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Home / Health / Deep brain stimulation for depression, mood disorders could be ethically abusive: Shots

Deep brain stimulation for depression, mood disorders could be ethically abusive: Shots



  Depressed person and a picture of neural networks in the brain.

Christina Chung for NPR / NPR

  Depressed person and a picture of neural networks in the brain.

Christina Chung for NPR / NPR

Our thoughts and fears, movements and sensations arise from the electrical impulses of billions of neurons in our brain. Electricity flows through neuronal circuits to control these actions of the brain and the body, and some scientists believe that many neurological and psychiatric disorders are due to dysfunctional circuits.

As this realization has grown, some scientists have asked if we could locate them. These faulty circuits reach deep into the brain and bring the flow into a more functional state, treating the underlying neurobiological cause of the symptoms, such as shaking or depression becomes.

The idea of ​​changing the brain to electricity for the better is not new. However, deep brain stimulation is more targeted than electroconvulsive therapy introduced in the 1930s. DBS attempts to correct a specific dysfunction in the brain by introducing precise timed electrical impulses into specific regions. It works by the action of a very precise electrode that is surgically inserted deep into the brain and is typically controlled by a device implanted below the collarbone. Once in place, physicians can externally set the pulses to a frequency they hope will repair the faulty circuit.

Listen: The Remote Control Brain

This week's Invisibilia podcast features the story of a woman with obsessive-compulsive disorder and obsessive-compulsive disorder depression who enrolled in a study to study deep brain stimulation. The story describes what it's like to adjust your mood by adjusting the settings on your device. Listen this story here .

The FDA has approved deep brain stimulation for only a handful of conditions, including movement disorders – dystonia, essential tremor, and symptoms of Parkinson's disease – and one type of treatment. resistant epilepsy. Now, many scientists in the US and around the world are experimenting with technology for psychiatric illnesses such as depression or obsessive-compulsive disorder.

The results of clinical trials are very mixed: some patients say they have been completely transformed meanwhile others have no effect or become worse.

Research continues, however, and the potential of technology to instantly and powerfully change mood raises ethical, social and cultural issues. NPR spoke with neuroethicist James Giordano, head of the Neuroethics Studies Program at Georgetown University Medical Center, about this new technology and its potential benefits and harms when used for psychiatric treatment. In addition to his work in Georgetown, Giordano has consulted with the US military on these technologies and their possible use.

This interview contains answers from two separate conversations with Giordano, one by Alix Spiegel and one by Jonathan Lambert. It has been edited for reasons of clarity and length.

What is deep brain stimulation and how does it work?

Scientists have stimulated the brain for a brain while now, but it was historically rather crude. A neurosurgeon [would] touches a brain region with an electrode and sees what happened, what types of functions were affected. However, we did not have a detailed picture of what we wanted to target in the brain, and the electrodes themselves were not very precise.

Now we have a much more detailed map of the networks and nodes of neurons involved in different pathologies [like Parkinson’s, obsessive-compulsive disorder, etc.] or different thought patterns or emotions. Deep Brain Stimulation provides a very specific and accurate method of applying electrodes to and around a small group of brain cells using electrodes in order to turn them on or modulate their activity.

Change the circuit, and you can change the behavior. The goal is to use DBS to modify the circuits to improve the symptoms in a very specific and precise manner.

How do you know what type of specific inputs the electrode should deliver and where in the brain to deliver it?

There is an old proverb in brain research: "If you have seen a brain, you have seen a brain." This is certainly true, but all brains are very similar, on which individual variations are built, because the brain structures are changed and developed as a result of experience.

So when we implant a device, we generally know where we are. However, if the patient is awake while we are implanting the device, we can further customize it to know exactly where to place it to achieve the desired effect. Further fine-tuning of the type of stimulation can be done after surgery, as the device can be set externally.

Although there is no FDA approval yet, DBS is currently investigating the treatment of psychiatric disorders. What is the current research findings?

Many studies undoubtedly find evidence that DBS may be effective in treating conditions such as Tourettes syndrome, obsessive-compulsive disorder and even depression. Patients report a reduction in symptoms, but we certainly still have many questions that need to be answered. For example when do we deal with DBS? Early in the development of a disorder? Later, after other options have been exhausted? These are questions that still need to be answered.

How would you explain the difference between the influence of an antidepressant on the brain and the effect of deep brain stimulation?

A drug like Prozac or antidepressants is basically like throwing water on your face to get a sip of water. Using something like deep brain stimulation is like putting a drop of water on the tongue. We can increase specificity and precision … and the precision and specificity of deep brain stimulation makes it a more effective tool in many ways. It can be turned on and off. It can be adapted at very short notice, making it a more flexible instrument that allows a much more precise control of mood.

And in comparison to antidepressants, are there any differences in the moral or ethical consequence of using a treatment that allows us to affect the mood so specifically?

Specificity is power. And the moral obligation that comes with great power is overwhelming. The responsibility to understand as much as possible what you are doing, not only at a neurobiological level, but also at an existential and even a social level. What do you do? Can you create a new normality [in terms of mood]? And if you create a new normal, do we have what I call "ethical equipment" aboard to tackle this problem? In some cases, I think the answer is yes, but in other cases, I believe that new ethical principles must be developed, as this is the case and the reality of using these things.

For example, expressive creativity. Is there an ethical principle of self-creativity … can I define myself and say that I want to create myself this way?

Do you mean theoretically in the future you could go to a doctor and say that I want to be a great artist?

Now we are not quite there, but I could certainly go to a doctor and say I want to be more open-minded, I want to be less inhibited. I want to be happier every day. I want to be more enlightened by my daily experiences … In an open society we say that you should be able to define "I want to be that" and this is a tool to get there? Maybe, but then we have to make up for it. What about others? … That comes back to a question of fairness. Can everyone get that? Who will get that?

What can go wrong with this technology? What should we be worried about?

Well, it's neurosurgery, and there are certainly risks associated with infection, problems with the procedure. Goals could be missed or misidentified. These are risks associated with the territory.

However, there are a few more cases that are more specific to DBS. What if you receive effects that you did not expect? By stimulating Area X, we may get a spillover effect that modulates other things, such as personality, temperament, character, and personal preferences. There have been case reports and anecdotes about such events, which are rare.

Could implanting a DBS device have unexpected consequences for our tastes or personal characteristics such as introversion and extroversion?

One of the better known cases, for example, was a person whose musical taste had nothing to do with country music. And after a deep brain implant for a movement disorder [the person] developed a real pathos for Johnny Cash's music and was entirely in the aesthetics of Johnny Cash. Is it possible that these things occur? Of course it is. The brain works as a coordinated group of nodes and networks that are intercommunicative and reciprocal. The change in field electrical field activity in one area is thus not necessarily completely independent of the wiring of the activities and functions of other brain areas, if you like. These upstream and downstream things are real effects.

Can a treatment with a DBS device change more than our mood, but also our personality?

Yes, although we have to ask ourselves if these changes are due to the positive consequences of DBS. If someone was introverted with Tourettes and then gets a DBS implant and behaves more extrovertly and socially more committed, is this a side effect of the DBS? Or because they no longer bear the burden of being someone with a constant verbal tic?

DBS also raises questions about personal autonomy. Do we get cases where people say, "My deep brain stimulator made me do that?" Perhaps. Very often, however, patients report that the condition that DBS treats affects their autonomy more than they feel deep brain stimulation.

What guidance would you give to doctors who work with a patient with DBS? Since they can influence the mood of a person by the level of electrical current in the device, how do they know which level they should set?

To the point of clinically relevant therapeutic improvement. For example, as one would define the levels that one could use for any other therapy, [like] cognitive behavioral therapy. Is the person functional? Say, "Yes, I feel better, my mood is better." The same applies to a drug. However, this is more effective as it directly affects the nodes and networks that appear as the substrate of the thing that causes that person's mood. So you want to be careful. The general tenor in the field is low and slow.

Beyond DBS, where could this technology ultimately go?

There is a do-it-yourself market, if you want, not for deep brain stimulation, but for transcranial electrical stimulation. This shows that there is an increasing interest in neuro-technologies, which not only aim to alleviate a disease, but also change important aspects of perception, emotions and behavior. This is sometimes referred to as a cosmetic use or designer application of neurotechnology. [If] I do not like important aspects of the personality. [such as being shy] Could I change that, for example, by using these neurotechnologies? These things are coming and it is not in the near future – now there is interest.

What pitfalls do we face as this technology becomes more widespread?

Errors are made. Hopefully, we will be smart enough to correct and recognize them if they are not only in technological and scientific, but also in ethical, moral and legal errors. In many ways, this is a beautiful new world of abilities. And I think we are very much looking for what the potential could bring. Yes, that could bring some really wonderful things, but even if it's used for cosmetic purposes like self-improvement, could it lead to potentially violent results? I can guarantee that things happen that are very, very problematic and in some cases devastating. Do I think the net effect will be beneficial because we will respond appropriately to the mistakes we make? Yes, that's my hope. Do I know that we will do that? I dont know.


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