By Lindy Keane Carter
Since childhood, the man had suffered from obsessive compulsive disorder (OCD) so severe that neither psychotherapy nor medications had reduced his symptoms. He also had experienced depression for most of his life that required medications and several rounds of electroconvulsive therapy. In his fifties, he was dealt a third blow when he was diagnosed with Parkinson’s Disease (PD). He underwent deep brain stimulation (DBS) therapy in his subthalamic nucleus (STN), and when he found that it alleviated his PD symptoms, he wondered if DBS could alleviate his OCD, too. MUSC specialists in psychiatry, neurology, and neurological surgery designed a treatment plan to explore this possibility. In addition, they recognized that his case represented a unique opportunity to learn whether an additional DBS electrode in a different area of the brain (the nucleus accumbens) could have an effect on the depression and apathy often seen in people with PD.
In July 2013, the patient was implanted with bilateral DBS electrodes for OCD by Istvan Takacs, M.D., Assistant Professor in the Department of Neurosciences and Director of Functional and Stereotactic Surgery, making this patient the first person reported to have dual implantations for both PD and OCD in different anatomic sites. In addition, he is the first PD patient reported to have a DBS electrode in the nucleus accumbens, known as the reward center of the brain. PD patients rate their depression and apathy to be the most debilitating symptoms, but they are excluded from DBS for depression because of a “pre-existing” neurological condition (PD). Nolan R. Williams, M.D., Chief Resident of Combined Neurology and Psychiatry, who is this patient’s interventional psychiatrist, says this case provides a unique opportunity to use DBS in a PD patient to advance scientific understanding of reward system dysfunction in PD. Since the procedure, the patient and his wife have noticed positive changes in his mood. “If his depression and apathy related to Parkinson’s, in addition to his OCD, continue to improve, then we have some exciting news to share with the Parkinson’s community,” remarks Dr. Williams.
MUSC has been at the forefront of applying brain stimulation technologies to the treatment of mental disorders. Mark S. George, M.D., Director of the Brain Stimulation Laboratory at MUSC, pioneered the use of transcranial magnetic stimulation for depression, and he and other MUSC investigators have expanded the application of brain stimulation technologies to many psychiatric illnesses. These include electroconvulsive therapy (for depression, bipolar disorder, schizophrenia), transcranial magnetic stimulation (for depression), vagus nerve stimulation (for depression), DBS (for OCD), and epidural cortical stimulation (EpCS) (for depression).
The case described here represents a new frontier in medicine: managing a treatment-refractory neurological disease and a psychiatric disease with the same therapeutic modality (DBS). There is not only integration between psychiatric conditions and neurological conditions, but also collaboration by the treating physicians in the same domain. The hope is that in the future, clinicians will be able to evaluate a psychiatric condition through neuroimaging, identify and use the technology that will optimize treatment, and normalize the dysfunctional circuitry of the brain early enough to alleviate the suffering and stigmatization of mental illness.