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Surgery for Psychiatric Disorders Neurosurg Clin N Am 14 (2003) xiii–xiv Preface Surgery for psychiatric disorders Ali R. Rezai, MD Steven A. Rasmussen, MD Benjamin D. Greenberg, MD, PhD Guest Editors Surgery for psychiatric disorders has intrigued negative effects on marital, parental, social, voca- the psychiatric, neurological, and neurosurgical tional, and other life functions. communities as well as the lay public for the past Advances in the efficacy, safety, and tolerabi- 70 years. Few other therapies have generated such lity of treatments for OCD and depression have controversy, enthusiasm, misconception, and, at been made in the past 20 years. However, a signif- times, indiscriminate use. Recent advances in image icant number of patients with OCD and major guidance, devices, and stereotactic procedures, as depression refractory to nonsurgical treatments well as rapid expansion of our knowledge of the remain severely ill. These individuals, who are liv- functional neuroanatomy of the major psychiatric ing lives of hopeless desperation, may ultimately disorders has led to renewed interest in neurosurgi- face the tragic end of suicide. The hope that sur- cal approaches to these conditions. This issue of gery can offer relief to these patients from agony the Neurosurgery Clinics of North America was and suffering is the fundamental imperative that envisioned with the purpose of compiling the demands ongoing research in this area. perspectives of experts on the cutting edge of It is clear that psychiatric neurosurgery research in the neurosurgical treatment of psychi- will undergo a rapid evolution over the next atric disorders. decade. Today, dedicated multidisciplinary teams Currently, the two most common psychiatric specializing in treating psychiatric patients have disorders amenable to surgical intervention are at their disposal the entire spectrum of modern obsessive-compulsive disorder (OCD) and major functional neurosurgical techniques, including depression. OCD affects 4 to 7 million people in lesioning, radiosurgery, and neurostimulation. the United States at an annual cost of $8 billion Advances in our understanding of the functional per year and was among the 10 leading medical neuroanatomy and electrophysiology of the rele- or psychiatric causes of disability in developed vant circuitry underlying these conditions will countries (1998 World Health Organization increasingly guide placement of lesions or deep study). Conservative estimates of the lifetime brain stimulation (DBS) electrodes. To promote prevalence of major depression are from 2.6% further growth in this field, centers with psychi- to 5.5% in men and 6.0% to 11.8% in women. atric and surgical expertise must design studies Approximately 50% to 85% of patients with major that are prospective and randomized, using reli- depression experience recurrent episodes of illness. able and validated diagnostic and evaluation tools In addition to subjective distress, the disorder can that measure changes in symptoms and quality of be a cause of profound disability, with pervasively life. 1042-3680/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1042-3680(03)00004-4 xiv A.R. Rezai et al / Neurosurg Clin N Am 14 (2003) xiii–xiv To critically examine neurosurgery for psychia- Given the past history of the field, it is particu- tric disorders, we must start by carefully examining larly important that research in this area move the past. Kopell et al provide a historical perspec- forward on a solid scientific and ethical founda- tive that reminds us of the complexities of psycho- tion. Collaborative efforts between centers with surgery and an enduring caution for the future. dedicated multidisciplinary teams of psychiatrists, These historical endeavors were limited by a lack neurosurgeons, and basic scientists are needed to of scientific rationale and other limitations such develop treatments with proven efficacy and safety as surgical techniques and devices, vague patient before the premature introduction of these proce- selection, indiscriminate use, and nonstandardized dures into routine clinical use. In this context, we evaluations. In spite of the decline of surgery for have included an editorial reprinted from a recent psychiatric disorders since the 1950s, early studies publication of the OCD-DBS collaborative group of stereotactic lesioning demonstrated significant in neurosurgery that focuses on recommendations improvements in symptoms of patients with major for future research efforts in this area. Finally, any depression and OCD with few cognitive or neuro- publication focusing on surgery for psychiatric logical side effects. Current stereotactic methods, disorders must include a thoughtful discussion using considerably smaller and more precisely of the ethical implications of these procedures. located targets, have much lower morbidity. Neu- Fins et al offer a careful and considered review roimaging research has focused attention on the of the ethical issues in this field, including issues relationship between activity in specific neuroana- of informed consent. tomical networks and psychiatric symptoms and Together, these articles provide a comprehen- on changes after effective treatment. The articles sive overview of the current state of surgery for by Rauch and Greenberg et al provide an overview psychiatric disorders and the complex issues sur- of the scientific foundation and the emerging thera- rounding the re-emergence of this field. They peutic strategies being explored today. represent a window into what promises to be The articles by Greenberg, Cosgrove, and an exciting future for the development of novel Chang et al consider the evidence for the safety neurosurgical approaches to psychiatric disorders and efficacy of lesioning procedures. The evidence that are based on the neurobiologic basis of these has definite limitations but nevertheless sheds light conditions. on critical issues in assessing the long-term effec- tiveness and morbidity associated with anterior Ali R. Rezai, MD cingulotomy, anterior capsulotomy, subcaudate Section of Stereotactic and tractotomy, and limbic leucotomy. Jeanmonod Functional Neurosurgery et al describe a novel lesioning approach to neuro- Department of Neurosurgery psychiatric disorders based on recent evidence The Cleveland Clinic Foundation related to thalamocortical dysrhythmias that their Cleveland, OH, USA group have shown are present in these conditions. Nuttin et al present recent data on the use of DBS Steven A. Rasmussen, MD technology for the treatment of OCD. Butler Hospital Two additional novel somatic treatments for Brown University refractory depression have also been the subject Providence, RI, USA of systematic study over the past decade. George et al review the neurobiologic rationale and sum- Benjamin D.Greenberg, MD, PhD marize treatment outcome data for transcranial Department of Psychiatry and Human Behavior magnetic stimulation, while Carpenter et al review Brown University similar evidence for vagal nerve stimulation. Providence, RI, USA Neurosurg Clin N Am 14 (2003) xv–xvi Letter to the editor Deep brain stimulation for psychiatric disorders There is increasing interest in the use of deep have ongoing oversight of the project should brain stimulation (DBS) as a treatment for pa- approve the investigational protocol. tients with psychiatric conditions. For example, 2. A patient assessment committee should eval- the preliminary results from the first trials, uate each patient as a possible candidate for reported by Nuttin et al [1], have shown that inclusion in the protocol. The role of this DBS may have beneficial effects in patients with committee is to ensure that potential candi- severe obsessive-compulsive disorder (OCD) that dates meet certain medical and psychiatric is refractory to treatment. These preliminary re- criteria and are appropriate for inclusion in sults suggest that DBS may have a role in the the study and to monitor the adequacy of the treatment of patients with intractable OCD. consent process. Patient assessment commit- Treatment of psychiatric patients with DBS re- tees should be constituted broadly to achieve mains investigational, however, and is not con- an ethically valid consensus, and they should sidered standard therapy. have the opportunity to obtain independent Concern regarding the use of neurosurgery for capacity assessments when indicated. the treatment of patients with psychiatric illnesses 3. Candidates for DBS surgery should meet is attributable largely to the indiscriminate and defined criteria for severity, chronicity, dis- widespread application of extensive, destructive ability, and treatment refractoriness. procedures before the stereotactic era. The tragic 4. The use of DBS should be limited solely to example of frontal lobotomy, which was per- those patients with decision-making capacity formed many times before adequate long-term who are able to provide their own informed safety data were available, remains an enduring consent. Patient consent should be main- caution. tained and monitored throughout the process, Given this history, it is incumbent on the sci- and patients should be free to halt their entific community to respect the dignity of pa- participation voluntarily. tients who may be included in studies by ensuring 5. Patient selection, surgical treatment, device adequate protection while providing access to programming, and comprehensive, regular potential therapeutic innovations. We recommend psychiatric follow-up should be conducted at that all investigators
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