BREAKDOWN: Read the Denver Post investigative series on mental health in Colorado
Electric shock therapy, no longer the fearsome, convulsing drama of the movies, has remained for decades the “gold standard” in treatment for people with severe depression.
But a modernized version of delivering electrical impulses to the brain eventually could replace electroconvulsive therapy, if the procedure is approved.
Deep brain stimulation, in which electrodes are implanted in the brain to receive continuous pulses from a pacemaker placed under the skin of the chest, is among the few treatments raising optimism for a long-sought breakthrough in mental illness.
Another is genetic research, a way to explain brain disease similar to how researchers are beginning to understand cancer. Cancer treatment has moved away from treating the categories of lung cancer or breast cancer or liver cancer, instead targeting specific genetic abnormalities by discovering which drugs will stop them.
Genes and genesis
Treating mental illness is at least as difficult as treating other chronic diseases including heart disease and cancer. Its causes, and the discovery of effective therapies, remain elusive, yet advances in neuroimaging, genetics and medications in recent years have made treatment seem less grim.
“We are on the cusp of really being able to understand so much more,” said Dr. Paul Summergrad, president of the American Psychiatric Association and psychiatrist-in-chief at Tufts Medical Center. “We need much more research.”
It’s clear the causes of mental illness are both genetic and environmental. Studies based on identical Scandinavian twins separated at birth showed that if one twin had schizophrenia, there was an 80 percent chance the other twin had it too. If one twin had major depression, the other twin did about half of the time.
A recent study found no single gene for schizophrenia but multiple, abnormal DNA “snips” in people who have it. Other studies have discovered genetic markers showing pre-existing inflammation for several psychiatric illnesses, although the field is a long way from biological tests that would reveal people’s risk for developing mental illness.
The cause of major depression is not understood. There is no genetic test to determine whether someone will develop schizophrenia. And there is no specific pill that stabilizes bipolar disorder — people with bipolar disorder must try different medication cocktails. And even then, pills might not work.
Researchers, though, are optimistic about advances in antipsychotic medication, as well as a growing awareness in the medical profession that people with mental illnesses have better outcomes when their mental and physical problems are treated in collaboration. The diseases are connected — people with depression are at greater risk of a second heart attack, for example.
Deep brain work
Understanding the way firing neurons in the brain affect depression or psychosis — and how they are influenced by genetics and the environment — remains a black hole.
“It’s super complex, and there is still a lot we do not know,” said Dr. David VanSickle, a neurosurgeon who uses deep brain stimulation to treat patients with obsessive-compulsive disorder at Littleton and Porter Adventist hospitals. He hopes he soon will be able to treat patients with major depression.
“I think it looks really promising. It may be the thing people go to in the future,” he said.
Deep brain stimulation targets neurological connections in the brain that are abnormal in people with depression. Hopes are high for deep brain stimulation in part because of the success rate of electroconvulsive therapy, nowadays a peaceful procedure that happens under anesthesia and drug-induced paralysis. It’s used for patients with depression so sinking it causes unrelenting suicidal thoughts and sadness that overshadows even hunger.
About 80 percent of severely affected patients who get electroconvulsive therapy show significant improvement.
The electrical shock causes neurons in the brain’s cortex to fire, changing the neurotransmitter levels. For reasons not entirely understood, the stimulation of the neurotransmitter levels improves depression.
Patients are put under anesthesia then given medication that relaxes their muscles to the point they do not move. The electrical stimulus lasts just eight seconds, and because the body is paralyzed, the seizure happens only in the brain.
“We have a lot of students who come through, and they are all underwhelmed by it because they saw ‘One Flew Over the Cuckoo’s Nest,’ ” said Dr. Claudia Clopton, a psychiatrist who performs the procedure at Porter Adventist Hospital. “It’s quiet and peaceful.”
About 250 patients, roughly half of whom were first-time patients, received electroconvulsive therapy at Porter from June 2013 to June 2014. Among new patients, 78 percent were there for major depression.
Patients typically are shocked three times per week for two to four weeks, and most of them end up feeling less depressed. The treatment is recommended only for those who are chronically suicidal or severely depressed to the point of not functioning.
Deep brain stimulation has been used for more than a decade on Parkinson’s patients and was more recently approved to treat people with obsessive-compulsive disorder. The procedure implants electrodes into the specific area of the brain linked to mental illness.
During studies on obsessive-compulsive disorder, researchers discovered the procedure appears to help patients with depression, although it is not yet approved to treat that.
The surgery starts with two holes, just more than a half-inch, in the patient’s skull. Then electrodes are placed in the brain. Later, a surgeon implants a pacemaker under the skin or muscles of the patient’s chest, and the pacemaker sends electrical pulses to the electrodes. The patient cannot feel the pulses, which inhibit the neurological circuits passing through the area of the brain connected to obsessive-compulsive disorder, Dr. VanSickle said.
VanSickle’s patients come to him as a “last-ditch effort.”
“I see people that have failed with everything else,” he said.
VanSickle treats more than 100 people each year with Parkinson’s but only a handful with obsessive-compulsive disorder, in part because insurance companies typically do not cover deep brain stimulation for mental health reasons, he said.
A targeted therapy
Deep brain stimulation is considered better than electroconvulsive therapy by some doctors because it targets a specific area of the brain instead of causing a seizure of the whole brain. Patients are less likely to experience memory loss.
Diane Wheeler doesn’t remember four years of her life, a side effect of two years of electroconvulsive therapy.
The therapy helped her, but only to a point. “I would get better, and then it would get worse,” she said. “I would be better for a month and then have to get it again.”
What worked for Wheeler was finding the right psychiatrist and the right combination of antidepressants, a process that took about a decade. She was hospitalized more than 10 times, usually after her psychiatrist told her to head to the emergency room because she was suicidal. “I’m never cured,” said Wheeler, who now works at Mental Health America of Colorado. “I can only stick with the plan I’ve got.”
Wheeler’s major depression came out of nowhere in the 1990s. She can’t pinpoint what put her over the edge, what made her slip into the “bottomless pit” that was so black and empty it caused her immense physical pain. She didn’t get help until she was thinking about ways to die.
From the outside, Wheeler’s life looked good. She was 47, raising two teenagers, working as a teaching mentor in Douglas County, president of the parent- teacher association. But behind the “mask” she learned to put on her face, she wanted to die. In her mind, her family was better off without her because she was too much to deal with, too “embarrassing.”
Besides her psychiatrist and support groups, Wheeler credits family support, mainly her husband, Jerry, for pulling her out of the darkness. “It was always knowing my family was behind me, whether it was good times or bad times,” she said.
Jennifer Brown: 303-954-1593, jenbrown@denverpost.com or twitter.com/jbrowndpost
BREAKDOWN: Read the Denver Post investigative series on mental health in Colorado
