Psychiatry 2008 - September 2008 - (Page 25)

[REVIEW] FUNCTIONAL NEUROSURGERY IN THE TREATMENT OF SEVERE OBSESSIVE COMPULSIVE DISORDER AND MAJOR DEPRESSION: Overview of Disease Circuits and Therapeutic Targeting for the Clinician by DHWANI B. SHAH, MD; ANGELIKI PESIRIDOU, MD; GORDON H. BALTUCH, MD, PhD; DONALD A. MALONE, MD; and JOHN P. O’REARDON, MD Drs. Shah, Pesiridou, and O’Reardon are from the Neuromodulation Treatment and Research Program, Department of Psychiatry, University of Pennsylvania, Philadelphia; Dr. Baltuch is from the Center for Functional and Restorative Neurosurgery, University of Pennsylvania; and Dr. Malone is from the Center for Neurological Restoration, Cleveland Clinic. Psychiatry (Edgemont) 2008;5(9):24–33 ABSTRACT Over the past 20 years, there has been a concerted effort to expand our understanding of the neural circuitry involved in the pathogenesis of psychiatric disorders. Distinct neuronal circuits and networks have been implicated in obsessive compulsive disorder (OCD) and major depressive disorder (MDD) involving feedback loops between the cortex, striatum, and thalamus. When neurosurgery is used as a therapeutic tool in severe OCD and MDD, the goal is to modulate specific targets or nodes within these networks in an effort to produce symptom relief. Currently, four lesioning neurosurgical procedures are utilized for treatment refractory OCD and MDD: cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy. Deep brain stimulation (DBS) is a novel neurosurgical approach that has some distinct advantages over lesioning procedures. With DBS, the desired clinical effect can be achieved by reversible, high frequency stimulation in a nucleus or at a node in the circuit without the need to produce an irreversible lesion. Recent trials of deep brain stimulation in both OCD and MDD at several neuroanatomical targets have reported promising early results in highly refractory patients and with a good safety profile. Future definitive trials in MDD and OCD are envisaged. INTRODUCTION No topic in psychiatry is as controversial as treating psychiatric disorders with neurosurgery. Since the advent of scientific study of the human brain, biologically oriented FINANCIAL DISCLOSURES: Magstim and Neuronetics are both TMS device manufacturers. Dr. Baltuch has no relevant conflicts of interest to disclose; Dr. Malone has received research funding and is a consultant to Medtronic and has received speaking honoraria from Eli Lilly and Bristol-Myers Squibb; Dr. O’Reardon has received grant support from Bristol-Myers Squibb, Cyberonics, Eli Lilly, Magstim, Neuronetics, Pfizer, and Sanofi, has acted as a consultant for Eli Lilly and Neuronetics, and is on the speaker bureaus of Eli Lilly and Bristol-Myers Squib; Dr. Pesiridou works as a research coordinator for Dr. O’Reardon; and Dr. Shah has performed part-time consulting with Neuronetics in 2007. ADDRESS CORRESPONDENCE TO: Dhwani Shah, MD, Neuromodulation Treatment and Research Program, Department of Psychiatry, University of Pennsylvania, Suite 4005, 3535 Market St., Philadelphia, PA 19104; E-mail: dhwani.shah@uphs.upenn.edu KEY WORDS: obsessive compulsive disorder, major depression, neurosurgery, deep brain stimulation, neurocircuitry [SEPTEMBER] Psychiatry 2008 25

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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