Psychiatry 2008 - September 2008 - (Page 26)

psychiatrists have sought to unravel its mysteries by identifying underlying neuropathological mechanisms resulting in psychiatric disorders. It was hoped that such insights would lead to cures for the most debilitating forms of these disorders through targeting brain regions that were responsible for generating psychopathology. Unfortunately, the history of surgical interventions in psychiatry has been marred by misguided applications of erroneous or overly simplistic approaches to psychiatric disease, sometimes resulting in significant negative outcomes. The birth and subsequent demise of psychosurgery in the 20th century serves as an important caution in considering neurosurgical interventions today. However, despite the success of psychotherapeutic and psychopharmacological strategies to treat mental illness, there still remains a large proportion of effort to alleviate psychiatric symptoms. A psychiatrist in general practice may well wonder what this new technology is and what it may offer therapeutically that is clinically distinct and relevant. We will review here the current literature pertaining to neurosurgical interventions in psychiatry, with a special emphasis on DBS and the underlying neurocircuitry involved in two major psychiatric disorders; obsessive compulsive disorder (OCD) and major depressive disorder (MDD). HISTORY Neurosurgical procedures to treat psychiatric disorders have been controversial, in part due to the significant morbidity associated with earlier approaches and, up to now, the irreversible nature of the procedure. In the past, there was also a lack of systematic follow-up to measure long-term functional with the level of precision that is available with modern neurosurgical approaches, the emphasis has shifted away from ablative or lesioning procedures, however precisely placed they might be. Rather, the focus is one of stimulation or inhibition (modulation) of nodes or targets within neural circuits by means of precisely placed electrodes with the object of restoring normal activity and function within the identified circuit. patients who suffer with persistent and debilitating illness that fails to respond to standard treatments. Until recently, many of our treatments in psychiatry were discovered serendipitously, including the initial discoveries of the effectiveness of antidepressants and electroconvulsive therapy.1 Over the past several decades, there has been a concerted effort by means of neuroimaging to expand our understanding of the neural circuitry involved in the pathogenesis of psychiatric disorders. In this context, a novel neurosurgical treatment intervention, deep brain stimulation (DBS), has emerged that targets focused regions of the brain in an 26 Psychiatry 2008 [SEPTEMBER] outcomes following such interventions. Finally, the indiscriminate use of earlier crude neurosurgical procedures, such as prefrontal and transorbital lobotomy, resulted at times in irreversible personality change and cognitive decline. By the mid-1950s, over 30,000 frontal lobotomies were performed in the US alone.2,3 Although some patients benefited from this procedure, many suffered permanent adverse consequences. Thus, psychosurgery, a term originally coined by Egas Moniz, who was awarded the Nobel prize for his efforts in pioneering prefrontal leucotomy, ultimately fell into disrepute. Given this troubled history, current approaches in neurosurgery to psychiatric disease are proceeding with due caution. In contemporary practice, patients must meet operationalized criteria for severity, chronicity, and disability and have a demonstrated inability to respond to standard available treatments, including psychopharmacology and psychotherapy. When surgical interventions are being considered, a multidisciplinary team consisting of psychiatrists, neurosurgeons, and other specialists involved in the care of the patient must review each case carefully to establish that conventional treatment has indeed failed and that a neurosurgical intervention is warranted. From an ethical standpoint, neurosurgery should be restricted to patients who have the requisite decision-making capacity, and the surgery must only be performed to restore function and relieve suffering. Needless to say, surgery should never be performed for political, law enforcement, or other nonmedical, sociological purposes.4 Finally, with the level of precision that is available with modern neurosurgical approaches, the emphasis has shifted away from ablative or lesioning procedures, however precisely placed they might be. Rather, the focus is one of stimulation or inhibition (modulation) of nodes or targets within neural circuits by means of precisely placed electrodes with the object of restoring normal activity and function within the identified circuit. A major virtue of this approach is the move away from irreversible or ablative lesions to one of reversible neuromodulation or what is termed functional neurosurgery. BRAIN REGIONS OF INTEREST IN OCD AND DEPRESSION Our understanding of the complex neurological underpinnings of mood and anxiety syndromes has improved over the past several decades, but much remains unknown. One reason

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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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