotional wounds. Time for the patient to feel confident that she would never again retreat to her room, or a hospital. Time for a marriage to overcome the emotional distance present for so many years. Such a process cannot be rushed.
This blog isn’t solely about depression and DBS. All severe mental illnesses that have left individuals disabled and family dynamics altered may create both a need for immediate treatment such as DBS and a plan for long-term rebuilding of lives. As we search for, and rely upon, immediate technological fixes for psychiatric conditions, it is important to remember that reversing abnormal brain circuits may not be sufficient for the patient to return to “normal.” A sort of rehabilitation must take place on the part of the patient and family. Psychotherapy can certainly be of value here. On some occasions, though, it just takes time. Clinicians must be willing to understand and endure this with the patient and family. Medicine continues to pursue briefer and less costly treatments for our disorders. Such a short-term focus may leave many patients with unrealistic expectations and a lack of emotional support for the road ahead. I hope we do not get so enthusiastic about technological cures for mental illness that we lose perspective on what it takes for these patients truly recover.
Other blogs in this series: