Psychiatric Neurosurgery 2009: Review and Perspective

Abstract

In the treatment of psychiatric disorders, modern lesion procedures and nonablative deep brain stimulation (DBS) offer a degree of hope for patients who remain severely ill and impaired despite pharmacological and behavioral treatments. The available data support the therapeutic promise of these procedures, primarily for those suffering with obsessive-compulsive disorder (OCD) or major depressive disorder (MDD). However, the use of neurosurgical treatments for psychiatric disorders must be approached with both caution and a commitment to long-term care. The data also show that psychiatric neurosurgical procedures can be implemented most successfully by dedicated interdisciplinary teams in the context of a multimodal treatment plan. Treatment using these procedures is further complicated by issues involving the criteria for patient selection, the long-term management of patients receiving psychiatric neurosurgery, and the different patterns of potential clinical benefits and burdens presented by DBS and contemporary lesion procedures.

Localization of Dysfunction in Major Depressive Disorder: Prefrontal Cortex and Amygdala

“…As Figure 4B shows, however, they do so in opposite directions. Rudebeck and Murray (91) compared performance one trial after an error (called trial E+1), one trial after an error-correct sequence (EC+1), one trial after an error-correct-correct sequence [EC(2)+1], and so forth. This analysis shows that PFo lesions cause an inefficiency in using positive feedback (blue asterisks in Fig.…”

“…Even when successful, no one knows quite why. Examples of neurosurgical treatments for MDD include lesions in several structures: the frontal cortex beneath the genu of the corpus callosum, fiber tracts ventral to the caudate nucleus, the anterior part of the internal capsule, the prelimbic white matter, and the anterior cingulate cortex (1, 2). Localized deep brain stimulation has targeted the subgenual medial frontal cortex and the internal capsule (3–5).…”

Strategies for the return of behavioral surgery

“…BS is complicated by issues involving patient categorization and selection criteria, the long-term management of these patients, and the different patterns of potential benefits and burdens. [22] The Canadian Network for Mood and Anxiety Treatments (CANMAT) reviewed the role of neurostimulation including ECT, repetitive transcranial magnetic stimulation (rTMS), VNS, and DBS in MDD, and concluded that while there was good evidence for ECT as first-line treatment, some evidence for rTMS as second-line treatment, the evidence for VNS was less robust, and DBS remained experimental therapy. [15] Therefore, there is a need for stringent ethical, governance, and regulatory frameworks to be put in place in each legal jurisdiction in the world to prevent potential misuse of BS.…”

Current and future indications for deep brain stimulation in pediatric populations

“…The OCD experience with DBS has been thoroughly reviewed elsewhere. 16,42 Importantly, the use of DBS for refractory OCD has been subjected to a double-blind randomized study, whose positive result indicates that the technology is indeed an effective form of last-resort treatment. 35 Such studies satisfy important criteria for the application of this technology to pediatric populations, where the threshold for surgical intervention is typically higher.…”