Joyce, my spouse was one of the earliest study subjects for VNS Therapy for Depression (December 13, 1999). I am her long time support person and health care advocate/activist of 5 decades. The intent of the blog is not to promote any therapy, product or treatment but to continue sharing our experiences and knowledge as it relates to VNS. I endorse patient education in collaboration with a caring, knowledgeable and licensed health care professional while also encouraging hope and persistence.
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We have been following the advances in deep brain stimulation (DBS) pretty closely here at ET. Just the other week, we explained the motivations behind treatments for Parkinson’s disease with DBS electrodes placed in the subthalamic nucleus, and hinted at a couple of ways that they might be improved. Perhaps the biggest advance in DBS systems since they were first developed has just been reported by a group of researchers working in the Movement Disorders Group at Oxford University. By recording activity with what is essentially a brain-computer interface (BCI), the researchers were able to close the stimulation loop with direct feedback from the subthalamic nucleus. The ability to incorporate meaningful data from the implant user’s brain into the moment-to-moment control of the stimulation puts the one-size-fits-all DBS system on the fast track to obsolescence — and ushers in the new era of personalized implants.
Once activated, most DBS systems generate continuous pulses, typically at a frequency above 100Hz. Always-on stimulation fatigues not only the batteries, but more importantly the brain itself. The symptoms of Parkinson’s disease fluctuate continuously and any form of smart control needs to be fast to be effective. Previous research has demonstrated that the spike output of motor neurons in the cortex of a monkey could be used as feedback to provide better results than continuous stimulation. Directly implementing these results in humans calls for a bit more caution though — blunt exploratory implantation of multiple brain areas comes at a price. The Oxford group, led by Peter Brown, realized that the stimulation electrodes themselves can be used to record local field potentials. These signals are not the signatures of single cells, but can be thought of instead as more diffuse summary reports of larger groups of cells.
In order to use these averaged potentials for control, some criteria is needed to pass judgement on their desirability. Studies in Parkinson’s patients have consistently shown that subthalamic nucleus activity in the beta frequency band (3-30Hz) correlates with motor impairment. Brown’s group was able to build a control system that was able to filter and capture activity in this band, and then use it to control the stimulation current. The device was tested in eight patients and provided significant improvements over both continuous and random stimulation conditions.
This proof-of-principle demonstration provides a tantalizing glimpse of what lies ahead. For now, the control hardware is a bulky external system, although work on miniaturizing its footprint to fit inside the skull is ongoing. Once that happens, we have the essentials of two closely-related kinds of devices that are also under development in several labs. One is a device to police undesirable activity, like for example, seizures. In fact an important study in this area just appeared in the journal Neurosurgery. The other, more intriguing use is for what is commonly referred to as a “memory implant.”
DBS electrodes, reaching down into a human’s brain
There is really no substantial, convincing, evidence yet that memory implants are practical. The main problem is that we don’t know how to interpret what little brain activity we can manage to record. What I suspect we will find going forward is that, rather than attempting to build memory implants from scratch that access high-level areas of the brain (like the hippocampus), they will instead directly evolve from the on-board learning algorithms, and storage, that are built into motor control implants like those described here.
The pace of advance of these kinds of implants will be driven to a large degree by the pace at which they are made open. Interoperability between components is essential, as well as keeping the user in the loop to provide direct input to device designers. A huge boost in this area was just provided by Medtronic, the leading implant manufacturer, when it finally caved to overwhelming user demand for access to critical data generated by their implants. The irony of users having better feedback from an inexpensive Fitbit than from their $30,000 implant was not lost on vocal advocate, user, and TED Talk giver, Hugo Campos. Others were quick to jump on Medtronic CEO, Omar Ischrak when he tweeted how much he enjoyed access to his Runtastic data, yet at the same time denying feedback to users of his own products.
Opening implant data to users is harmless enough, although giving them unbridled control over critical parameters certainly has its risks. The larger community has already realized what the medical community has been slow to accept — the benefits of providing users with control over their implants far outweighs these risks, and that fact can no longer be ignored. Increasingly, we interact with our external environment through our personal electronic devices — that same power, and ease of interaction, for our inner space will be sought, demanded, and granted.
Provided by Joseph Helpern's laboratory at MUSCAn image of tractography, a technique that tracks the movement of water molecules in the brain to create a 3-D map of its highly complex network of axons. By tracking these pathways, MUSC researchers are studying brain disorders including ADHD and Alzheimer's disease. The colors represent the direction water molecules are moving.
We now know that many disorders are physiological, not psychological
Posted: Sunday, April 14, 2013 12:01 a.m. UPDATED: Sunday, April 14, 2013 9:42 a.m.
Text size: AAA
Exhaustion weighs her down until she gets out of bed. Trudging to the shower and going down the grocery store aisles feel like a long slog through dark molasses.
By the numbers
Who are the mentally ill? They are our neighbors, friends, family — and us. Put five people in a room and one has suffered from a mental illness in the past year. One in five adults (46 million Americans) experiences mental illness each year. One in 17 suffers serious mental illness such as schizophrenia, major depression or bipolar disorder.One in 10 children lives with a serious mental or emotional disorder. The rate of mental illness is more than twice as high among those aged 18 to 25 (29.9 percent) than among those 50 and older. Less than one-third of adults and half of children with a diagnosable mental disorder receives mental health care in a given year. Half of all lifetime cases of mental illness begins by age 14, three-quarters by 24. More than 50 percent of students 14 and older with a mental disorder drop out of high school — the highest dropout rate of any disability group. 24 percent of state prisoners and 21 percent of local jail prisoners have a recent history of mental illness. 70 percent of children in juvenile justice systems have at least one mental disorder. The annual economic, indirect cost of mental illness in the U.S. is about $79 billion, mostly in lost productivity. Adults living with serious mental illness die 25 years earlier than other Americans, largely due to treatable medical conditions. An estimated 8.7 million American adults had serious thoughts of suicide in the past year. Of them, 2.5 million made suicide plans, and 1.1 million attempted suicide.
Sources: Substance Abuse and Mental Health Services Administration, National Alliance on Mental Illness, National Institute of Health, U.S. Department of Health and Human Services, National Center for Mental Health and Juvenile Justice
The heaviness caused by major depression has come and gone throughout Lisa Livingston Baker's life. And when her husband died in 2008, she could not even lift her body from her bed.
Major mental illnesses
Mental illness refers to a wide range of disorders that affect mood, thinking and behavior. More common ones include: Attention-deficit/hyperactivity disorder: Characterized by inattention, hyperactivity and impulsivity. Strong scientific evidence indicates ADHD is a biologically based disorder. Research also suggests a strong genetic basis. Bipolar disorder (formerly known as “manic-depressive disorder”): A major mood disorder in which a person experiences episodes of depression and mania (extreme irritability or euphoria). Likely caused by an imbalance of neurotransmitters or hormones. Trauma and major loss may play roles.Major depression (known as clinical depression): A combination of depressed mood, poor concentration, insomnia, fatigue, appetite disturbances, excessive guilt and suicidal thoughts. Depression is twice as common in women for reasons not fully understood. Likely caused by biological differences in the brain along with trauma or major loss. Post-traumatic stress disorder: Severe or repeated exposure to trauma can affect the brain in a way that makes a person feel like the event is happening again and again. Can induce anxiety, sleeplessness, anger or substance abuse. PTSD can affect everyone from survivors of sexual trauma and natural disasters to emergency and rescue personnel and military veterans. Generalized anxiety disorder: A severe, chronic, exaggerated worrying about everyday events. Likely caused by genetics, brain chemistry and environmental stresses. Obsessive-compulsive disorder: Obsessions are intrusive, irrational thoughts or impulses that repeatedly well up in a person's mind. Compulsions are repetitive rituals such as handwashing, counting, checking, hoarding or arranging. Evidence suggests that OCD is caused by a chemical imbalance in the brain. People whose brains are injured also can develop OCD. Panic disorder: Feelings of terror that strike suddenly and repeatedly with no warning. Symptoms include sweating, chest pain and irregular heartbeats. More common in women. Brain abnormalities, family history, major life stress and abuse of drugs and alcohol may play roles. Schizophrenia: A group of severe brain disorders in which people interpret reality abnormally. May result in hallucinations, delusions and disordered thinking and behavior. Likely caused by differences in the brain, genetic vulnerability and environmental factors that occur during a person's development. Personality disorders Borderline personality disorder: Characterized by unstable moods, interpersonal relationships, self-image and behavior. Antisocial personality disorder: A person's thinking and relating to others are abnormal and destructive, such as disregard for right and wrong, lying and behaving violently. Narcissistic personality disorder: Characterized by an inflated sense of self-importance and a deep need for admiration. Personality disorders are thought to be caused by genetic and environmental factors. Sources: National Alliance on Mental Illness, Mayo Clinic, WebMD
She blamed herself.
First in a series
The mentally ill are under pressure and scrutiny like never before. Mental health budgets have been slashed. State inpatient beds are at historic lows. Emergency rooms and jails are the new front lines of care. In the wake of mass shootings — and would-be school shooters such as Alice Boland — some want registration of the severely ill. But there is promise for change. State funding may increase. Research is showing these illnesses are based in flawed physiology, not character flaws. And many who suffer are challenging the stereotypes that affect them. The Post and Courier is examining these issues in a series of stories over the next few months. We start with the stigma and its undercurrent of shame.
The master's-educated teacher struggled to raise her three girls as she took medications and entered therapy. Books and tapes about coping amassed beneath her bed.
“I've done it all,” the Summerville mom sighed. “And how many more Lisas are out there?”
Millions. One in four adults experiences mental illness in a given year. One in 17 suffers serious mental illness such as schizophrenia, major depression or bipolar disorder, according to the U.S. Department of Health and Human Services.
And at perhaps no other time have they received more public attention than today.
Megachurch Pastor Rick Warren's son committed suicide a week ago after a long battle with major depression.
Lawmakers are debating mental health care funding, gun control and registries of the mentally ill. And last week, 9th Circuit Solicitor Scarlett Wilson voiced doubt that the state can fully rehabilitate the violent mentally ill.
What does all this attention mean for the average person with a mental illness, suffering amid a public that stigmatizes them?
Baker can't count how often she's heard:
Buck up. Get over it. Just cheer up!
“People make you feel bad about yourself — and you make you feel bad about yourself,” Baker said. “I'm not a bad person. I'm not lazy or weak. I'm a good person. I'm trying.”
She recently joined a clinical trial at the Medical University of South Carolina that administers a brain stimulation treatment based on researchers' improving knowledge of the brain as a highly complex electro-chemical organ, one that can malfunction just like any body part.
After receiving most of her treatments, Baker can laugh again. She even tackled her taxes.
And it's not just the relief. The boost proves to her that the depression is caused not by personal failure, as stigma insinuates, but rather by malfunctioning brain circuitry.
It's proof that the illness isn't her fault.
Biology trumps
Dr. Mark George trained in psychiatry and neurology. He doesn't see a distinction between the two.
Both deal with disorders caused by dysfunctional brain circuitry. So why are neurological disorders — Parkinson's disease, for instance — viewed without the stigma that clouds others like depression and bipolar disorder?
“Stigma is really hard for me to deal with. I've trained across these disciplines, and to me it's all the same,” said George, director of MUSC's Center for Advanced Imaging Research and its Brain Stimulation Laboratory.
Stigma stems from historical misunderstandings, such as when people thought the mentally ill were inherently weak-minded or evil, or when George's medical school professors taught that the brain was a fixed organ, incapable of changing and repairing itself.
Not true.
Modern imaging technology is allowing researchers to track the brain's activity and to examine its wiring, structures and tissue micro-architecture to see exactly what is going on inside a living, thinking organ.
It has revolutionized knowledge of psychiatric disorders.
“The brain is really the last frontier in medicine,” George said.
What is now clear to researchers is that malfunctioning brain circuitry, and its interplay with genetics, trauma and environmental stress, plays a major role in many illnesses, including depression, anxiety and addictions. A new mantra rising among medical professionals calls mental illnesses “brain disorders.”
“We have these powerful imaging tools so we can see all of these things,” George said. “This new understanding should make people wake up to stigma.”
For instance, when imaging showed differences in the brains of people with attention deficit hyperactivity disorder, it indicated that the problem wasn't bad parenting or a lack of discipline. It was based in physiology.
“That was huge. Imaging can add that legitimacy,” said Joseph A. Helpern, professor and vice chairman for research in radiology and endowed chair in brain imaging at MUSC.
Today, MUSC psychiatry is the largest research department in its College of Medicine, and is especially known for research of addictions and imaging techniques. And just this month President Barack Obama announced his BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative to map the brain's activity in unprecedented detail.
So much research promises better understanding of this final frontier, and new treatments for when its circuits malfunction.
“In mental illness and addiction, the brain is different,” said Rhonda Faughender, clinical director for adult services at Palmetto Behavioral Health System. “But we can retrain our brains.”
Which means there is hope for people like Baker.
Biology of change
Baker sits in a small room in the Institute of Psychiatry lying on what resembles a dentist's chair.
Dr. Baron Short, clinical director of MUSC's Brain Stimulation Services, positions a plastic block containing an electromagnetic coil onto the upper left area of Baker's forehead. She wears neon yellow earplugs to block out the rapid and fairly loud tapping of electrical pulses that penetrate her scalp and skull.
Brain tissue lacks pain receptors, so she can't feel where the pulses penetrate into her prefrontal cortex, the upper front area of the brain.
Coils pulse for four seconds, then quiet for 20. The sensation on her skin is irritating but not painful, Baker said, like getting snapped by a rubber band.
Transcranial Magnetic Stimulation, recently approved by the FDA for the treatment of depression, aims to rouse the prefrontal cortex. It is considered the brain's CEO, responsible for abstract thinking and regulating behavior and emotions, and it tends to be underactive in people with depression.
This underactivity, in turn, appears to affect the brain's limbic system, a primitive area often called the “feeling and reacting brain” that is important in memory formation. This area tends to be overly active in people with depression.
“We're helping the brain re-regulate itself,” Short explained.
Brain stimulation may hold promise in treating other illnesses, including addiction, which imaging indicates is another form of brain disorder. This also could change societal views of addiction — after all, when it comes to stigma, few disorders carry more shame than drug addiction, George said.
Yet it appears that some people are predisposed to addiction due to overly active brain regions that control craving and desire, while impulse-control areas are not as active. Researchers are testing ways to correct this circuitry just as they are with depression and other illnesses.
On Monday, George and a team of researchers will publish a study in the journal Biological Psychiatry that showed high-frequency TMS significantly reduced nicotine craving even in heavy smokers.
“People still think it's about bad behavior and not an illness,” George said. “But it's not you. It is a part of the brain that needs to exercise differently.”
Surviving stigma
Today, when someone is released from a psychiatric hospital, there are no sympathy cards in the mail, no meals provided by friends, no flowers or well-wishers eager to visit.
Often, there is only the suffocating silence of fear and rejection.
“We as a people don't look at mental illness as an illness. If we just pull up our bootstraps and go, we can go. And it's so untrue. It's an illness just like heart disease or cancer,” said Wanda Brockmeyer, emergency services director for Roper St. Francis Healthcare.
When Baker turned 50 recently, she cried.
“This isn't where I wanted to be,” she said. Then she reminded herself: I'm not a loser.
She wonders if others see her that way.
“Imagine if you said to a person, 'If you had only been stronger, you wouldn't have gotten cancer,'” Baker said.
She agreed to share her story here to challenge the stigma, to remind people that those with mental illness are parents, children, neighbors. And that their illnesses aren't their fault.
Reach Jennifer Hawes at 937-5563, follow her on Twitter at @JenBerryHawes or subscribe to her at facebook.com/jennifer.b.hawes.
NEUROLOGY
Electric stimulation under study to treat brain trauma from stroke to
Parkinson's and even dementia
Victoria
Colliver
Published
5:15 p.m., Tuesday, October 30, 2012
Dr. Emily Kappenman (left) prepares
psychologist Michael Callaghan for transcranial direct current stimulation. Photo:
Sarah Rice, Special To The Chronicle / SF
Dr.
Marom Bikson, who developed the transcranial direct current stimulation device,
demonstrates the product at the Highland Hospital workshop. Photo: Sarah Rice,
Special To The Chronicle / SF
Internist
Kim Wood from Joplin, Mo., watches Marom Bikson demonstrate how to use the
device. Photo: Sarah Rice, Special To The Chronicle / SF
Applying a current of electricity through the
brain conjures up the kind of nightmare-inducing seizures immortalized in the
1975 film adaption of Ken Kesey's
"One Flew Over the Cuckoo's Nest."
But a kinder, gentler, almost imperceptible
form of electric brain stimulation - an experimental approach known as
transcranial direct current stimulation - is gaining traction as a promising
therapy for brain injuries due to stroke or other traumas, depression,
dementia, attention-deficit disorder and other conditions.
Transcranial direct current stimulation, or
tDCS, bears little in common with electroshock therapy or invasive forms of
deep brain stimulation, which involve drilling holes in the head and implanting
electrodes.
The level of the current used is tiny -
typically between 1 and 2 milliamps, or less than one-one-hundredth of a single
electrical watt. At most, the current causes a tingling or slight itching, if
it's felt at all.
Even the technique's staunchest defenders
acknowledge that the idea of treating a broad range of disorders with something
you can hardly feel and that has few, if any, side effects sounds more like
snake oil than science.
"How could this do anything? It seems so
small. We're talking about a few volts," said Marom Bikson,
associate professor of biomedical engineering at City University of New York who
co-founded Soterix Medical
Inc., a company that holds patents to Bikson's transcranial direct current
stimulation devices.
Jolt to
the brain
But Bikson said studies have shown a few
volts of current can change the rate at which a brain cell fires in a way that
is believed to improve brain plasticity, or its ability to change and learn new
things.
"It's not some magical, unknown
hocus-pocus," he said.
The concept is fairly simple: After dampened
electrodes are strapped to a patient's scalp, a device charged by a 9-volt
battery - the kind used in transistor radios - delivers a small current to
change the activity in targeted regions of the brain.
The current, which is typically delivered for
10 to 30 minutes over multiple sessions, is thought to be able to excite or
inhibit the brain's neurons in the stimulated area.
A positive current could help people with
depression, stroke or other brain traumas, while a negative current may be
helpful for such conditions as epilepsy or language recovery. Both currents can
be used at the same time, and the effects of the stimulation are thought to
continue or even increase, even after the device has been turned off.
Transcranial direct current stimulation has
been used in a small number of hospitals - mostly on the East Coast - since
about 2000 but has not been approved by the U.S. Food and
Drug Administration. Soterix and other manufacturers plan to seek
FDA approval for the devices once enough research has been done.
Earlier this month, Bikson was part of a
research team that demonstrated the technique for doctors, therapists and other
health experts during a one-day workshop at Alameda County
Medical Center's Highland
Hospital in Oakland.
Getting
the word out
Dr. Lance Stone, medical director of
rehabilitation and restoration at the county's Fairmont
Hospital in San Leandro, was introduced to the technique earlier
this year and invited the researchers to give his colleagues and other
specialists the opportunity to learn more about it.
Stone is interested in the device's use in
the emerging field of neurorehabilitation, which teaches or retrains patients
with nervous system injuries such as stroke, Parkinson's disease or other brain
trauma.
"There seems to be countless potential
applications (of the technique) for acquired neurological disorders, but the
main ones seem to be primarily pain, motor recovery and depression," said
Stone, who plans to apply for a research grant to study the device.
The concept of using electrical stimulation
for health purposes dates back thousands of years to the Greeks, whose medical
practitioners were said to use electric eels in water to reduce symptoms of
arthritis and other types of pain.
Modern usage of electroconvulsive therapy,
formerly known as electroshock therapy, has been controversial, dating back to
its early use in the 1940s and '50s in psychiatric hospitals. While it has been
making a bit of a lower-voltage comeback in patients with severe depression, the
method is generally considered a last resort because of the risk of memory loss
and other side effects.
Trials and
studies
Transcranial direct current stimulation has
been around for decades, but the technique earned interest in the 1990s and
early 2000s after some European physicians published promising results of the
work. Currently it's the subject of numerous ongoing clinical trials and
studies in this country.
In 2010, a team of Oxford
University scientists published a small study that showed tDCS
improved math skills in the majority of participants.
That same year, researchers at Beth Israel
Deaconess Medical Center in Boston published findings that showed
that the motor skills of stroke patients treated with the device, along with
physical and occupational therapy, improved threefold compared with those who
received a placebo form of stimulation and the same amount of physical and
occupational therapy.
But some health experts warned that the
technique's safety and effectiveness are unknown and that larger, controlled
human clinical trials are needed.
"Whenever you do something - whether
it's swallowing a drug or applying current - there may be a downside,"
said Dr. Sidney Wolfe,
director of Public Citizen's
Health Research
Group, a consumer and health advocacy lobbying organization.
Sounds
promising
Wolfe said the device sounds promising and is
the subject of a myriad of clinical trials but shouldn't be approved until the
larger, controlled studies are conducted. "The variety of medical problems
for which they are trying this is enormous, and in most of the studies the
number of patients is so small it's not statistically significant," he
said.
"The brain is an electrical organ,"
said Edwards. "What we're trying to do is develop methods that interfere
with brain activity in a targeted way and positively influence it."
Edwards said several companies in the United
States and around the world are already making transcranial direct current
stimulation devices and he expects more.
Part of the appeal of the device is that it
is relatively low cost - retailing for about $800. In addition, it's portable,
so it can be used in many different settings.
Using on
patients
Some doctors and researchers who attended the
recent workshop had no experience using the device, while others had already
tried it on a few patients. The device, which is considered investigational by
the U.S. Food and Drug
Administration, can be used either as part of a clinical trial or by
a medical doctor for specific cases.
UC Berkeley psychologist Ludovica Labruna has
experimented with using the device for language acquisition - to see if
subjects could learn languages more quickly after receiving tDCS sessions. But
she said her results have been somewhat disappointing, and she's not sure if
she's using the device correctly.
"TDCS looks so simple, but it's really
not so simple to apply because there are so many variables," Labruna said.
"You really need to be trained."
Similar concerns drew Emily Kappenman to the
workshop.
Kappenman, a postdoctoral researcher at UC
Davis' Center for the Mind and Brain, said she's interested in the device's
potential for working with patients with anxiety. She said she's tried it to
see whether it helps people become less distracted and anxious by moving their
attention away from certain emotions.
"It's hard to tell if it's working yet
or if we're using optimal levels," she said. "It's hard to know what's
best."
Brain
stimulation
Brain stimulation uses magnetic or electrical
energy to improve brain function. Here are some of the techniques in use or
being studied:
Electroconvulsive therapy (ECT): With ECT, an electric current passes briefly through the scalp to the
brain, inducing a seizure. It's generally considered only for those with severe
depression or other serious mental illnesses who do not respond to other
treatments.
Transcranial magnetic stimulation (TMS): TMS uses wrapped coil wires to generate electric current throughout the
scalp and can induce involuntary movements. Although it has a few potentially
serious side effects, including seizures, the treatment received federal
approval for patients with severe depression in 2008.
Transcranial direct current stimulation
(tDCS): Weaker still than TMS, tDCS has not been
approved, but researchers are studying its use to help patients with strokes
and other brain injuries. It has also been considered for use in healthy
subjects, with researchers testing everything from memory enhancement to
improved golf swing.
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