Surgery and Depression.

[Quinn1988]

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Is it really possible to treat Depression through Surgery? All I'm finding are vauge answers that don't really answer the question. Assuming that is true, what part of the brain would be operated on?

 

[nitemagi]

Look up deep brain stimulation.

 

[Quinn1988]

Look up deep brain stimulation.

Where my confusion is DBS/ECT are controversal treatments that can be very beneficial.I get there are high risks with DBS/ECT, however, so is the w/u for meningitis(Sp?) and I have yet to see anyone actually provide a valid argument against meningitis.

 

[Therapist4Chnge]

If you are considering DBS/ECT, the person has probably failed at least 3 or 4 medication trials and/or other interventions. If the depression is bad enough, risk becomes a very relative term.

 

[Quinn1988]

If you are considering DBS/ECT, the person has probably failed at least 3 or 4 medication trials and/or other interventions. If the depression is bad enough, risk becomes a very relative term.

Your comment just made me think something....3-4 Med trials seem rather small. How is it even possible to determine if the pt is deemed a "treatment failure" over a period of 3-4 med variations?

 

[Ibid]

If you are considering DBS/ECT, the person has probably failed at least 3 or 4 medication trials and/or other interventions. If the depression is bad enough, risk becomes a very relative term.

The question I always ask and never get a straight answer to is "If ECT is the last resort and critically a life saving intervention for the most severly depressed then why are more people not dying in those places where ECT is not used?" It does not add up to me.

 

[nitemagi]

The question I always ask and never get a straight answer to is "If ECT is the last resort and critically a life saving intervention for the most severly depressed then why are more people not dying in those places where ECT is not used?" It does not add up to me.

Because no one talks about those patients. They rarely have advocates that speak up about their struggles, and stigma pervades.

 

[Ibid]

Warning: The post below contains ideas that some people might find offensive or consider total bull****.

imo depression is adaptive and evolved according to the precautionary principle. When we hit our thumbs with a hammer it hurts for a good reason. But....it also hurts one hell of a lot more than you might consider needed...actually one effing hell of a lot more than needed....jesus christ that hurt!! Why so bloody much??

Common garden depression is the same it "hurts" a lot more than we think it should. Therein lies the answer to many problems imo.

 

[nitemagi]

Warning: The post below contains ideas that some people might find offensive or consider total bull****.

imo depression is adaptive and evolved according to the precautionary principle. When we hit our thumbs with a hammer it hurts for a good reason. But....it also hurts one hell of a lot more than you might consider needed...actually one effing hell of a lot more than needed....jesus christ that hurt!! Why so bloody much??

Common garden depression is the same it "hurts" a lot more than we think it should. Therein lies the answer to many problems imo.

There's an evolutionary hypothesis about depressed mood as possibly being adaptive, for the purpose of conserving resources or marshaling support from others. But that's for normal sadness. The consensus is usually that major depression (i.e. severe depression) in all its incapacitating aspects, is never adaptive. Maybe an evolutionary principle gone awry.

 

[Ibid]

Because no one talks about those patients. They rarely have advocates that speak up about their struggles, and stigma pervades.

I see, you are saying that they do die but somehow they show up in the numbers in another way. My ideas was that maybe they got help in another way without ECT.

There's an evolutionary hypothesis about depressed mood as possibly being adaptive, for the purpose of conserving resources or marshaling support from others. But that's for normal sadness. The consensus is usually that major depression (i.e. severe depression) in all its incapacitating aspects, is never adaptive. Maybe an evolutionary principle gone awry.

Yes, normal sadness is pretty nasty and I see what you are saying. I suppose there is no way of adapting to an impossible situation so possibly this is a case where we are in an obvious intermediate evolutionary step. (I guess being in an intermediate evolutionary step is just the human condition in a nutshell)

 

[billypilgrim37]

"If ECT is the last resort...

There's no good reason for ECT to be a last resort for severe depression other than our inability to educate the public about the treatment and previously-appropriate stigma being incredibly difficult to eradicate.

If I show up to the emergency room severely depressed (unable to go to work, persistently suicidal), book the ECT suite for me Monday morning.

 

[Ibid]

There's no good reason for ECT to be a last resort for severe depression other than our inability to educate the public about the treatment and previously-appropriate stigma being incredibly difficult to eradicate.

If I show up to the emergency room severely depressed (unable to go to work, persistently suicidal), book the ECT suite for me Monday morning.

I can understand that. My problem with it as an intervention is that the right of someone to have ECT interferes with the right of people to refuse it specifically if they desire. It is just my personal belief that with respect to ECT an advance directive not to be given ECT should be respected even for people legally detained.

My belief, driven by Royal College Guidelines on information that patients should be given, is that it can potentially cause the loss of personal memories. To that extent it is different to other interventions.

All the research in this area seems completely biased one way or the other. Nothing seems to be objective. Not that I can find. Experimenter bias seems utterly rife in ECT studies. No wonder the public is confused if professionals appear not to be able to agree.

 

[notdeadyet]

I can understand that. My problem with it as an intervention is that the right of someone to have ECT interferes with the right of people to refuse it specifically if they desire. It is just my personal belief that with respect to ECT an advance directive not to be given ECT should be respected even for people legally detained.

I wonder if you are overestimating the ease with which someone is given ECT in this country. It's not a walk in, elective procedure most places. I wonder if you might also be overestimating ECT being given to people against their will.

The admittedly few patients that I've met that have gone through ECT were very happy with it. Two have said that without it, they are pretty sure that they would have died. The kind of people that tend to make use of ECT are exactly the ones that we fear losing to suicide without intervention.

 

[notdeadyet]

Quinn1988- When you talk about "surgery and depression," I don't think ECT makes the cut. It's not a surgical procedure. DBS is another animal, and DBS would still be considered very much in the experimental phase for use in treating depression.

 

[Therapist4Chnge]

....I don't think ECT makes the cut. It's not a surgical procedure.

*rimshot!*

 

[Quinn1988]

Quinn1988- When you talk about "surgery and depression," I don't think ECT makes the cut. It's not a surgical procedure. DBS is another animal, and DBS would still be considered very much in the experimental phase for use in treating depression.

True, however, someone else bought up ECT in an earlier post. All I am curious about is why the information on DBS is so vauge. There also have been very, very few websites that go into details about it in terms of success rate and things of that nature. Now that you bring it up, how is ECT not considered a surgical procedure? Though there is no cutting involved, EGD/Colonoscopies are considered a surgical procedure and neither of which is used as a primary approach to treat the pts.As you already know, EGDs serve no prurpose except in obtaining biopsies, and to give GI a better idea of what is going on. The little info I have been able to find on ECT is that it's actually used as a treatment approach, not so much trying to get an idea of what's going on since by the time it gets to the pooint ECT is used, everyone is well aware of what is going on by then for the most part.

 

[Ibid]

I wonder if you are overestimating the ease with which someone is given ECT in this country. It's not a walk in, elective procedure most places. I wonder if you might also be overestimating ECT being given to people against their will.

Possibly I am although I had not quantified it in my mind. What I see where I am is people getting it on their lunch hour.(just about if not actually) So it doesn't match the usual retoric about the circumstances in which is usually used.

The thing I find most bothersome is the extent to which some physicians have it as a kind of favorite intervention. To the extent that they have a reputation for giving it to everyone. Obviously forming on opinion on the intervention itself on the basis of some isolated shoddy work by Dr. Electricity is wrong. But the possibility of malpractice makes me desirous of greater protection against these sorts of practitioners and an outright ability to say no in advance is where I am with it at the moment.

The admittedly few patients that I've met that have gone through ECT were very happy with it. Two have said that without it, they are pretty sure that they would have died. The kind of people that tend to make use of ECT are exactly the ones that we fear losing to suicide without intervention.

The last person I saw having it was someone I have known for several years. They completed the act of suicide sometime last week. I'm a little cut up about that to be honest beyond the usual sort of mild puzzlement and what might be called an empty reflectiveness that seems to last an inappropriately short time.

But certainly the majority of people I know would say the same thing and would have the procedure again even though they feel that they have lost some memories. Most of the complaints that people have relayed to me have been about the way the procedure was done.

Having said that I have seen shocking abuse as well. These instances bother me greatly. Not that I have any monopoly on concern about poor practice.....

 

[notdeadyet]

All I am curious about is why the information on DBS is so vauge. There also have been very, very few websites that go into details about it in terms of success rate and things of that nature.

You're probably seeing very little marketing because there's very little market. DBS isn't being used as an option for treatment of depression outside of research. There's lots of information about it if you do a PubMed search, though. You'll see a lot more for DBS in regards to Parkinson's and movement disorders, but you'll see a little for psychiatric uses in research settings as well.

Now that you bring it up, how is ECT not considered a surgical procedure? Though there is no cutting involved, EGD/Colonoscopies are considered a surgical procedure and neither of which is used as a primary approach to treat the pts. As you already know, EGDs serve no prurpose except in obtaining biopsies, and to give GI a better idea of what is going on.

You wouldn't consider EGD or Colonscopy surgeries, you'd consider them both "procedures." And EGD's and Colonscopies have bigger purposes than just biopsies. They're used for banding, sclerotherapy, polyp removal, cauterizing, ballooning, stenting, etc. When you start using a scope to cut something, it becomes a surgery.

I would consider ECT a procedure as well. If you make an incision while doing ECT, you could consider it surgery, but it also probably means you're doing it wrong.

The little info I have been able to find on ECT is that it's actually used as a treatment approach, not so much trying to get an idea of what's going on since by the time it gets to the pooint ECT is used, everyone is well aware of what is going on by then for the most part.

You're right. ECT is not used investigatively, it's purely therapeutic.

 

[Quinn1988]

You're probably seeing very little marketing because there's very little market. DBS isn't being used as an option for treatment of depression outside of research. There's lots of information about it if you do a PubMed search, though. You'll see a lot more for DBS in regards to Parkinson's and movement disorders, but you'll see a little for psychiatric uses in research settings as well.

You wouldn't consider EGD or Colonscopy surgeries, you'd consider them both "procedures." And EGD's and Colonscopies have bigger purposes than just biopsies. They're used for banding, sclerotherapy, polyp removal, cauterizing, ballooning, stenting, etc. When you start using a scope to cut something, it becomes a surgery.

I would consider ECT a procedure as well. If you make an incision while doing ECT, you could consider it surgery, but it also probably means you're doing it wrong.

You're right. ECT is not used investigatively, it's purely therapeutic.

My apologizes, I was intending the term "to see what's going on" include the varying options used in an EGD/Colonoscopy. Now not to get nit picky, but technically you are cutting something when you are removing the polyp. Anyway back on topic, something else one of your comment brings to mind is though it is purely therapeutic, why isn't used when you have a mentally unstable person who could be deemed "unfit" to stand trial? Plus, I am willing to wager half the folks who are deemed unstable are probably just as stable as you and I. Just my opinion.

 

[nitemagi]

My apologizes, I was intending the term "to see what's going on" include the varying options used in an EGD/Colonoscopy. Now not to get nit picky, but technically you are cutting something when you are removing the polyp. Anyway back on topic, something else one of your comment brings to mind is though it is purely therapeutic, why isn't used when you have a mentally unstable person who could be deemed "unfit" to stand trial? Plus, I am willing to wager half the folks who are deemed unstable are probably just as stable as you and I. Just my opinion.

Quinn, my understanding is you're pre-med right now? These are complex questions, and you're looking for black/white answers. Unfit to stand trial has no direct association with a particular mental illness or treatment. Unfit to stand trial d/t a mental illness is usually the case in patients with psychosis. Psychosis isn't usually treated with ECT, with the exception of some MDD with psychotic features cases. There are increasing burden of proof to override someone's rights, based on which rights. In most states it takes less proof to hospitalize someone against their will for a few days than it does to give them a medication against their will (which is more invasive). ECT requires a high burden of proof and judicial involvement, often a court order from a judge directly, rather than say a hearing officer in involuntarily hospitalizing someone. It's a very effective treatment, but any invasive medical procedure against someone's will without permission from the court to override their objection is technically "assault and battery." Therefore it's not first line treatment.

 

[LizzytheShrink]

There's no good reason for ECT to be a last resort for severe depression other than our inability to educate the public about the treatment and previously-appropriate stigma being incredibly difficult to eradicate.

If I show up to the emergency room severely depressed (unable to go to work, persistently suicidal), book the ECT suite for me Monday morning.

BRAVO! Couldn't have said it better. I've been pleased to have great success with some very sick patients using ECT. The stigma is the worst. I've said the same thing - if I ever end up in that terrible situation, suffering from intractable depression, sign me up!

 

[Quinn1988]

Quinn, my understanding is you're pre-med right now? These are complex questions, and you're looking for black/white answers. Unfit to stand trial has no direct association with a particular mental illness or treatment. Unfit to stand trial d/t a mental illness is usually the case in patients with psychosis. Psychosis isn't usually treated with ECT, with the exception of some MDD with psychotic features cases. There are increasing burden of proof to override someone's rights, based on which rights. In most states it takes less proof to hospitalize someone against their will for a few days than it does to give them a medication against their will (which is more invasive). ECT requires a high burden of proof and judicial involvement, often a court order from a judge directly, rather than say a hearing officer in involuntarily hospitalizing someone. It's a very effective treatment, but any invasive medical procedure against someone's will without permission from the court to override their objection is technically "assault and battery." Therefore it's not first line treatment.

You are correct in identifying me as pre-med Dr. While I know there is no such thing as black/white answers coming to medicine, especially psych, what I was getting at is those unfit to stand trial per a psychiatrist counter act the purpose of corrections and in a way the judicial system. Are you referring to a 51/50? If so, last I checked those were only good for 72hrs pending what symptoms present itself which I really don't see how that gives the psychiatrist enough time to be in a good position to develop a Treatment Plan let alone identify symptoms that deem one unfit. What about those who are great actors and know how to dodge prison? If you do not mind me asking and I am in no way questioning your judgment, how would this treatment be considered Assault? If someone is to the point ECTs are being discussed, the person clearly is not thinking straight therefore have no idea/comprehend the actions that landed them in court to begin with. Are there even differentials Dx someone as psychotic? Lastly, the purpose of the DOC is to rehabilitate. If one is psychotic, and treatment options start failing, how is it possible the rehab concept be carried out?

 

[nitemagi]

You are correct in identifying me as pre-med Dr. While I know there is no such thing as black/white answers coming to medicine, especially psych, what I was getting at is those unfit to stand trial per a psychiatrist counter act the purpose of corrections and in a way the judicial system. Are you referring to a 51/50? If so, last I checked those were only good for 72hrs pending what symptoms present itself which I really don't see how that gives the psychiatrist enough time to be in a good position to develop a Treatment Plan let alone identify symptoms that deem one unfit. What about those who are great actors and know how to dodge prison? If you do not mind me asking and I am in no way questioning your judgment, how would this treatment be considered Assault? If someone is to the point ECTs are being discussed, the person clearly is not thinking straight therefore have no idea/comprehend the actions that landed them in court to begin with. Are there even differentials Dx someone as psychotic? Lastly, the purpose of the DOC is to rehabilitate. If one is psychotic, and treatment options start failing, how is it possible the rehab concept be carried out?

Evaluation for capacity to stand trial is a FORENSIC evaluation, following an arrest and is ordered by the court.

A 5150 is the california code for a 72 hour hold for involuntary hospitalization based on the criteria of danger to self, danger to others or inability to maintain food/shelter/or clothing due to a mental illness.

A 5150 does not require court approval. A 5250 (14 day hold) following the 5150, has to have a hearing involving a hearing officer.

A court ordered forensic evaluation , nor a 5150, nor a 5250, allows for treatment over objection. Medication over objection requires a separate hearing (in CA called a REISE) with a hearing officer, which has a higher burden of proof to get passed. Any other treatment over objection (such as ECT or surgery) requires petitioning the court for permission for that particular procedure, with the exception of an emergency (imminent risk of death that could be averted by intervention). Few physicians would intervene though in even an emergency without contacting their hospital's risk management.

"Not thinking straight" is not a medical or legal concept, and thus has no bearing on hospitalization or treatment over objection. Severe depression or even psychosis doesn't necessarily impact AT ALL someone's capacity (ability to understand and weigh risks/benefits/alternatives of a specific choice) or someone's competency.

There are many many legal protections that protect patients from having their rights violated, by a physician or by the state. These procedures (hearings, etc) involve step by involvement of the judicial system and increasing burdens of proof for each aspect of someone's rights that are taken away.

If you stab someone with a knife without their permission, that's assault. If you draw blood from someone without their permission, that's assault. An individual has civil rights until the courts state they don't. Loose concepts like "not thinking straight" doesn't obviate that process, nor does mere presence of a mental illness, even in the case of psychosis. That psychosis has to be PROVEN to impact the individual's judgment in a way that the court deems is significant enough to remove their rights to make certain future decisions.

Whopper, wanna weigh in?

 

[splik]

ECT is another animal altogether but functional neurosurgery for mental disorder has been making a comeback primarly for intractable OCD, but it has also been used for bipolar disorder and depression. The chief surgical procedure for intractable depression is the anterior cingulotomy. Since the numbers having functional neurosurgery are so small the evidence is all case series rather than randomized controlled trials so the evidence is fairly week. For actually lesioning parts of the brain (e.g. cingulotomy, amygdalotomy) quite frankly the side-effects are pretty terrible and i do not think it is really possible to have truly informed consent. It is usually patients rather than psychiatrists who push to have for surgery (as with epilepsy) but just as with epilepsy these patients usually aren't all that much better afterwards.

DBS is relatively new and was primarily used for movement disorders, then epilepsy and increasingly for depression and bipolar disorder (but still we are talking handfuls of cases). The side-effect profile is probably alot more benign unless you make an error during the procedure, but the cases I have seen it really does make a difference.There is no hard long-term outcomes stuff yet, we are talking a handful of cases but it is fascinating. I am not sure how much it costs here but is is extremely expensive. In the UK it was about £20 000 so the markup is probably more than double in the UK so we are looking at >$100 000 and the stimulator needs to be replaced after about 20 years and sometimes less.

Surgical treatments are inappropriate most of the time as most depression is not that severe and can be treated with CBT, IPT, short-term dynamic therapy, antidepressants, ECT, TMS (and the Israelis have been experimenting with deep TMS apparently with similar results to ECT in depression) most of the times.

As an aside I personally would not want ECT unless I had very severe depression with psychotic features that had not responded to other treatments first and had lasted >3 months. About 1 in 3 people experience significant autobiographical memory impairment and personally I value my memory too much so it would have to be a really awful scenario where ECT would win.

 

[Quinn1988]

Evaluation for capacity to stand trial is a FORENSIC evaluation, following an arrest and is ordered by the court.

A 5150 is the california code for a 72 hour hold for involuntary hospitalization based on the criteria of danger to self, danger to others or inability to maintain food/shelter/or clothing due to a mental illness.

A 5150 does not require court approval. A 5250 (14 day hold) following the 5150, has to have a hearing involving a hearing officer.

A court ordered forensic evaluation , nor a 5150, nor a 5250, allows for treatment over objection. Medication over objection requires a separate hearing (in CA called a REISE) with a hearing officer, which has a higher burden of proof to get passed. Any other treatment over objection (such as ECT or surgery) requires petitioning the court for permission for that particular procedure, with the exception of an emergency (imminent risk of death that could be averted by intervention). Few physicians would intervene though in even an emergency without contacting their hospital's risk management.

"Not thinking straight" is not a medical or legal concept, and thus has no bearing on hospitalization or treatment over objection. Severe depression or even psychosis doesn't necessarily impact AT ALL someone's capacity (ability to understand and weigh risks/benefits/alternatives of a specific choice) or someone's competency.

There are many many legal protections that protect patients from having their rights violated, by a physician or by the state. These procedures (hearings, etc) involve step by involvement of the judicial system and increasing burdens of proof for each aspect of someone's rights that are taken away.

If you stab someone with a knife without their permission, that's assault. If you draw blood from someone without their permission, that's assault. An individual has civil rights until the courts state they don't. Loose concepts like "not thinking straight" doesn't obviate that process, nor does mere presence of a mental illness, even in the case of psychosis. That psychosis has to be PROVEN to impact the individual's judgment in a way that the court deems is significant enough to remove their rights to make certain future decisions.

Whopper, wanna weigh in?

Maintaining food/shelter is reason to request 51/50? Wow. I knew HI/SI were but not the unable to maintain food and shelter part. I know this may seem cynical, couldn't someone that is homeless just act like they are mentally unstable in order to obtain food and shelter? Proving psychosis. That is rather hard to prove isn't it? In terms of not having pts permission to do something then act on it anyway being assault, I also noticed you said ECT by without pts permission being something that can be petitioned, isn't this petitioning to assault someone who is not of sound mind? What I do not get is what good does having a court ordered eval done though the person likely may not be outside prision walls for quite sometime do? If someone pleas insanity, then is either sent to a psych unit or prison, how can one be held accountable since clearly the pt is mentally unstable. Personally I see insanity pleas as garbage and used as an easy out. How does this assist in the victims family pursuit for closure? Only in MY OPINION and no one else's, pleaing insanity sends the messasge as long as insanity pleas are ultilized, a person can do what they please and have a low probability of going to prison and much, much more likely to transfer to a psych ward for further treatment.

 

[nitemagi]

Maintaining food/shelter is reason to request 51/50? Wow. I knew HI/SI were but not the unable to maintain food and shelter part. I know this may seem cynical, couldn't someone that is homeless just act like they are mentally unstable in order to obtain food and shelter? Proving psychosis. That is rather hard to prove isn't it?

It can be, and malingering for shelter is very common. Malingering psychosis is a lot less common than malingering suicidality. That is a much longer discussion. The more you see, the more you recognize most malingerers aren't especially sophisticated at malingering, and thus easily detectable. Most, not all.

In terms of not having pts permission to do something then act on it anyway being assault, I also noticed you said ECT by without pts permission being something that can be petitioned, isn't this petitioning to assault someone who is not of sound mind?

You first make the case they don't have the capacity to make a decision like this on their own (via independent capacity eval or through conservatorship), THEN petition for permission.

What I do not get is what good does having a court ordered eval done though the person likely may not be outside prision walls for quite sometime do? If someone pleas insanity, then is either sent to a psych unit or prison, how can one be held accountable since clearly the pt is mentally unstable.

Is English a second language for you? Some of your grammar is hard to decipher.

NGRI laws vary by state. There's places where the court may ask for an evaluation to see that someone has capacity to stand trial (might be competency, I'm not sure on this one). If they don't have it, they may be sent to a forensic hospital for treatment to restore capacity. This is different than having the capacity to stand trial, but then being found Not Guilty by Reason of Insanity AFTER the trial.

Personally I see insanity pleas as garbage and used as an easy out. How does this assist in the victims family pursuit for closure? Only in MY OPINION and no one else's, pleaing insanity sends the messasge as long as insanity pleas are ultilized, a person can do what they please and have a low probability of going to prison and much, much more likely to transfer to a psych ward for further treatment.

Few people that plead NGRI actually succeed. They're usually found guilty.

Track down a forensic psychiatrist in your area and discuss this with them. Get a mentor. You're clearly using this one thread to answer every question you have about the field.

 

[dl2dp2]

Track down a forensic psychiatrist in your area and discuss this with them. Get a mentor. You're clearly using this one thread to answer every question you have about the field.

This. The initial question is no longer related to the other questions.