In an episode of ABC’s Four Corners this week, the use of spinal cord stimulators for chronic back pain was brought into question.

Spinal cord stimulators are devices implanted surgically which deliver electric impulses directly to the spinal cord. They’ve been used to treat people with chronic pain since the 1960s.

Their design has changed significantly over time. Early models required an external generator and invasive surgery to implant them. Current devices are fully implantable, rechargeable and can deliver a variety of electrical signals.

However, despite their long history, rigorous experimental research to test the effectiveness of spinal cord stimulators has only been conducted this century. The findings don’t support their use for treating chronic pain. In fact, data points to a significant risk of harm.

What does the evidence say?

One of the first studies used to support the effectiveness of spinal cord stimulators was published in 2005. This study looked at patients who didn’t get relief from initial spinal surgery and compared implantation of a spinal cord stimulator to a repeat of the spinal surgery.

Although it found spinal cord stimulation was the more effective intervention for chronic back pain, the fact this study compared the device to something that had already failed once is an obvious limitation.

Later studies provided more useful evidence. They compared spinal cord stimulation to non-surgical treatments or placebo devices (for example, deactivated spinal cord stimulators).

A 2023 Cochrane review of the published comparative studies found nearly all studies were restricted to short-term outcomes (weeks). And while some studies appeared to show better pain relief with active spinal cord stimulation, the benefits were small, and the evidence was uncertain.

Only one high-quality study compared spinal cord stimulation to placebo up to six months, and it showed no benefit. The review concluded the data doesn’t support the use of spinal cord stimulation for people with back pain.

What about the harms?

The experimental studies often had small numbers of participants, making any estimate of the harms of spinal cord stimulation difficult. So we need to look to other sources.

A review of adverse events reported to Australia’s Therapeutic Goods Administration found the harms can be serious. Of the 520 events reported between 2012 and 2019, 79% were considered “severe” and 13% were “life threatening”.

We don’t know exactly how many spinal cord stimulators were implanted during this period, however this surgery is done reasonably widely in Australia, particularly in the private and workers compensation sectors. In 2023, health insurance data showed more than 1,300 spinal cord stimulator procedures were carried out around the country.

In the review, around half the reported harms were due to a malfunction of the device itself (for example, fracture of the electrical lead, or the lead moved to the wrong spot in the body). The other half involved declines in people’s health such as unexplained increased pain, infection, and tears in the lining around the spinal cord.

More than 80% of the harms required at least one surgery to correct the problem. The same study reported four out of every ten spinal cord stimulators implanted were being removed.

High costs

The cost here is considerable, with the devices alone costing tens of thousands of dollars. Adding associated hospital and medical costs, the total cost for a single procedure averages more than $A50,000. With many patients undergoing multiple repeat procedures, it’s not unusual for costs to be measured in hundreds of thousands of dollars.

Rebates from Medicare, private health funds and other insurance schemes may go towards this total, along with out-of-pocket contributions.

Insurers are uncertain of the effectiveness of spinal cord stimulators, but because their implantation is listed on the Medicare Benefits Schedule and the devices are approved for reimbursement by the government, insurers are forced to fund their use.

Industry influence

If the evidence suggests no sustained benefit over placebo, the harms are significant and the cost is high, why are spinal cord stimulators being used so commonly in Australia? In New Zealand, for example, the devices are rarely used.

Doctors who implant spinal cord stimulators in Australia are well remunerated and funding arrangements are different in New Zealand. But the main reason behind the lack of use in New Zealand is because pain specialists there are not convinced of their effectiveness.

In Australia and elsewhere, the use of spinal cord stimulators is heavily promoted by the pain specialists who implant them, and the device manufacturers, often in unison. The tactics used by the spinal cord stimulator device industry to protect profits have been compared to tactics used by the tobacco industry.

A 2023 paper describes these tactics which include flooding the scientific literature with industry-funded research, undermining unfavourable independent research, and attacking the credibility of those who raise concerns about the devices.

It’s not all bad news

Many who suffer from chronic pain may feel disillusioned after watching the Four Corners report. But it’s not all bad news. Australia happens to be home to some of the world’s top back pain researchers who are working on safe, effective therapies.

New approaches such as sensorimotor retraining, which includes reassurance and encouragement to increase patients’ activity levels, cognitive functional therapy, which targets unhelpful pain-related thinking and behaviour, and old approaches such as exercise, have recently shown benefits in robust clinical research.

If we were to remove funding for expensive, harmful and ineffective treatments, more funding could be directed towards effective ones.

Ian Harris, Professor of Orthopaedic Surgery, UNSW Sydney; Adrian C Traeger, Research Fellow, Institute for Musculoskeletal Health, University of Sydney, and Caitlin Jones, Postdoctoral Research Associate in Musculoskeletal Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

According to the World Health Organization, about 280 million people worldwide have depression and about one billion have a mental health problem of any kind.

People living in the ancient world also had mental health problems. So, how did they deal with them?

As we’ll see, some of their insights about mental health are still relevant today, even though we might question some of their methods.

1. Our mental state is important

Mental health problems such as depression were familiar to people in the ancient world. Homer, the poet famous for the Iliad and Odyssey who lived around the eighth century BC, apparently died after wasting away from depression.

Already in the late fifth century BC, ancient Greek doctors recognised that our health partly depends on the state of our thoughts.

In the Epidemics, a medical text written in around 400BC, an anonymous doctor wrote that our habits about our thinking (as well as our lifestyle, clothing and housing, physical activity and sex) are the main determinants of our health.

2. Mental health problems can make us ill

Also writing in the Epidemics, an anonymous doctor described one of his patients, Parmeniscus, whose mental state became so bad he grew delirious, and eventually could not speak. He stayed in bed for 14 days before he was cured. We’re not told how.

Later, the famous doctor Galen of Pergamum (129-216AD) observed that people often become sick because of a bad mental state:

It may be that under certain circumstances ‘thinking’ is one of the causes that bring about health or disease because people who get angry about everything and become confused, distressed and frightened for the slightest reason often fall ill for this reason and have a hard time getting over these illnesses.

Galen also described some of his patients who suffered with their mental health, including some who became seriously ill and died. One man had lost money:

He developed a fever that stayed with him for a long time. In his sleep he scolded himself for his loss, regretted it and was agitated until he woke up. While he was awake he continued to waste away from grief. He then became delirious and developed brain fever. He finally fell into a delirium that was obvious from what he said, and he remained in this state until he died.

3. Mental illness can be prevented and treated

In the ancient world, people had many different ways to prevent or treat mental illness.

The philosopher Aristippus, who lived in the fifth century BC, used to advise people to focus on the present to avoid mental disturbance:

concentrate one’s mind on the day, and indeed on that part of the day in which one is acting or thinking. Only the present belongs to us, not the past nor what is anticipated. The former has ceased to exist, and it is uncertain if the latter will exist.

The philosopher Clinias, who lived in the fourth century BC, said that whenever he realised he was becoming angry, he would go and play music on his lyre to calm himself.

Doctors had their own approaches to dealing with mental health problems. Many recommended patients change their lifestyles to adjust their mental states. They advised people to take up a new regime of exercise, adopt a different diet, go travelling by sea, listen to the lectures of philosophers, play games (such as draughts/checkers), and do mental exercises equivalent to the modern crossword or sudoku.

For instance, the physician Caelius Aurelianus (fifth century AD) thought patients suffering from insanity could benefit from a varied diet including fruit and mild wine.

Doctors also advised people to take plant-based medications. For example, the herb hellebore was given to people suffering from paranoia. However, ancient doctors recognised that hellebore could be dangerous as it sometimes induced toxic spasms, killing patients.

Other doctors, such as Galen, had a slightly different view. He believed mental problems were caused by some idea that had taken hold of the mind. He believed mental problems could be cured if this idea was removed from the mind and wrote:

a person whose illness is caused by thinking is only cured by taking care of the false idea that has taken over his mind, not by foods, drinks, [clothing, housing], baths, walking and other such (measures).

Galen thought it was best to deflect his patients’ thoughts away from these false ideas by putting new ideas and emotions in their minds:

I put fear of losing money, political intrigue, drinking poison or other such things in the hearts of others to deflect their thoughts to these things […] In others one should arouse indignation about an injustice, love of rivalry, and the desire to beat others depending on each person’s interest.

4. Addressing mental health needs effort

Generally speaking, the ancients believed keeping our mental state healthy required effort. If we were anxious or angry or despondent, then we needed to do something that brought us the opposite of those emotions.

This can be achieved, they thought, by doing some activity that directly countered the emotions we are experiencing.

For example, Caelius Aurelianus said people suffering from depression should do activities that caused them to laugh and be happy, such as going to see a comedy at the theatre.

However, the ancients did not believe any single activity was enough to make our mental state become healthy. The important thing was to make a wholesale change to one’s way of living and thinking.

When it comes to experiencing mental health problems, we clearly have a lot in common with our ancient ancestors. Much of what they said seems as relevant now as it did 2,000 years ago, even if we use different methods and medicines today.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.

Konstantine Panegyres, McKenzie Postdoctoral Fellow, researching Greco-Roman antiquity, The University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.