IMPORTANCE Select cases of intractable obsessive-compulsive disorder (OCD) have undergone neurosurgical ablation for more than half a century. However, to our knowledge, there have been no randomized clinical trials of such procedures for the treatment of any psychiatric disorder.OBJECTIVE To determine the efficacy and safety of a radiosurgery (gamma ventral capsulotomy [GVC]) for intractable OCD. DESIGN, SETTING, AND PARTICIPANTSIn a double-blind, placebo-controlled, randomized clinical trial, 16 patients with intractable OCD were randomized to active (n = 8) or sham (n = 8) GVC. Blinding was maintained for 12 months. After unblinding, sham-group patients were offered active GVC.INTERVENTIONS Patients randomized to active GVC had 2 distinct isocenters on each side irradiated at the ventral border of the anterior limb of the internal capsule. The patients randomized to sham GVC received simulated radiosurgery using the same equipment. MAIN OUTCOMES AND MEASURESScores on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Clinical Global Impression-Improvement (CGI-I) Scale at 1 year. Response was defined as a 35% or greater reduction in Y-BOCS severity and "improved" or "much improved" CGI-I ratings.RESULTS Two of 8 patients randomized to active treatment responded at 12 months, and none of the 8 sham-GVC group patients responded (the absolute difference was not statistically significant: 0.25; 95% CI, Ϫ0.05 to 0.55; P = .11). At 12 months, median Y-BOCS scores were 23.5 in the active group vs 31 in the sham patients (P = .01). The median Y-BOCS scores decreased 28.6% in the active treatment group and 5.8% in the sham group (P = .04988). The median CGI-I scores were 3 and 4 in the active and sham treatment groups, respectively. At 54 months, 3 additional patients in the active group had become responders. Of the 4 sham-GVC patients who later received active GVC, 2 responded by post-GVC month 12. The most serious adverse event was an asymptomatic radiation-induced cyst in 1 patient. CONCLUSIONS AND RELEVANCEIn this preliminary trial, patients with intractable OCD who underwent GVC may have benefitted more than those who underwent sham surgery although the difference did not reach statistical significance. Additional research is necessary to determine if GVC is better than deep-brain stimulation.TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01004302

Major depressive disorder (MDD) and cardiovascular diseases are intimately associated. Depression is an independent risk factor for mortality in cardiovascular samples. Neuroendocrine dysfunctions in MDD are related to an overactive hypothalamus-pituitary-adrenal (HPA) axis and increased sympathetic activity. Novel intervention strategies for MDD include the non-invasive brain stimulation (NIBS) techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). In fact, although these techniques have being increasingly used as a treatment for MDD, their cardiovascular effects were not sufficiently investigated, which would be important considering the dyad MDD/cardiovascular disorders. We investigated this issue through a systematic review for published articles from the first date available to May 2012 in MEDLINE and other databases, looking for main risk factors and surrogate markers for cardiovascular disease such as: cortisol, heart rate variability (HRV), alcohol, smoking, obesity, hypertension, glucose. We identified 37 articles (981 subjects) according to our eligibility criteria. Our main findings were that NIBS techniques might be effective strategies for down-regulating HPA activity and regulating food, alcohol, and cigarette consumption. NIBS’s effects on HRV and blood pressure presented mixed findings, with studies suggesting that HRV values can decrease or remain unchanged after NIBS, while one study found that rTMS increased blood pressure levels. Also, a single study showed that glucose levels decrease after tDCS. However, most studies tested the acute effects after one single session of rTMS/tDCS; therefore further studies are necessary to investigate whether NIBS modifies cardiovascular risk factors in the long-term. In fact, considering the burden of cardiac disease, further trials in cardiovascular, depressed, and non-depressed samples using NIBS should be performed.

BackgroundMotivation is a crucial and widespread theme within medicine. From clinical to surgical scenarios, acquiescence in taking a pill or coming to a consultation is imperative for medical treatment to thrive. The “decade of the brain” gave practitioners substantial neuroscientific data on human behavior, helped to explain why people do what they do and created the concept of “motivated brain”. Findings from empirical psychology stratified motivation into stages of change, which became more complex over the decades. This research seeks to improve the understanding of how people make decisions about their health, and how to better understand strategies and techniques to help them resolve ambivalence in an effective goal-oriented way.MethodsWe establish a dialogue with Ricoeur’s phenomenology of the will in order to understand the meaning of these scientific findings. Starting from Husserlian phenomenology, Paul Ricoeur developed his thoughts away from transcendental idealism, through emancipating the intentional structures of the will from the realm of perception.ResultsThrough introducing the concepts of the voluntary and the involuntary, Ricoeur deviated from Cartesian dualism, which renders the body as an object body, a target of natural vicissitudes. The new dualism of the voluntary and the involuntary is dealt with by reference to what Ricoeur called the central mystery of incarnate existence, which considers man “double in humanity, simple in vitality”. This duality makes it possible to consider the brain to be the natural organ of behavior in the human body, and to use empirical psychology as a path to escape from shallow subjectivations of concepts.ConclusionsPaul Ricoeur’s simplicity (or unity) of existence provides an invitation for medicine to rethink some of its philosophical assumptions, such that patients can be considered to be autonomous subjects with authorial life projects. Ricoeurian anthropology has a deep ethical impact on how medicine should use technology, which arises from empirical psychology findings. The usage of this new knowledge also needs to be thoroughly inspected, since it shifts the social role of medical science.