Who Holds the Clicker?
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MARIO'S GOOD MOOD continued. He had obsessions and compulsions, but they were smaller now, overshadowed by the grand energy that saturated his existence. For two weeks, he saw Greenberg every day. Greenberg adjusted the settings, turning the frequency, current, and pulse up or down. Sometimes, as a setting was changed, Mario felt that peculiar wash of sadness. Then he evened out.
Six weeks went by. Mario's daughter, Kaleigh, was born. She was a textbook perfect case of a baby; she screamed, she shat, she drooled, her entire unregulated being a little vortex of chaos. Mario changed her diaper, saw the golden smear of shit, and in his heart he backed way up. Over the next few months, his mood dipped. He had a terrible time feeding the baby. Sometimes it took him so long to give her breakfast that it would be time for lunch and he'd have to start all over again. The baby, strapped in the high chair, screamed, squash all over her mouth. Wipe that up. Right away. He was better, yes, but not nearly enough.
Mario went back to see Greenberg. Over a span of a few months, with Mario reporting the waxing and waning of his symptoms, Greenberg eventually got the setting right. Mario began to pick up dirty things. It was, at last, okay.
When Mario talks about that time now, tears come to his eyes. "It was like a miracle," he says. "I still have some OCD symptoms but way, way less. Dr. Greenberg and Rasmussen saved my life. Sometimes they travel to conferences together on the same plane. I tell them not to do it. It makes me very nervous. Who would adjust me if the plane went down? No one else in this country knows how to do it. It's like the president and the vice president traveling together."
AT THREE RESEARCH sites in this country (Butler Hospital, the Cleveland Clinic, and the University of Florida, funded to various degrees by Medtronic, the NIMH, and the National Alliance for Research on Schizophrenia and Depression), 15 or so OCD patients have since been implanted. So far, Greenberg and his fellow researchers have seen 50 percent of these patients improve, to varying degrees. Some experience a complete remission, others a more partial relief. In March, Mayberg released the first findings on depression—of her six patients, four experienced complete remission, while the other two derived no benefit at all. "The results for depression are extremely encouraging," says Mayberg. "We are very excited."
This excitement, coupled with our growing awareness of psychopharmacology's limitations, positions psychosurgery for a potential comeback. After all, when you take a drug you are perhaps altering your brain in ways as or more profound than neural implants do. When you take combinations of drugs, as many psychiatrically ill people do, you put yourself at risk for medication-induced Parkinson's and a whole raft of other serious side effects. "There is seemingly an advantage to any treatment that can be reversed. However, in the case of DBS this advantage is somewhat illusory," warns Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan. "Stimulation on neural tissue is likely to induce long-lasting, and perhaps permanent, changes in neural circuitry and chemistry." But Dr. Mayberg asks, "How do we know those changes aren't for the better?" Indeed, researchers hope that DBS might allow patients to better engage in behavioral therapy, eventually making artificial stimulation no longer necessary.
The hopes of implant makers like Medtronic are as big as the market they imagine. They forecast a day when neural implants will treat a wide variety of psychiatric problems, from eating disorders to substance abuse to schizophrenia. "How many people eat too much or don't eat enough or have some sort of mental illness?" asks Thomas Gunderson, a health care analyst with Piper Jaffray & Co. "There's a big market out there." Yet as these devices proliferate, so too will the ethical issues that stick to them like barnacles. Beyond questions of whether a severely mentally ill patient can provide informed consent, there continue to hover fears that DBS could fall into the hands of the state, or the overworked prison systems, and be used as a management device. After all, both of these things nearly did happen in the last century. Neurosurgeon Rees Cosgrove, at that bioethics conference, said, in an effort to caution restraint and thereby prove to the public that times have truly changed, "If we do not do this right and care- fully, and, you know, properly… I do not think we will have another opportunity."
"It's easy for any good neurosurgeon to do this now," Cosgrove added. "That's the dangerous part—it's easy." Even now, no formal regulations prohibit doctors from using Medtronic implants for psychiatric purposes. And whether or not a particular device or usage has received FDA sanction means little anyway. Drugs are used all the time for "off label" purposes; so too could surgery. What will stop neurosurgeons both mercenary and curious from performing these operations on a public clamoring for relief? How long until implants are used to treat milder forms of mental illness? To take this its inevitable step forward, what will stop people from pursuing implants for augmentation purposes? Cosgrove described a patient who, after implantation, became more creative.
But perhaps the simplest conundrum is this: DBS for psychiatric disorders is very experimental. There are no animal models of DBS for anxiety or depression, so these forays into the human brain are largely unguided, despite all the high-tech equipment. At the 2004 meeting Cosgrove, who believes the procedure holds great promise, ticked off other issues: There's no possibility of large-scale, placebo-blind trials. Thus far Medtronic is the only maker of brain implants, and the major funder of the investigational studies. There's a risk of infection, of equipment malfunction. Most importantly, Cosgrove said, "We don't understand how deep brain stimulation works.… We are not clear what the optimal targets are. We don't even know what the optimal stimulation parameters are, and we don't know what the long-term effects are…it's not as simple as we make it out to be."
But for Mario, it is simple. "I've had a hard life," he says. "My parents got divorced. My father died. I broke my foot. I have OCD." He pauses. "But," he says, "I have been helped."
BACK IN THE 1950S, Rune Elmquist and Ake Senning developed the first implantable cardiac pacemaker, which made some people nervous, suggesting, as it did, an ever-diminishing gap between technology and the soul. Now, pacemakers are as common as grass. Perhaps there will come a time when neural prosthetics will be just as banal, when we will view the brain and its surgical manipulations without awe and hand-wringing.
And yet in no other place is there the potential for a surgeon to so acutely and immediately make memories evaporate, dreams rise, fingers freeze, hopes sputter. The argument could be made that we are not entirely our kidneys, but that we do live entirely within the circle of our skulls.
For Mario, this is all armchair philosophizing, irrelevant to his situation. "I don't care what it means," he says. "I care that I'm better. I'm not all better, but I'm better." So much better that recently he's let the batteries to his implants run down, though whether this indicates a DBS cure or just an OCD remission, Dr. Greenberg says, it is far too soon to tell.
Either way, Mario is proud of his progress. His wife recently gave birth to a second child. He carries with him pictures of his four-year-old daughter, Kaleigh, who wears tiny gold hoops in her ears. She and Mario play "tent" in the morning, climbing under the quilts, where he shows her shadow puppets. A bird flies. See, a spider. This is the chapel, this is the steeple, open it up, and here are the people. His wife showers; water hits the walls with a sound like static. Outside, cars roar on the roads. Under there, so close to his daughter, Mario can hear her breathe: He is not afraid to hold her hand. Some might say Mario, with his implants, has agreed to a strange sort of bondage, but Mario doesn't think so. He would say he's been freed.
Lauren Slater writes frequently about psychology, psychiatry, and medicine in general as it is practiced at the very borders of acceptability. She is the author of six books, including Prozac Diary, Opening Skinner's Box: Great Psychological Experments of the 20th Century, and her latest, a work of fiction, Blue Beyond Blue.
Illustration By: Malcolm Tarlofsky
