Mental healthcare providers don’t like to talk about the potentially terminal nature of depression. But for many who are marooned in the chasm of major depressive disorder, therapy and medication fail. These are some of the folks who fascinate Jair Soares the most.
Soares, the jovial Brazilian-reared MD and PhD who serves as chairman of the Department of Psychiatry and Behavioral Sciences for UTHealth, among other roles, is hoping that this seemingly incurable population may benefit from a new treatment called deep brain stimulation (DBS). The method involves the implantation of an electrode in the brain with the intention of sending continuous electrical impulses to correct disruption in a misbehaving neural pathway. The technique has been used since 1987 to treat patients with Parkinson’s disease and other movement disorders, but applying the technology to mental health is new. Or very old, depending on how you look at it.
Doctors have been using electricity to treat depression at least since the 1930s. Electroconvulsive therapy, or ECT, is experiencing renewed popularity as old stigmas wear away. Dr. M. Justin Coffey, the medical director of the Menninger Clinic’s Center for Brain Stimulation, came to Houston two-and-a-half years ago. Since then, he’s seen growth both in ECT and another treatment, TMS (transmagnetic stimulation), which applies magnetic pulses to the brain via the scalp.
ECT uses electric currents to create a brief seizure in the brain while the patient is under anesthesia. Why do seizures reset the brain’s chemistry? Soares says doctors still aren’t sure. But according to Coffey, who is a neuropsychiatrist, “ECT is the single most effective treatment in all of psychiatry and all of neurology.”
Coffey says it’s a tragedy that Texas, especially, has laws that bow to unfounded fears based on inaccurate portrayals of the treatment in movies and TV of patients being electrocuted into drooling oblivion. It’s illegal to perform the treatment on any patient younger than 16 in this state, and the paperwork alone is enough to keep both doctors and patients away. Nevertheless, both UTHealth and Menninger now perform the regimen, as well as Ben Taub Hospital and a few smaller psychiatric clinics.
Because it is less dramatic, transmagnetic stimulation has experienced none of ECT’s bad publicity. But for the same reason, it may be less effective. “At Menninger, we see the sickest of the sick, and the data on TMS don’t really support that it will work if you’ve tried multiple medications,” Coffey says of patients for whom drugs haven’t helped. Nonetheless, UT and Menninger both perform it, as do no fewer than eight other devoted “shops” as Coffey calls them, throughout the city. The appeal is that patients, free from anesthesia, can leave and immediately go about their days, as opposed to ECT, which requires brief sedation.
If deep brain stimulation proves effective, it could make both ECT and TMS recede in popularity. So far, Soares’s study has attracted six participants. This is no small feat, considering that it involves neurosurgery and steep patient requirements. His is the first such study in North America. The only other took place in Bonn, Germany. “Results seemed amazing,” Soares says. “We’re now trying to replicate and extend that.” As he describes it, DBS is like a chisel compared to ECT’s sledgehammer.
In order to qualify, patients must have failed at a cure using both ECT and at least three medications (though Soares says it’s usually many more). So far, the treatment has been effective on most, but not all, of the participants, though Soares hopes the others may report improvement over time. “Surgery allows us to stimulate a deeper part of the brain and, like a pacemaker, you can increase intensity or decrease it,” Soares explains. However, Coffey, a friend of Soares’s, questions whether we understand depression and the brain sufficiently to target the right spots. He also argues that yet another form of electrical brain treatment, transcranial direct-current stimulation, is making strides that may have similar effects to DBS without the risks involved in neurosurgery.
But Soares has high hopes that surgery might make those crippled by depression functional again. He’s aiming to complete an initial study of 10 people this year. “Then we can plan a larger, more definitive trial,” he says, looking toward an experiment that will take place at sites across the country. For patients living in darkness, it won’t be a moment too soon.