Sunday, November 22, 2009

Expectations are disappointments waiting to happen

Experimental - Efficacy - Safety - Titration - Patience - Transient


I have just returned from my 11 months checkup. Although 11 months, probably I was off the first 6 months, so this is month 5.


When I agreed to this, my thinking was very simple: I'll try ANYTHING to get rid of this.


Over the past few months, I have seen some mild (positive) changes. Can I say for sure its the DBS? Absolutely not. Maybe. I'd go so far as to say probably the changes are due to the DBS. But this blog is dealing with reality. My reality.


I made a decision months ago to only report physical problems and to generalize any ups and downs because this is an experiment. My reactions may or may not be the same for anyone else. But (again another but) I feel real compelled to go off on a tangent of expectations and reality and just how new this field is.


Below is a link to a video of Dr. Mayberg discussing the first woman implanted and her reactions, which were remarkable and extraordinary - IN THE OPERATING ROOM. I apologize I wasn't able to embed it, please take the time to listen.


http://www.dailymotion.com/video/x9vgvq_treating-depression-deep-brain-stim_tech

Dr. Mayberg talks about the IMMEDIATE change in this woman.



Next is a video of Dr. Resai and a woman who underwent the surgery. Note the part where after implantation, they bring her in to modify the parameters on her device to zero in on lifting her depression. This is similar to Parkinson's implants where they may spend hours adjusting the generator and choosing which contacts on the leads to use (there are 4 on each wire - 1 wire on each side of the brain). Fascinating and it really really looks like this could be a cure that doesn't take much time.






But back to reality which has to do with bringing this product to FDA approval and that means following rigorous scientific & ethical guidelines. What the researchers actually know about how this is working is baffling little, I'm afraid. For standard FDA research and approval of anti-depressant drugs, there is a 12 week period. The experimental group is given the new drug for 12 weeks and their progress monitored and measured. At the end of the 12 weeks, the results are compared to the control group which was receiving a placebo. Using statistics, the differences are compared and it is decided whether the new drug made a 'significant' change over the control group. There are hundreds of Internet links about various studies and how strong the placebo effect is (18-22%). And how ineffective many of the anti-depressant drugs are. To generalize most studies, 1/3 get remission, 1/3 have some good progress and 1/3 don't get any help over 12 weeks. Then the process may start over at a different dosage - another 12 weeks.


One of the problems with VNS was the ability to figure out what the proper 'dosage' of current to the vegus nerve is for each person. I'm no expert on it, but I know it was controversial - I am sure Herb has plenty of articles and literature on it.


So why am I bringing all this up? As much as my team emphasized "don't get your expectations up", "this is brand new totally completely untested and may not work" it was damn hard not to get them up. And every month when I go for my 'adjustment/checkup' and run through the same questions, it reminds me how bad I have gotten over the years AND maybe this next adjustment will do the trick and next month I'll be CURED. My expectations.

Denise commented in a previous blog:

"From what I've read there seem to be about five sites which could be targeted
to alleviate depression. Therefore, if you were to participate in a DBS trial
and you don't find it of any benefit, what do you do next, opt to attend another
trial where they are targeting another site??? You could go on forever like
that.

Dr Helen Mayberg mentioned that a number of patients noticed acute affects
in the operating room, wouldn't it make sense, whilst they are doing the
operation for them to try stimulating more than one site to see if the patient
reacts better depending on the site that is being stimulated. Or is it not that
simple?

Also, Dr Helen Mayberg says that the patients in her study who failed to
respond to treatment showed no subgenial cingulate changes. I'm not sure which
area of the brain they have stimulated in your case but if it is the "Brodmann
area 25" have they noticed any changes in the Subgenial Cingulate area of your
brain?"

All good questions Denise, and I hope to find out the answers - but for now, we're following the 'protocol' of the experiment. This phase is more about safety of the device than the efficacy. I would LOVE for them to play with the settings for a few hours and fine tune the response, but that's not the protocol. (My apologies to the experimenters if this sort of stuff was supposed to be under wraps - I think the followers need to understand this is SLOW going for a reason. I don't like it - at all - but I understand it and I want to make sure anyone dreaming of having this done understands there is a LOT of work to do before it comes to market and gets approved).

Let me be very very clear - the informed consent was clear and I understood what they were saying - but my own desire kept thinking about the internet stories of miraculous change. One reader here, PsyFi, shared a little of her experience and it was nothing short of miraculous. Another reader and follower shared that though it took quite awhile to find the settings that seemed to help him, it was worth it.


So what am I going on and on about? With any luck, the FDA will approve the next steps for St. Jude's study which to my understanding will include up to 200 more implants. I'm all for it. However, for all of you hoping to get into it, or hoping the medtronics study is for you, or are just plain suffering and expecting this to come and rock your world when it is generally available - be prepared to find out there is more to the story than what the Internet videos/articles discuss. That adjustment phase is done 'by the book' on a rigid adjustment schedule. So even if this is going to work completely for me, getting it 'titrated' is taking a lot of time.


I can completely understand the necessity for a slow pace on such a NEW technology. I just didn't manage my expectations well. As it turns out, from what I've recently been told, a lot of the operating room experiences were transient. i.e. the patient still had to undergo a lot of trials and errors on getting it adjusted for them.


By what I've found on the Internet, including a new German study, there are still fewer than 60 of us. (Medtronic rep, feel free to give us a head count if you can - yes head count is a pun). The gizmo has 4 contacts on each wire - 1 wire on each side. Each contact can be negative or positive with different voltage & milliamps & frequency. Thousands of combinations. I don't know how long it took the pioneers of Parkinson DBS to hone in on their protocols, but it is going to take at least that long for us. And although the video above (where the woman is being adjusted) looks like it may be a simple procedure, remember we are dealing with emotions - not physical movements. A Parkinson patient can visibly see and feel whether their tremors are gone and the setting is working. For moods, it may take quite a bit more fine tuning.


Of course, being the optimist and willing to do my part to promote the science, I offered to take the programming gizmo home with me and adjust as necessary. Fat chance. And understandably it will never get to that. Just because someone has a bad day at work, we can't just go home and up our gizmo. But alas, I had to try.


I've added a link about DBS and rats. Interesting about serotonin being more effected than norepinephine (noradrenaline). I am not on any drugs that affect serotonin - I'm on drugs that affect norepinephine. Possibly I will see more rapid change when I'm able to switch drugs. (Supposedly after awhile, the study allows more testing of combinations etc). BUT - I'm not going to get my expectations up.... ya right.


Overall, putting my expectations rant to the side, I have had some interesting effects. Again, I wouldn't swear they're from the DBS, but probably are. Some of my 'blah' emotions seem to be shifting. I don't want too get detailed, but I am having 'some' different reactions emotionally than I was. I have been able to maintain 20-25 hours working however I did have some bad days and dropped about 5 hours at the last minute - just couldn't do it.

Psyfi, others, or the original Canadians care to comment? Or you can contact me if you want to be anonymous. Note the comments on the last post. A U.K. DBS patient has put together a group for "us". (I hate google groups, FYI, Yahoo would have been my choice). I think allowing us Guinea pigs to share may not be a good idea - but I will say - knowing there are others out there who have gone through this makes me feel wonderful. Maybe the sponsors should consider their own controlled groups - hint hint to the IP address in Plano). There is also another USA DBS person who has put up his own site. That should be interesting as well.

I hope everyone has a good turkey day and thanks for letting me vent.

11 comments:

Anonymous said...

Welcome to LabRatDom.

I was in that original VNS study and will freely testify (can I get an "amen?") that it was a debacle. The painstaking (emphasis on "pain") retardation of the DBS study is surely a direct response to not-doing what Cyberonics did trying to hurry the VNS study.

I am also in your DBS study.

I am in Month 13.

Imagine my surprise (and I don't think you have to imagine because you've lived it) that it was the DAY OF my surgery (in pre-op prep) that I learned I would not be 'awake' for the implantation. "How on Earth," I lamented, "would they ever be sure they got the right spot and the right setting if I weren't awake to tell them?"

Now I've learned, a year hence, that "they" really have no set protocol regarding what to do with folks (specifically I am referencing myself here) who do not respond during the first 12 Months. Now what?

I've also learned that amplitude is really the only parameter that is going to be addressed. So that 'bazillion' of parameter-setting combinations decreases a bit when you are not tweaking pulse-width, frequency, time-on/time-off, etc. Mind you, that is not to say they won't try a different node on the implanted lead, but it does affect that 'bazillion' value somewhat. :)

As you allude, I also fantasize about walking into the Medtronics study and saying, "Gee, can you relocate my leads and give your settings a go? The ANS model doesn't seem to be quite working for me. Pretty please? C'mon, I already have the hardware loaded."

I admire your courage to blog. I admire your stick-to-it-ness. I admire your candor. And, I like your rant.

Mine is rage.

The only encouragement I have is that I am assured that this stage-of-the-game (i.e., the study in which we are currently participating) is a "feasibility study." Meaning: will this protocol produce viable data with deference to patient safety? My answer is "no." Safety first - Fun second...doesn't work with a population at this level of depression. In fact, being this "safe," in my opinion, puts us at risk.

This format is not feasible. How you and I have lasted this long is beyond my comprehension. Then again, depression is beyond my comprehension.

I ask only this: that you be as vocal and articulate to your study personnel as you are here--because--if, indeed, this is a "feasibility study," then they have to hear from us that this more than sux; that this is cruel; and, that this format may make for good math, but it makes for bad medicine.

Thanks for letting me vent.

Anonymous said...

Seen this?

CLICK HERE: http://whyy.org/cms/news/health-science/special-features/2009/06/21/living-with-chronic-depression/7912/comment-page-1#comment-818

278-005 said...

Raging anonymous - if you're up to it, contact me. 278-005@live.com. I have some ideas. Neither one of us wants to jeapordize or derail the study - but to make it more workable for the p=e=o=p=l=e involved.

And thanks for the Tara interview. Quite interesting. I guess it may be time to turn my tags back on and let the pieces fall where they may.

Anonymous said...

from the canadian connection,
I am also comment 818 that anonymous mention.
I just celebrate 4 years after my operation and I am extremely glad I did it. The reality is our protocole was very different than yours. I was awake during the whole operation...( 9hours or more) and at a certain time they start the stimulation and found where I responded the best. After a little more then 2 weeks they started the stimulator with those parameters. It worked well for a while then I started to go down again. I am not going to go into detail but they had to make special adjustment for me, that involve more than the amplitude. Even recently 3 month ago, the doctor had to readjust the amplitude. I consider myself very lucky because in phase one the protocol was not has ridgid. In fact they were not sure it was going to work. My doctor was so happy to see me react so well, especially because I was patient number one of the phase one trial by mediatronic

Anonymous said...

Anon from the Canadian connection: Tahnk you for your post!

- Anon from the US ANS connection.

herb said...

I wanted to take a moment to wish the author of the website and all the readers wellness as well as a Very Healthy, Happy, Peaceful and Prosperous New Year.

As I’ve come to learn through these many decades there is no simple answer to obtaining remission and/or recovery from these horrific mood disorders. What is required is continued patient education, hope and persistence in finding and trying a therapy that will benefit the patient.

Until then I thank the author, respondents to this forum and other forums that have shown the courtesy to me and others to share their experiences as well as knowledge relating to this and other therapies.

Once again, I wish you all well.

Warmly,
Herb
VNSdepression.com

Denise said...

Hi,

I was wondering what kind of depression those of you who have had DBS suffer from. I know that the blogger has melancholic depression but I thought that many depressions were classed as episodic, that is they have a beginning and an end.

I've been diagnosed as having dysthymia/anxiety and double depression, I've never had what you would call an episode. From 17 to 24 I was dysthymic with anxiety and that was treated really well with antidepressants then after coming off antidepressants for 3 years after I hit 35 my depression anxiety and this time suicidal thoughts came back. I'm now 43 and have had this depression and anxiety since 35 with a two year relatively good period when the Paxil worked. So I have been chronically depressed (you could say) for eight years but I wouldn't class this as an episode. So I do get confused about people who have chronic, severe depression as from what I've read the only depression that is chronic is dysthymia.

Do you all have frequent episodes of major depression with periods of normality in between? This is what I am trying to ascertain.


Denise

Jan said...

Hi Denise,

I don't have much time now but here's my experience. I was struck with a "chronic, therapy-resistant, major depression" (just quoting from my medical reports)in April 1998 and never had "episodes": for all those years I was simply depressed 24/7 and never had a period of "normality". I had my dbs surgery in June 2008 and it has helped me enormously. I'm not in remission, but have a life again. But more about that in a next comment.

Keep well,

Jan

Anonymous said...

My name is Eric I had my DBS 5 years ago at Toronto Western. Things were at "40 percent" better but have recently stopped entirely. A senior doctor said it's the battery but they hesitate to change it without the "Battery Dead" reading on Medtronic's interface. I'm mixed up and scared. I'm a 33 year old engineer balancing on the webs of depression aviodance. I have fallen. Help.

Anonymous said...

Hi,
Could you link to the sites you mentioned in the last paragraph please? I am a Medtronic implantee and I am looking for a support group.

Thanks so much and hope you are faring well.

278-005 said...

Medtronic Anon - send me your email. There is a Facebook group solely for TRD DBS.

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