Psychosurgery Evolves Into New Neurosurgery Approaches

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.”

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.”