Meet the Mumbai neurosurgeons who use surgery to cure mental illness

Benjamin Ward mails us a selfie Itrsquos of him with fianceacute Alyssa both flashing wide smiles Itrsquos a precious picture not just because the two are to marry next January but also for Wardrsquos expressionAbove Dr Sanjay Mongia and Dr Paresh K Doshi beloware among the few Indian practitioners of functional neurosurgery for OCD and depression PicsShadab Khan and Pradeep DhivarThis is a man who claims he had forgotten to smile for five years while battling treatment resistant depression in Sydney where he worked as a professional carpenter His parents Lyndal and Colin Ward were habituated to seeing him return home early from work sometimes sobbing uncontrollably A video of Australian patient Benjamin Wardrsquos surgery done in 2013 shows Dr Doshi asking him at each placement of the electrode if he is feeling better ldquoYou have to find the sweet spotrdquo Dr Doshi says of the procedureldquoI was unable to work or meet people Often Irsquod contemplate suiciderdquo says Ward 28 over the phone from Sydney Between 2008 and 2013 he tried 15 varieties of antidepressants Electroconvulsive Therapy ECT a technique that attaches electrodes on a patientrsquos scalp to allow a finely controlled electric current to reach him under general anesthesia offered relief that barely lasted weeksAustralian Benjamin Ward 28 with fiance Alyssa Before Ward was operated using DBS in Mumbai he suffered from treatment resistant depression for five yearsHis incessant research led him to Deep Brain Stimulation DBS surgery It requires that two 11 mm wires are inserted into the patientrsquos brain and connected to a pacemaker placed under the skin of the chest Providing a continuous stream of electricity it stimulates the affected part of the brain which in the case of depression is the subgenu cingulate gyrus This helps relieve depression say experts of functional neurosurgery PET scan studies have revealed that previously hypo functioning areas of depression became hyper functioning posttreatment confirming that the condition was reversible Ward was led to Mumbaibased stereotactic and functional neurosurgeon at Jaslok Hospital amp Research Centre Dr Paresh K Doshi In October 2013 Ward underwent a fivehour surgery to cure him of unflagging sadnessDBS can be reversed ldquoIf the electrode isnrsquot working you can remove itrdquo says Dr DoshiThe inner circleSitting in his cabin on the 11th floor of the Peddar Road hospital Doshi says he grew interested in functional neurosurgery a stream concerned with altering and correcting the central nervous systemrsquos brain and spinal cord physiology or normal function as a medical student at Nair Hospital Within a year of his return from Londonrsquos National Hospital for Neurology and Neurosurgery he joined Jaslok In 1998 he was off to France to train in DBS a procedure used on Ward and one that has been commonly used worldwide to treat patients suffering from Parksinonrsquos since the late 1990s Its use in epilepsy was recognised in 2008Dr Samir Parikh Fortis HealthcareFor the last five years however functional neurosurgery is also being used to treat psychiatric disorders including depression and more commonly obsessive compulsive disorder OCDDr Sanjay Mongia Asian Heart InstituteldquoIn 2010 while going through some world literature in the field I realised that it was possible to use DBS for certain psychiatric ailments too After much research and setting up ethical guidelines at our hospital we decided to offer it to psychiatric patientsrdquo says the 52yearoldThis makes Doshi one among just a handful of doctors in the country who use popular neurosurgical procedures amidst much debate to treat depression and OCDHe walks up to his shelf to bring out a volume of Textbook of Sterotactic and Functional Neurosurgery by Andres M Lozano Philip L Gildenberg and Ronald R Tasker Recounting the history of psycho surgery he speaks of American physician Walter Freeman and neurosurgeon James Watz who in the 1940s became advocates of lobotomy The highly controversial procedure required them to severe connections to the prefrontal cortex in the frontal lobes of the brain ldquoFreeman and Watzrdquo says Doshi ldquowent berserkTheyrsquod travel across the US in a van with an ice pick cutting the sub frontal fibres of patients who were brought to them Between 1935 and 1950 it is estimated that 90000 such procedures were conducted across the worldrdquo he shares Patients were lsquotreatedrsquo for depression schizophrenia aggression and other mental health disorders However because their limbic system mdash the primary house for the brainrsquos emotional responses mdash was cut off patients would turn apathetic and lethargic In the 1960s there was a turnaround in psychiatric care when it was discovered that administering a specific dose of drug chloropromazine would help treat patients with serious schizophrenia and surgery wasnrsquot the only option Now there are antidepressants used on depression and OCD patients mood stabilizers for bipolar disorder and anxiolatics for anxiety disorders in the marketScreening the patientHowever as Ward will tell you not all patients respond to drugs and Cognitive Behaviour Therapy as well as others Which is why doctors like Doshi ensure that the patients they take on are chronic resistant casesldquoWe only take on patients referred by a psychiatristrdquo says Dr Sanjay Mongia 45 Mumbaibased neurosurgeon who uses the Gamma Knife procedure to operate on patients suffering from OCD ldquoThey should have taken medication for at least seven years and undergone 10 to 20 therapies from multiple psychologists without much relief for me to consider them for surgeryrdquo he says when we meet him at the Asian Heart Institute Bandra Kurla ComplexDr Y C Janardhan Reddy NIMHANSThe threehourlong Gamma Knife procedure is a noninvasive method in which tiny beams of radiation are focused on a specific spot of the brain to create lesions in affected parts ldquoA patient suffering a mental health condition experiences neurochemical changes in the brain These in turn lead to neurophysiological changes When we conduct surgery we target a particular area of the brain and create lesions or damage specific cells that affect those nuclei or group of cells that are causing the chemical imbalance in the first placerdquo he explainsDr Mohit Bhatt Kokilaben Dhirubhai Ambani HospitalIn the five years that Mongia has been using Gamma Knife for OCD all his surgeries have been conducted on patients outside Mumbai he has treated a total of 20 patients ldquoI have rejected at least twice the numberrdquo he saysDoshi too has performed DBS for depression on Ward and used ablative surgery creating lesions in the brain by using a radiofrequency electric generator which transfers the electrical current into heat at the tip of the electrode producing a thermal lesion immediately on just three others suffering from psychiatric disorders two of them with OCD and a third with OCD and depressionA major problem Doshi believes is that most patients especially Indians donrsquot maintain a detailed drug history ldquoWe need to know the line of treatment that a patient has received in the five to 10 years before they came to us Which drugs what dosage and duration of intake are all crucial informationrdquo Even if a patient is referred to him he will ask them to first consult Jaslokrsquos inhouse psychiatrist Dr Amit Desai and neuro psychologist Dr Shraddha Shah to ensure that the patient is indeed a case fit for surgeryWhich is why a medical student from north Maharashtra who approached Doshi was first asked to consult a Thane psychologist for Cognitive Behaviour TherapyTime for successldquoI have been suffering from OCD for 15 yearsrdquo says the 25yearold over the phone ldquoI constantly clean my book covers or adjust the car mirror I canrsquot stop I seek perfection in everything Even a dog ear in a book will keep niggling merdquo he says The problem has affected his studies making him repeat the second year of MBBS While his family he says is aware of his condition his friends havenrsquot been told yet ldquoI found out about Dr Doshi and arrived in Mumbai last week to consult himrdquo he addsYet itrsquos patients who are enthusiastic about a surgical solution who need the sternest warning Besides results are slow to show While Ward says it took him two months postsurgery to ldquobecome completely okayrdquo most doctors advise a waitandwatch period of at least a few years where the postoperative treatment will include medication and therapy ldquoThis is not an appendectomy where on removing the offending organ everything will be finerdquo says Dr Y C Janardhan Reddy professor of psychiatry and consultant ObsessiveCompulsive Disorder Clinic at the Department of Psychiatry in National Institute of Mental Health amp Neurosciences NIMHANS BengaluruTwo years ago NIMHANS started using the Gamma Knife procedure to treat patients with severe OCD It was an extension of their clinical service Of these they have seen good results with only one The statistics he says are neither encouraging nor discouraging ldquoThis is science you are not going to see miracles We will have to treat 20 to 25 patients to acquire a statistic You canrsquot abandon a practice based on three casesrdquo he points out The success rates most say range between 60 to 70 per cent After all even if the electrodes are attached to the right spot accurate strength of current administered and lesions created a hundred other factors can varyWhile DBS comes with the attraction of reversibility mdash ldquoif the electrode isnrsquot working you can remove itrdquo says Doshi mdash and the Gamma Knife will leave you with transient headaches and dizziness its most common side effect the challenge says Mongia is also that MRIs and PET Scans that have helped identify the region of the brain where depression or OCD sits canrsquot identify the exact spot This is why a DBS is done while the patient is awake For instance in a video of Wardrsquos surgery Doshi is seen asking him at each placement of the electrode if he is feeling better ldquoYou have to find the sweet spotrdquo he saysThis is also why though research has shown that regions that control OCD could also control alcoholism it isnrsquot specific and established yet And though it is believed that psychosurgery may help relieve bipolarism and schizophrenia much more research needs to be doneAnd then the cautionDr Mohit Bhatt in fact believes far too little research has been done into the subject Director for Neurosurgery at Andherirsquos Kokilaben Dhirubai Ambani Hospital and Research Centre he says ldquoMy main reservation is that a patient with Parkinsonrsquos has a simple presentation and the area in the brain where the problem exists can be delineated You can put an electrode there and correct it This has been proved in thousands of surgeries and animal experiments However no such model exists for psychiatric problemsrdquoHe argues that there is no crisp border of abnormal area for psychiatric disorders Additionally psychiatric problems are difficult to assess ldquoItrsquos not just physical but emotional behavioural presentations too And these differ in socioeconomic groups The emotional reaction of a depressed person in India will not be the same as that from another part of the world Also how a person feels fluctuates every day We need a good scientific model firstrdquoDr Samir Parikh Director of Mental Health and Behavioral Sciences at Fortis Healthcare believes surgery should be the last resort ldquoIn the last five years I would have considered surgery for say two patients but I didnrsquot end up referring them The percentage of people who will not respond to any line of treatment is minisculerdquo he says adding that with more awareness on mental health issues people will consult doctors in the early stages making psychosurgery even less essentialFor now however Ward is glad the option was available to him ldquoI am back at work fulltime and able to do all that I enjoyrdquo he laughs ldquoI am riding my motorbike meeting friends and going to the beachrdquo