Psychosurgery Evolves Into New Neurosurgery Approaches

More than 50 years after indiscriminate use of prefrontal lobotomy gave psychosurgery a bad name, some psychiatrists are cautiously experimenting in carefully designed research protocols with neurosurgical procedures for severe and refractory psychiatric disorders.

The procedures—which include cingulotomy, capsulotomy, and deep brain stimulation—are under investigation for psychiatric disorders in only a few centers around the world. They undergo extensive scrutiny by institutional review boards in the United States, as well as additional review of prospective patients by independent committees.

Their most promising uses may be in patients with extremely severe and refractory cases of obsessive-compulsive disorder (OCD). The procedures today are guided by magnetic resonance imaging (MRI).

One psychiatrist involved with studying the procedures acknowledged the caution with which researchers approach the subject—and public comments about the research—in part because of the disastrous experience with frontal lobotomies performed on thousands of patients in the 1940s and 1950s.

Benjamin D. Greenberg, M.D., said that even the term “psychosurgery” is eschewed today in favor of “neurosurgery for psychiatric disorders.”

“There is a history associated with the term ‘psychosurgery,’ and it is not a good one,” said Greenberg, an associate professor in the department of psychiatry and human behavior at Brown University School of Medicine and director of outpatient services at Butler Hospital in Providence, R.I.

But Greenberg and medical ethicist Joseph Finns, M.D., both told Psychiatric News that dramatic changes since the early days of psychosurgery—in technological acumen, knowledge and understanding of brain circuitry, regulatory strictures, and appreciation of the importance of informed consent and other ethical considerations—make the current environment vastly different and more conducive to safe investigation.

“It is important to distinguish the past from the present and the differences in the science and the regulatory environment today,” Finns told Psychiatric News. Finns is chief of the division of medical ethics at Weill Medical College of Cornell University and an associate professor of public health and associate professor of medicine in psychiatry.

“One of the major differences is that we now have an ethics and research infrastructure,” said Finns. As early as 1941, Walter Freeman, M.D., was criticized by psychiatrist colleagues for indiscriminate use of lobotomy. “But there was no regulatory context to control his activities,” he noted.

“On a purely scientific basis, the imaging technique using MRI today is so different today from what Freeman did blindly,” Finns said. “Now it’s a more precise surgery undergirded by knowledge of the physiology of brain structure.”

Deep Brain Stimulation

Greenberg and colleagues at Butler Hospital have focused on experimentation with deep brain stimulation—a nonablative technique in which a brain “lead,” or wire 1.27 mm in diameter, is implanted stereotactically with MRI guidance into specific brain targets. The leads, which have four platinum-iridium electrode contacts, are connected via an extension wire to pulse generators—sometimes called “brain pacemakers”—typically placed in the chest.

Greenberg noted that the procedure is already FDA approved for Parkinson’s disease and severe tremor and thus has the advantage of being familiar to neurosurgeons. A collaborative group at Butler Hospital/Brown University, the Cleveland Clinic in Cleveland, Ohio, and the University of Florida, Gainesville, is testing the therapeutic effectiveness and safety of deep brain stimulation in patients with intractable OCD. The group also includes researchers at the University of Leuven in Belgium.

Results so far are preliminary and are not ready for publication.

Greenberg emphasized that patients chosen for the procedure have extraordinarily severe and intractable cases of OCD. “These are extremely disabled patients,” he said. “Their compulsive rituals consume virtually their entire waking lives, and they have not responded to sustained treatment efforts with behavior therapy and medication. We definitely think there is a clinical need to investigate these procedures systematically.”

He underscored the caution with which the procedure—and others like it—are being investigated. “We don’t think it’s ready for widespread use at the current state of knowledge,” Greenberg said. “We are particularly worried that there is a potential for that to happen outside of rigorously conducted research protocols, and we continue to educate our surgical colleagues about the need to view treatments as investigational.”

In the review article “Mechanisms and the Current State of Deep Brain Stimulation in Neuropsychiatry” in the July 2003 CNS Spectrums, Greenberg and co-author Ali R. Rezai, M.D., outlined ethical issues and recommendations.

“Patients must meet operational criteria for the primary neuropsychiatric disorder under study and for the severity of that illness,” they wrote. “It is just as important to assure that all proven medication and behavioral therapies have been given adequate trials and exhausted. We propose that the case of patients who are potential candidates for deep brain stimulation also undergo a second level of consideration by an interdisciplinary review committee with appropriate expertise, including a bioethics perspective that is independent form the investigative team.”

Point-Counterpoint

Despite the controversy that has surrounded psychosurgery, many psychiatrists today appear willing to consider psychiatric neurosurgery for selected patients.

A paper in the spring 1999 Journal of Clinical Neuroscience reported the results of a random sample of APA members showing that 83 percent knew about the existence of neurosurgical treatment for intractable OCD. Seventy-four percent of psychiatrists in the same survey indicated that they would consider referring appropriate patients.

Greenberg reports his own anecdotal evidence showing a high degree of awareness of neurosurgery for intractable OCD. At a 2002 psychopharmacology review course, 85 percent of an audience of 124 psychiatrists responded that they knew of psychiatric neurosurgery for OCD. And, in this unscientific sample, the majority (68 percent) indicated they would consider referring patients with intractable illness.

Greenberg reported these anecdotal findings in “Neurosurgery for Intractable Obsessive-Compulsive Disorder and Depression: Critical Issues” in the April 2003 Neurosurgery Clinics of North America.

Still, neurosurgery for psychiatric disorders is bound to remain controversial.

In a point-counterpoint article addressing the question, “Should neurosurgery for mental disorder be allowed to die out?,” Raj Persaud, M.D., a consulting psychiatrist at Maudsley Hospital in London, argued for why the question should be answered in the affirmative. The article appeared in the September 2003 British Journal of Psychiatry.

“[P]sychosurgery is based on a flawed and impoverished vision of the relationship between brain tissue and psychological disorder,” Persaud wrote. “It is unlikely that any psychiatric problem can be located in one so-called ‘abnormal’ brain region. The notion of abnormality remains deeply problematic given the huge overlap between psychiatric and normal populations in all contemporary measurements of brain structure and functioning.”

Greenberg responded, however, that the issue is really one of safety and clinical efficacy, not mechanisms of action. “All treatments in psychiatry, including medication and psychotherapy, are in fact empirical and were not developed from an understanding of mechanisms of disease,” he said. “The other thing to consider is the very real risk of having no treatments to offer people who have extreme levels of suffering and are at high risk of suicide.”

Finns agreed. “It is critical to realize that chronic mental illness is as malignant as any malignant disease. These are devastating illnesses for patients and their families, and we have an obligation to protect them and to investigate procedures that might ultimately help them.”

“Mechanisms and the Current State of Deep Brain Stimulation in Neuropsychiatry” is posted online at www.cnsspectrums.com/pdf/art_359.pdf. “Neurosurgery for Intractable Obsessive-Compulsive Disorder and Depression: Critical Issues” is posted at www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12856488&dopt. ▪