Monday, November 30, 2009

“Psychosurgery”: Promise, Perils, and Patients’ Protection

Psychosurgery. For some, the word connotes all the promising therapeutic applications of modern neuroscience; for others, it connotes all the baneful excesses of unregulated pseudoscience. In his recent front page story for the New York Times (Nov. 27), Benedict Carey presented a balanced and nuanced view of what is sometimes termed “psychiatric neurosurgery,” focusing mainly on cingulotomy, capsulotomy, and other neurosurgical approaches to refractory obsessive-compulsive disorder (OCD).

For one of the patients interviewed by Carey, neurosurgery to treat her intractable OCD was clearly very helpful; yet for other patients, neurosurgery for their OCD had adverse behavioral effects despite some improvement in their obsessive-compulsive symptoms. Thus, in one Swedish study by Ruck and colleagues, only 3 of 25 patients with OCD undergoing capsulotomy were in remission without adverse effects at long-term follow-up. Ten patients “were considered to have significant problems with executive functioning, apathy, or disinhibition” after their procedures.

Psychiatric Times has discussed both the medical and ethical issues surrounding psychosurgery, pointing out both the need for better understanding of the underlying brain circuits targeted by psychosurgery and the imperative of safe-guarding the rights of potential candidates for psychosurgery. One conundrum noted by Dr. Christian Ruck, and cited in the Times article, is that “innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid.” This is not to impugn the humanitarian motives that underlie most instances of psychosurgery; it is merely to say that institutions that perform psychosurgery may have a vested interest in seeing and presenting their outcome data in the best possible light.

In addition to the need for very strong informed consent procedures and intra-institutional review boards, there is also a case to be made for outside, independent review of an institution’s psychosurgery program. Indeed, in the U.N. General Assembly’s statement on the protection of persons with mental illness, we find the following injunction:

“Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility and, to the extent that domestic law permits them to be carried out, they may be carried out on any other patient only where the patient has given informed consent and an independent external body has satisfied itself that there is genuine informed consent and that the treatment best serves the health needs of the patient."

Given the rarity of psychiatric neurosurgery—the Times noted that about 500 such procedures have been carried out in the United States over the past decade—review of each case by an independent neuropsychiatric expert outside the “provider” institution seems feasible. There is no doubt that for some suffering patients who have not responded to standard treatment, psychosurgery may be the only viable option. But as Alan Stone, MD concluded in his article for Psychiatric Times, "Given the historical burden of the old psychosurgery, the new neurosurgeons have a special obligation to proceed with utmost scientific caution."

Ronald Pies, MD

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