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VIEWS & REVIEWS: M. Schüpbach, M. Gargiulo, M. L. Welter, L. Mallet, C. Béhar, J. L. Houeto, D. Maltête, V. Mesnage, and Y. Agid Neurosurgery in Parkinson disease: A distressed mind in a repaired body? Neurology 2006; 66: 1811-1816 [Abstract] [Full text] [PDF]

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Neurosurgery in Parkinson disease. A distressed mind in a repaired body?

Mazen G. Jabre, PharmD, Boulos-Paul W. Bejjani, MD   (9 November 2006)

Reply from the Authors

Yves Agid, Michael Schüpbach, Marcela Gargiulo, Marie-Laure Welter, Luc Mallet, Cécile Behar, Jean-Luc Houeto, David Maltête, Valérie Mesnage   (9 November 2006)

Neurosurgery in Parkinson disease. A distressed mind in a repaired body? 9 November 2006
Mazen G. Jabre, PharmD, Parkinson, Memory & Movement Disorders Center Notre Dame des Secours Hospital, Byblos/Jbail-Lebanon, Boulos-Paul W. Bejjani, MD Send Correspondence to journal: Re: Neurosurgery in Parkinson disease. A distressed mind in a repaired body? mazenj{at}inco.com.lb Mazen G. Jabre, PharmD, et al.	Shüpbach et al demonstrated discrepancy between motor and social impact of subthalamic stimulation (STN DBS) on PD patients. While motor symptoms improved, social adaptation remained unsolved with new conflicts and life problems.[1] During the past seven years, we have treated 74 PD patients bilaterally with STN DBS. We have never encountered social, marital and professional troubles. After a mean of 34.2 months after surgery, sole STN DBS provided a 63.5% improvement of the general motor function. Clinical complications decreased by 86%, when compared to preoperative condition. Twelve of our patients retired before surgery because of PD and were still age-fit for work and six (50%) resumed full-time work after surgery. Of the total series, four patients were transferred to part-time positions or were about to quit work because of PD. All resumed full-time work responsibilities after surgery. Twenty-two (except one patient) maintained full active professional status. Of the seven single patients, one got married after surgery. One familial conflict was noted in the family of a juvenile PD patient. One patient from the Arab Gulf with newly-developed hypomania and hypersexuality became temporarily separated from his wife. These problems were effectively managed by adjusting stimulation parameters and neuroleptics. A European patient, living abroad, got divorced and remarried. Interestingly, most of the negative incidences we encountered were in our juvenile population (15%). Despite regular personal outreach interventions adopted for all our PD patients, this population did not respond well. After surgery, seven patients (10.81%) were dissatisfied because of the persistence or new onset of moderate or severe axial symptoms because of the discrepant response of peripheral and axial PD symptoms to treatment. Interestingly, patients and their relatives developed this reaction despite careful preoperative instructions about prognosis, surgical outcome, and re-channeling of expectations into realistic end-points. Is the distressed mind observed in Shüpbach et al’s article more frequent in Western societies? Is it common in the younger population? Are problems more frequent in patients undergoing late surgery? Could the social culture in our region, the outreach paraclinical and psychological support, or the 24/7-hotline service we provide, be responsible for such favorable outcomes? Further studies are needed to understand genuine DBS socio-medical impact. References 1. Shüpbach M, Gargiulo M, Welter ML, et al. Neurosurgery in Parkinson disease. A distressed mind in a repaired body? Neurology 2006; 66: 1811-1816. Disclosure: The authors report no conflicts of interest.
Reply from the Authors 9 November 2006
Yves Agid, Centre d' Investigation Clinique Inserm U 679, Hopital Pitie-Salpetriere, 47 Bd De L' Hopital, 75013 Paris, France, Michael Schüpbach, Marcela Gargiulo, Marie-Laure Welter, Luc Mallet, Cécile Behar, Jean-Luc Houeto, David Maltête, Valérie Mesnage Send Correspondence to journal: Re: Reply from the Authors agid{at}ccr.jussieu.fr Yves Agid, et al.	We thank Drs. Jabre and Bejjani for their letter describing psychosocial aspects among their patients with Parkinson disease and subthalamic stimulation. Their observation that social adjustment is mostly unproblematic in their patients is interesting. Differences in outcome cannot be explained by different methods of electrode implantation because targeting and surgical technique is the same in Byblos as in our center. [2] In addition, the motor improvement is excellent in both patient groups. Four possible explanations for the discrepancies between their experience and the results from our study can be considered. [1] First, the accessibility of psychological support with a 24/7-hotline may contribute to better psychosocial outcome in Lebanese patients. While we do provide qualified psychological support, it is not possible to have the same accessibility and constancy of staff as their center because our patient load (250 patients since 1996) is heavier. Second, the difficulties in psychosocial adjustment in our cohort became apparent only in a prospective trial with in-depth interviews with patients and their caregivers. We believe that some conflicts may not be revealed to the physicians without specific exploration. Third, the social security system has an impact on the efforts of patients to pursue a professional activity. There are important differences between the French and Lebanese society that may explain some of the differences in outcome. Fourth, the decisive factor for social adjustment is most likely the structure of the society in which the patient lives that define a person’s role in the family, at work and in society according to gender, age and profession. For example, whereas divorce is very common in Western societies, it is still taboo in others. Divorce and failure to resume work after STN surgery does not necessarily equal worse psychosocial function. It may enhance quality of life, as observed in some of our patients. In conclusion, as illustrated by these different results from two centers with similar treatment approaches, the structure and values of a society are pivotal for the psychosocial health of a given population. To enhance the psycho- social health is a task that goes far beyond medical care. Reference 2. Bejjani BP, Dormont D, Pidoux B, et al. Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg. 2000;92:615-625. The article to which this Correspondence refers was supported by grants from the Swiss National Science Foundation and the Swiss PD Association (M.S.). Disclosure: The authors report no conflicts of interest.