Sunday, May 22, 2005

Psychiatry and the surgical treatment of depression, Part I

Thanks to Kidney Notes for linking this article in the NY Times. It was only a matter of time: Michael Crichton's 1972 book The Terminal Man becomes reality.

I have enough strong thoughts about this that I've chosen to post on it in two parts.

Cyberonics, a biotech company, manufactures an implantable vagus nerve stimulator used to treat seizures. This company has been trying to get FDA approval to market the device for the treatment of intractable depression as well.

In June 2004, an FDA advisory committee recommended such approval. However, the following August the FDA denied approval pending further data from the company. (Advisory committee recommendations are not binding and can be overruled by the agency.) Recently, the FDA announced that it is reconsidering approval for the marketing of this device for the treatment of intractable depression.

Are we about to enter a brave new world where psychiatry becomes a surgical subspecialty? While I like to think of myself as "forward-thinking", this development has left me with deep feelings of ambiguity. What are we as a society to think about the prospect of altering human behavior and mood through computers and integrated circuits?

Don't get me wrong, I'm all in favor of treating severe depression that's unresponsive to conventional therapies. Certainly, this is one of the most horrendous maladies to befall a human being. Depression cuts at the heart of all aspects of one's being, one's psyche.

I lecture on the treatment of depression to our residency program's interns during their ambulatory medicine rotation. I describe the following in an effort to get them to appreciate the impact of major depression on a patient's life: All of us have experienced a severe depressive mood at some point in our lives. For most of us, such episodes have been situational that is to say triggered by some cataclysmic event in our lives. Such events might be the loss of a job, the failure of a relationship, severe medical illness or even the death of a loved one.

That gnawing, unremitting pain is something all of us can relate to. At times it can be searing and can leave us with the sense that things will always be like this, that we'll never get over it. And yet...most of us do. We move on. Perspectives change. What was once an insurmountable gloom eventually lifts. We start to feel normal again. In fact, for many of us, we even begin to wonder how it was that we ever felt so bad, so down, so filled with hopelessness.

Almost all of us have gone through this, but we get over it. Imagine now that this depth of feeling, this personal torment persisted. Imagine this overpowering gloom following us forever. How paralyzed would we be? How empty would our lives be? How hopeless? And yet that is exactly what major, severe depression is like, an almost unimaginable pall over the very fabric of life.

So no, I never underestimate the psychic pain of my truly depressed patients. I have wholeheartedly embraced the use of psychotherapy, of antidepressants and yes, even electroconvulsive (shock) therapy, in short, whatever works. If planting a pacemaker into the chest and threading leads up into the neck to the vagus nerve will help, then I guess I'll come to grips with it.

If one day, we're treating major depression with IC chips implanted in the brain and that works, well I'll get used to that too. But I think all of us are at least a little bit squeamish about such developments. And I think that some healthy skepticism is definitely in order. Before embarking on such heroic measures to alter mood and behavior, we need to be sure that the science is good, that the procedure is indicated and that safety and efficacy is established.

When we're dealing with those aspects of our being that cut at the very heart of our humanity, we need to be especially careful.

I've posted Part II on this topic here.

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1 Comments:

Anonymous MD said...

Very good thoughts, Dr.Ford.

I am somewhat inclined to think, however, that the true ethical dilemna we face with some psychiatric treatments arises not from the sort of scenario you describe, but from the opposite.

We are not bothered so much by strange treatments for severe, even life-threatening disease, but for the mild, barely perceptible ones.

Like you, I can more easily reconcile the use of a "machine" to alter the mind (and thus behavior) in a patient whose mind is shot to hell, whose psychopathology is so profound that she can no longer even find meaning in life. If the machine can somehow stop that wretchedness, stabilize her so that she can start picking up the pieces and rebuilding her life, it would be difficult to object to simply because the machine is unconventional.

But the mild cases... The Paxil for the little bad moods she's been feeling lately... the Prozac for feeling just a little down... maybe even a future machine that can be applied and removed by the patient at will - "I'd like to feel a little perkier tonight when he gets home"...

This challenges our very notions of how hard-wired or even meaningful our very personalities are. It challenges our notions of disease, psychology, life.

May 23, 2005 1:54 AM  

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