A 28-year-old African man, who has been suffering from schizophrenia ever since he was 15 -- with no drugs working on him and confining him to a room full of delusions and hallucinations -- is just about experiencing reality. That’s because he has undergone deep brain stimulation (DBS) surgery at Marengo Asia Hospital, Gurugram, which claims this is India’s first such procedure done on a schizophrenic patient. “We studied the literature carefully before proceeding for a Nucleus Accumbens-Deep Brain Stimulation surgery. Thirteen such surgeries have happened in the world and we chose to do so after studying the case minutely. He qualified because he was treatment-resistant. For years, he was scared to step out and had become a social recluse. He had wild hallucinations and extreme anxiety. But he also had positive signs, like he had a sharp insight into and awareness about his condition. Since no existing protocol exists for his condition and we had global references in similar cases, we went for permanent neuro-modulation. Now 80 per cent of his hallucination has gone,” says Dr Himanshu Champaneri, a senior consultant neurosurgeon at the Marengo Asia Hospitals Gurugram. What’s DBS? This is a procedure in which surgeons implant electrodes in the deeper structures of the brain connected to a pacemaker-like device in the chest. These electrodes produce electrical impulses that can regulate abnormal impulses and restore balance. These also affect certain cells and chemicals within the brain. The amount of stimulation is controlled by the device placed under the skin in your upper chest. A wire that travels under your skin connects this device to the electrodes in your brain. Why DBS in schizophrenia? Psychosurgery is a new field and could help those suffering from treatment-resistant schizophrenia, a complex psychiatric disorder that affects millions of people worldwide. A study by the University of Colorado, published in Frontiers in Surgery, found that people with schizophrenia (SZ) and schizoaffective disorder (SAD) have overall lower surgical risk than people with Parkinson's Disease, which is reassuring when considering potential surgical interventions such as DBS for the treatment of SZ and SAD. Most of these patients saw resolution of psychotic symptoms. “Twenty per cent of SZ and SAD patients are treatment-refractory. It’s our responsibility to ensure these novel and advance therapeutics are available to populations who feel they have run out of options, as is our duty to ensure clinicians, patients and caregivers make informed ethical decisions when considering DBS as a new experimental treatment option,” said Judith Gault, Ph.D., associate research professor of neurosurgery at the University of Colorado School of Medicine and corresponding author. “Besides, DBS is a reversible surgery. You can turn the battery off, take the electrodes out or add them without damaging the brain if the body doesn’t have the need for them. DBS allows for adjustment. It has also worked in cases of Parkinson’s, dystonia, other psychiatric disorders and obsessive compulsive disorder (OCD),” says Dr Champaneri. Why this patient became a test case He chose this novel technique for his patient only after thoroughly assessing his condition. Despite undergoing various medication regimens, he had been experiencing persistent hallucinations and delusions among other symptoms of schizophrenia. He had isolated himself in his room for eight years, severely impacting his quality of life, his social life and his academic growth since he dropped out of school. The patient's symptoms of schizophrenia had progressively worsened over the years, manifesting in complete social withdrawal. He became increasingly resistant to the prescribed medicines. The condition began to significantly impact the patient's ability to function in daily life. And he became increasingly resistant to the prescribed medicines when he chose to come to India for an enhanced treatment called neuromodulation. “In accordance with the Mental Health Act 2017, India, approval was taken from the government mental health review board to perform this psychosurgery. The patient was operated on June 14 and has shown significant improvement, with his delusions going down and not returning. The entire procedure took 8-10 hours and the patient was monitored in the ICU overnight. On day 2 postoperatively, he was able to walk and also felt 50-60 per cent improvement in his symptoms. On day 10, he felt 80 per cent reduction in his hallucinations, delusions and anxiety. DBS acts by modulating the abnormal brain networks, so the patients are expected to improve further with the passage of time. While DBS is primarily known for its application in movement disorders such as Parkinson's disease, its potential in treating psychiatric disorders, including schizophrenia, appears promising,” says Dr Champaneri. “The advantages of DBS surgery lie in its ability to offer a personalized approach to treatment. By targetting specific regions of the brain, DBS can potentially alleviate symptoms and improve the patient's quality of life when traditional medications and therapies prove insufficient. The target chosen in schizophrenia is called Nucleus Accumbens, which is responsible for the patient’s symptoms like hallucinations and delusions. This can be used in hopeless cases. We just hope that such intractable cases find some hope through neuro-modulation,” he adds. WHO studies estimated that the burden of mental health problems in India is 2443 disability-adjusted life years (DALYs) per 100 000 population; the age-adjusted suicide rate per 100, 000 population is 21.1. The economic loss due to mental health conditions, between 2012-2030, is estimated at USD 1.03 trillion. It is estimated that 6-7 per cent of the population suffers from mental disorders. The lifetime incidence of schizophrenia is 1.4 per cent in the Indian population. It is a serious condition with a multitude of problems including social isolation and stigmatization. The awareness for which is still very low even in the literates.
