Jamie Talan's Deep Brain Stimulation: A New Treatment Shows Promise In The Most Difficult Cases is the first book to offer a popular look at DBS, one of the more exciting emerging treatments in neurology and psychiatry.Deep Brain Stimulation is not a textbook and the depth of scientific detail is kept pretty low, but the breadth of the material is good. Talan reviews the many kinds of disorders for which DBS has been trialled, from the early 1990s when it was used in Parkinson's disease up to the past five years where it's been tried for everything from epilepsy, depression and Tourette's Syndrome up to lifting patients out of persistent vegetative states (maybe).
Unfortunately, Talan doesn't discuss the controversial history of the first era of human brain stimulation, including the morally murky work of Robert G. Heath at Tulane University in the 1960s. She mentions Tulane once in passing but more detail would have been welcome, if only because it's a rather spicy tale.
The book's most engaging passages are the stories of individual patients. There's the man with Parkinson's who experienced amazing benefits from DBS, and who was so keen to keep them that he didn't tell doctors about the infection which developed a few weeks after surgery, in case they took the electrode out. After literally keeping the infected site under his hat for a few days, it progressed to a brain abscess, and he nearly died. Happily, he not only survived but was able to get the electrodes reimplanted.
Then there's the most moving case, that of the woman suffering from severe OCD and depression, who was given experimental DBS for the former condition. She died by suicide several months later, but said in her suicide note that the DBS had worked - her OCD symptoms were gone. Her depression was as bad as ever, though, and this is what led her to suicide. She wanted people to know that deep brain stimulation helped her, and didn't want her death to go down in the records as a mark against it.
The precursor to DBS was ablative neurosurgery - destroying particular parts of the brain in order to relieve symptoms. Talan describes its use in movement disorders such as Parkinson's, but she glosses over the history of "psychosurgery", the use of surgery to treat mental illness. People using DBS in psychiatry often prefer not to talk about psychosurgery - it's not exactly good PR. But clearly it is relevant. For all its faults, psychosurgery did seem to help some patients, which is why it's still used today in rare cases, although DBS may soon replace it.
DBS for depression and OCD usually target the same prefrontal white matter pathways that psychosurgery severed, so scientifically, psychosurgery has lessons for DBS. The ethical issues overlap too. Although DBS is reversible, unlike brain lesioning, it carries the same risks of serious complications like infection or brain bleeding. And there's the same question of whether seriously mentally ill people can give informed consent.
The book's strongest chaper is the last, which covers the ethical and practical difficulties of DBS. The danger is that enthusiastic doctors with no experience of the procedure, encouraged by the tales from other hospitals, might start doing it inappropriately. There's also a risk that patients or their families might volunteer for DBS prematurely or have impossibly high expectations. The initial results have been very promising, but there have been no large placebo-controlled trials so far (except in some movement disorders). And even with the best surgeons, in most disorders the response rate seems to hover around the 50-60% mark. Talan warns that DBS risks being a victim of its own hype. That's an important message.
10 comments:
The link gives a misleading view of Heath's work. The work wasn't secret. It was common knowledge around Charity Hospital and the medical schools, because the patients were on public wards and the implants were done by Tulane neurosurgeons. There was a film clip of an implant subject being interviewed by Heath during stimulation. The clip was shown at routine house staff and student conferences.
It didn't have the sadistic overtones of the accounts of the Canadian woman who was tortured for months in a deliberate attempt to break her will. The implants stayed in a few weeks and the whole thing was called off when there were a couple of cases of meningitis and the neurosurgeons blew the whistle, according to rumors.
Heath may have taken funding, but likely he would have done the experiments anyway. His theory was that the a positive reinforcement gives us little rewards for normal thinking that meshes with reality. When this fails, we drift off into clang associations and word salad. The theory has some merits, considering the role of the negative symptoms in schizophrenia. It just wasn't sensible to start with trying to jump-start the limbic system in human subjects. But Heath had the "clinical material" and a mission to find the cause and cure of schizophrenia.
Never attribute to evil what can be amply explained by folly.
Heh, I suspected there was another side to the story, but that was the only reference to his work I could readily find online.
You followed the standard narrative, and there's no reason for you to know what's now ancient history. I have no passion for defending Heath, just a mild annoyance with the way we tend to lump all those experiments together and declare them pure evil.
Heath went on to announce that he'd extracted a psychotogenic material, taraxien, from the blood of schizophrenics. When that dien't work out, he announced the discovery of autoantibodies to septal tissue in schizophrenic blood. This left his credibility somewhat damaged in some circles, but seems to have caused no harm to patients or encouragement to the woo-woos.
He was a very capable administrator in managing a sprawling department. And a person who joined his department early in his tenure had won a Nobel for a hypothalamic releasing factor by the time he retired. If he'd only kept his egomania under control, he'd be better remembered.
The Nobel prize winner is Andrew Schally.
Recently I had occasion to look over the listing of Robert Heath's publications. He had broad scientific interests, meaning, he was not a monomaniac.
Some of the antagonism directed at Heath was political. For instance, Seymour Kety despised him, so much that Kety and others formed a new society, the Psychiatric Research Society, to break away from the Society of Biological Psychiatry, with which Heath was associated. Having served as President of both organizations, I can attest that old feelings died hard.
I met Heath several times at meetings of the Society of Biological Psychiatry in the 1970s and 1980s. He was not an obvious egomaniac, but a thoughtful and charming southern gentleman.
Heath's early insights into circuit activity in psychosis and mood disorder, including a role for the cerebellum, are now coming back into focus.
Barney Carroll.
My sources are from a different vantage point, mostly house staff and medical students interested in psychiatry back in the day. Their stories are entirely consistent with Barney Carroll's remarks.
Heath certainly behaved as a gentlemen, from all accounts, but that wasn't the main impression. He was something of an Alpha Male. Tall, strikingly handsome, command presence a general or CEO would be proud of, articulate, relaxed but in control. Said to have had a heiress wife and a vacation home on
a large spread in MS, called "Hedonia". Trained at a top place in his field (Columbia, IIRC), Department Chairman at a young age, very competent at running a big, complicated department.
I always wondered if he didn't think of himself as destined to make a great medical breakthrough and so relaxed critical standards in evaluating his findings. It was the era of the doctor-hero, with Salk and the transplant surgeons appearing on magazine covers. An alternative and more charitable interpretation is that he thought that his gifts and the resources at his disposal obligated him to attack problems of great significance. Either way, his eminence when he embarked on that course meant that people took it into account when the results weren't confirmed. It wasn't just a matter of a hardworking academic going off track because of a run of faulty data from the lab. I know about such a case, and there were no issues of tragedy or Schadenfreude.
He wasn't an egomaniac in any obvious way. No stories of tantrums, treating underlings badly, arrogance. But there was a stubbornness in the way he continued to pursue the project, and it appeared to be tied in with his self-regard.
Why was Kety down on him?
Why was Seymour Kety critical of Robert Heath?
My impression was that they differed fundamentally in their approach to studying schizophrenia. Kety gained fame by pioneering an indirect method of estimating brain oxygen consumption in the late 1940s. We know it now as the Kety-Fick principle. He was not a successful departmental administrator – he left the chair at Johns Hopkins within months. He did not treat seriously ill patients. He did not conduct primary clinical research, though he did promote neurochemically minded young investigators, notably Joe Schildkraut. He segued to genetic studies of schizophrenia, using not his own case material but Scandinavian data sets. If you read those seminal studies now you will see a certain amount of what appears to be post hoc modification of the end points – the schizophrenia spectrum concept – in order to make a coherent story from the data. But the world wanted to hear that schizophrenia had a high heritability index, and his work gained acceptance. Indeed, it quickly became orthodoxy, even though modern genetic studies have had limited success in schizophrenia. The new orthodoxy is about multiple genes with small effects, which can accommodate a lot of fuzziness.
Heath could not have been more different. He built a distinguished department of psychiatry. He was a hands-on clinical investigator. He treated the worst of the worst patients suffering from schizophrenia. He possessed superb training in neurosurgery at Columbia. He understood electrophysiology. He was willing to go out on limbs with hypotheses about brain circuits in psychosis, mood disorders, and homosexuality. By the standards of his time he was on the cutting edge of experimental work. The studies on autoantibodies to the septal nuclei and on taraxein in schizophrenia were basically pilot studies, and when they were not confirmed Heath did not get upset.
We might tag him with hubris, but Kety regarded him as a heretic for premature efforts to investigate psychosis directly, before indirect methods told us where to look.
Thanks for the history. I agree with your positive comments about Heath. But the taraxien and autoantibody work strike me as more than pilot studies. They were extraordinary claims and required especially careful checking before publication. He never retracted either, AFAIK.
Many thanks for the fascinating discussion, both.
I am writing a paper about the taraxein story. I have a question that perhaps someone can shed light on: Why did the announcement of the "discovery" of taraxein receive so much attention. The reason I ask is that the history of psychiatry is replete with announced discoveries - including of putative endogenous schizogens - that didn't pan out. What made taraxein different?
To Alan Baumeister:
If you read these contemporary articles, listed below, you will see that Heath's work on taraxein was very quickly challenged by well-publicized non-confirmations. See the invited discussions of the first article, in particular.
The entire episode resembled another in the late 1970s when hemodialysis was proposed for schizophrenia. The self-correcting function of science was not slow in coming. Barney Carroll.
Behavioral changes in nonpsychotic volunteers following the administration of taraxein, the substance obtained from serum of schizophrenic patients.
HEATH RG. MARTENS S. LEACH BE. COHEN M. FEIGLEY CA.
American Journal of Psychiatry. 114(10):917-9; discussion 919-20, 1958 Apr.
[Journal Article]
UI: 13508921
Taraxein, fact or artifact.
SIEGEL M. NISWANDER GD. SACHS E Jr. STAVROS D.
American Journal of Psychiatry. 115(9):819-20, 1959 Mar.
[Journal Article]
UI: 13627267
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