Saturday, August 07, 2010

Psychosurgery is alive and well

There are many misconceptions circulating about leucotomy. It is widely believed that the intervention was completely abandoned. This is very far from reality. Indeed the development of drugs for the treatment of psychiatric disorders gave new horizons to the field. However, even the most successful of drugs had side effects ranging from barely tolerable to nearly lethal (Ivan Oransky, in Out of Mind, Schizophrenia, The Scientist, December 2007 supplement).

Different groups pursued psychosurgery with improved techniques. The following paper from the seventies describes good results with another approach:
Postgraduate Med. J. 1973, December, 49 (578) 865-882
Stereotactic limbic leucotomy—a follow-up study of thirty patients
Desmond Kelly and Nita Mitchell-Heggs
This prospective study reports the results of stereotactic limbic leucotomy at a mean of 17 months following surgery. Clinical improvement had occurred in twenty-four (80%) of the patients, fifteen (50%) of them being symptom free or much improved. Fourteen of sixteen patients suffering from obsessional neurosis were improved, as were five of seven with chronic anxiety and the degree of improvement at 17 months was superior to that at 6 weeks. Psychometric scores of anxiety, obsessions and neuroticism were all significantly reduced at 17 months. The mean depression scores were also significantly reduced and this result was superior to that reported in a previous study of ‘free-hand’ operations.
Adverse effects were not a problem following limbic leucotomy. Emotional blunting, disinhibition, post-operative epilepsy and excessive weight gain were not encountered, and intelligence was unaffected by the operation. Limbic leucotomy is a much more limited and precise procedure than older ‘free-hand’ operations which we have studied, but its therapeutic effects are comparable and in obsessional neurosis, superior.

Surgeons in Great Britain at the Wales University Hospital in Cardiff can target with an electrode introduced through a hole in the anterior side of the skull, areas of the brain the size of a pea. They perform the operation on carefully selected patients, with good results. They have conducted 56 operations during the last decade. Neurosurgeons at Ninewells Hospital in Dundee also have performed psychosurgery in 34 patients between 1990 and 2001. Moreover, Ballantine and his colleagues in Boston practice an operation called cingulotomy, a derivative of leucotomy, for depression and severe pain. It targets a tiny region of the cingulum and destroys it. The cingulum is a bundle of nerve fibers that runs from the back to the front of the brain, straddling the two cerebral hemispheres.

In November 2009 the New York Times reported that the Food and Drug Administration approved one of the psychosurgical techniques for some cases of obsessive-compulsive disorders. The paper also revealed that during the last decade more than 500 people have undergone brain surgery for problems like depression, phobias, anxiety, Tourette syndrome and obesity.
In the same article one can read the following comment: "The great promise of neuroscience at the end of the last century was that it would revolutionize the treatment of psychiatric problems. But the first real application of advanced brain science is not novel at all. It is a precise, sophisticated version of an old and controversial approach: psychosurgery, in which doctors operate directly on the brain. Such surgery offers both hope and risk".
The article mentions that the psychiatrist Dr. Benjamin Greenberg in charge of the psychosurgery program at Butler Hospital considers that in the future millions suffering from severe psychiatric conditions could benefit from brain surgery.

Egas Moniz made a prescient statement at the end of his last lecture when he retired from the Medical Faculty in 1944. He claimed that Neurology was at the dawn of a new era where surgery of the brain would be increasingly used to solve psychiatric problems. He cited the great Russian neurologist, Bechterew, who surprisingly had made the same claim in 1897.