Last week the Daily Mail ran an article with the title “Brain surgery saved my husband from the torment of depression” and the byline Ruth Leon. The article is about the writer and broadcaster Sheridan Morley who died in 2007 – sixteen months after undergoing deep brain stimulation (DBS – in which electrodes are inserted in the brain) for the treatment of depression. He was 65. Journalist Ruth Leon is his widow and has just published a book about her life with her husband: But what comes after… the tragic story of a wife, a husband and the illness that nearly destroyed them.
Sheridan Morley was the son of British actor Robert Morley. He was a prolific author of books about the stage and screen and also wrote an autobiography, Asking for trouble, shortly before he had a stroke in 2002. In the book he writes about having a nervous breakdown (about the time he was leaving his first wife for Ruth Leon) and how he had psychotherapy and then a stay in the Cardinal Clinic in Windsor, where he was treated with drugs. He continued to take the drugs – in such high doses his prescriptions were queried by pharmacists – after leaving the clinic. A stroke in 2002 left him even more depressed and he was given ECT, according to this article in Tuesday’s Express.
In October 2005, he underwent DBS at the Radcliffe Infirmary in Oxford. Ruth Leon seems to think DBS was a success although his doctors aren’t so sure. “In clinical terms his operation wasn’t really a success”, Guy Goodwin is quoted as saying in the Express article. Professor Goodwin and his colleagues published an article about DBS for depression following a stroke in the October 2009 Journal of Neurosurgery, “Reduced limbic connections may contraindicate subgenual cingulate deep brain stimulation for intractable depression”.
DBS as a treatment for psychiatric disorders dates back to the 1950s, when it was used by Robert Heath at Tulane University in the US. But it appears to have been held in abeyance for several decades and only recently has it started to be used again on people who have depression or OCD, having been used more extensively over the past twenty years or so as a treatment for Parkinson’s disease. At the moment the use of DBS for psychiatric disorders is unregulated in England and Wales (in Scotland it is covered, along with psychosurgery, by section 234 of the Mental Health (care and treatment) (Scotland) Act 2003). The Mental Health Act Commission (MHAC) originally in their 11th biennial report, published in 2005, suggested that DBS should be placed in section 58 of the Mental Health Act 1983 along with ECT. But by the time of the publication of the 12th biennial report two years later they had changed their mind and were recommending that DBS be included in section 57 along with psychosurgery. In the 13th and final biennial report they had this to say:
“In our previous report we suggested that deep-brain stimulation (DBS) – a procedure related to leucotomy but effected through the placing of electrodes [in] the brain rather than cutting brain tissue – should be afforded the protections of s57. The governments in England and Wales have yet to pass any regulation concerning [DBS], although the Scottish Parliament has done so. This means that the treatment can only be given in Scotland following certification that the patient gives informed consent and it would be appropriate to give it, whereas in England and Wales the procedure remains unregulated and could, in theory, be given against a detained patient’s will under the direction of a Responsible Clinician, or under the Mental Incapacity Act to any patient lacking capacity to refuse it. Whilst DBS remains at an experimental stage, and is certainly not likely to be in widespread use in the immediate future, there seems to us to be a good argument for regulating such procedures as soon as cases appear or are likely to appear, no matter how rarely”.
And in their first annual mental health report The Care Quality Commission, which replaced the Mental Health Act Commission, is still talking about how they would welcome consideration of the matter by the government.
If DBS was placed in section 57 it would mean that each operation would have to be approved by a panel from the Care Quality Commission, who would have to ascertain not only that the operation was appropriate but that the patient’s consent was valid and free from the undue influence of, for example, family and doctors.
DBS is being vigorously promoted by a group of doctors in Canada (although one of them, Helen Mayberg, who used to be at Toronto University is now working at Emory University in the US) who are paid consultants for St Jude Medical Inc, the company which manufactures DBS devices and has just been given permission from the Food and Drug Administration in the US to conduct more extensive trials on the treatment of depression with DBS. In some cases they hold patents for the devices. A pilot study in Canada published earlier this year revealed that, of 20 people who underwent DBS, 2 committed suicide. The authors do not appear to be too concerned by this: “No significant adverse events were reported during this follow-up, although two patients died by suicide during depressive relapses”. Of the seven authors, at least four are or have been paid consultants for St Jude Medical, Inc.
The British media have adopted an uncritical attitude towards DBS. This is how the BBC reported Mayberg’s visit to London in June 2005:
“She said that although DBS was still in its infancy as a treatment for depression, it was very promising. “The effects were immediate. One patient told me she felt suddenly relieved. These are the sickest of the sick. They are not just having a bad day.” About 10% of people will have an episode of major depression in their lifetime. Conventional treatment will fail in about 10% of these. It is these patients who might benefit from DBS, said Professor Mayberg”.
The following year the Guardian ran an article about experiments with DBS planned by doctors at Bristol: “If the trials are successful, deep brain stimulation could be extended to the estimated 50,000 people in the UK who suffer from depression but cannot be helped by drugs or electroconvulsive therapy”. When it emerged earlier this year that one woman who had undergone DBS in Bristol had been left so severely depressed that her doctors decided to perform a cingulotomy (a type of traditional ablative psychosurgery) on her, the media coverage was nevertheless still along the lines of “deep brain stimulation hope for depression”. (That one came from the BBC). And, although Sheridan Morley’s doctors do not appear to consider his treatment to have been a success, the media coverage is even more enthusiastic: “British experts are continuing to develop deep brain stimulation in the hope it might treat the estimated 500,000 Britons whose severe depression does not respond to conventional drugs” (That came from the Daily Mail article mentioned earlier – the Guardian’s 50,000 people who might be treated with DBS for depression has multiplied by 10 over 5 years.) There is an article by Frédéric Gilbert and Daniela Ovadia about DBS and the media here. The authors argue that the media portrays DBS in way that is very similar to the way psychosurgery was portrayed in its early days:
“Deep brain stimulation (DBS) is optimistically portrayed in contemporary media. This already happened with psychosurgery during the first half of the twentieth century. The tendency of popular media to hype the benefits of DBS therapies, without equally highlighting risks, fosters public expectations also due to the lack of ethical analysis in the scientific literature”.*
*Gilbert F and Ovadia D (2011) Deep brain stimulation in the media: over-optimistic portrayals call for a new strategy involving journalists and scientists in ethical debates. Front. Integr. Neurosci. 5:16. doi: 10.3389/fnint.2011.00016