And who is going to hold 50,000 clickers?

The November/December 2005 issue of Mother Jones contained an article by Lauren Slater about Deep Brain Stimulation (DBS) entitled "Who holds the clicker?" The title was taken from the following exchange at a meeting of the President's Council on Bioethics

DR. COSGROVE: It's a little computer that's telemetry, via telemetry, the same way you do cardiac pump pacemakers, the same technology.
And the neurologist or the psychiatrist, as we do for patients with Parkinson's disease, you can select which contacts, the current, the pulse duration, the frequency, and you do that all through the little hand held device that is superimposed over the pulse generator.
PROF. SANDEL: Who holds the clicker? Like where is that, in the doctor's office?
DR. COSGROVE: The doctor has that, yeah, yeah.
The patient can turn the device on or off with a magnet that they just pass over the device. So they only have the ability to turn it on or off. The physician is the one who has the ability to program.

The Guardian recently published an article about DBS, written by the paper's science correspondent Alok Jha, which, in its uncritical enthusiasm for the procedure, was reminiscent of early media coverage of psychosurgery. This topic was covered by Gretchen Diefenbach and co-authors in their analysis "Portrayal of Lobotomy in the Popular Press: 1935-1960" (Journal of the History of Neuroscience1999 Apr;8(1):60-9). They noted that: "in most cases mention of negative side effects was either absent or cursory." In the Guardian article there is no mention at all of any risks or side effects to brain surgery. Just as the early articles on psychosurgery stressed the precision of the operations ("the psychosurgeon… cuts at exactly the right angle in exactly the right plane") so too does the Guardian article ("Brain scans are used to pinpoint which parts of the brain are acting incorrectly"). It may be possible with modern scanning techniques to accurately locate structures inside the brain, but can we be sure they are acting incorrectly? Do we even know what correct is?

The Guardian article claims that an "estimated 50,000 people in the UK who suffer from depression but cannot be helped by drugs or electroconvulsive therapy" are potential candidates for DBS. But it doesn't say how they arrived at that estimate. If these people haven't been helped by ECT, then they must be taken from the ranks of ECT survivors and there are probably some 200,000 of those in the UK. So 50,000 who hadn't been helped (and were prepared to continue with evermore invasive treatment) would represent quite a high failure rate for ECT.

The true purpose of the article is revealed in the following passage:

Identifying suitable volunteers for the trial will be crucial. "It can either be people referring themselves or health professionals referring them," said Dr Malizia. "They must have good medical information from the past and they must be anchored to a local clinical service that will carry on looking after them."

But if there are really 50,000 candidates for DBS in the UK there should be over 300 in the Bristol area. So why do Andrea Malizia and his colleagues need the help of the Guardian to recruit eight patients?

Although the Burden Neurological Institute wasn't mentioned in the article, Andrea Malizia and David Nutt are part of the Bristol Neuroscience Group which includes the BNI, and Nik Patel is a neurosurgeon at the Frenchay Hospital, where the BNI is based. It is a shame that Alok Jha didn't even glance into the bizarre history of brain experiments at the BNI (coming to this blog soon!).

In response Sophie Corlett (the acting chief executive of MIND) urged caution - "Regrettably, miracle cures invariably aren't" and pointed out "If the NHS cannot currently fund comparatively cheap treatments such as therapy, how are we to expect that 50,000 people will be able to benefit from an expensive, invasive operation?"
She also mentions something Alok Jha ignored - the ethical problems associated with DBS:

And who's to say that deep brain stimulation is the solution for these people? A narrow medical model of depression, a complex problem, fails to do justice to human psychology and the human condition. We hope that this research leads to positive results, but we also hope no one will ever suggest that using "hair-thin electrodes" to apply electricity "into the core of the brain" will be a substitute for a cohesive and holistic approach to mental wellbeing.