- Centre of Neurosciences, Department of Neurosurgery, Consultant Neurological Surgeon, Ninewells Hospital and Medical School, Scotland, U K
Centre of Neurosciences, Department of Neurosurgery, Consultant Neurological Surgeon, Ninewells Hospital and Medical School, Scotland, U K
DOI:10.4103/2152-7806.91608Copyright: © 2012 Eljamel S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Eljamel S. Strategies for the return of behavioral surgery. Surg Neurol Int 14-Jan-2012;3:
How to cite this URL: Eljamel S. Strategies for the return of behavioral surgery. Surg Neurol Int 14-Jan-2012;3:. Available from: http://sni.wpengine.com/surgicalint_articles/strategies-for-the-return-of-behavioral-surgery/
Background:Behavioral surgery (BS) is resurging because of unmet clinical need, advances in basic sciences, neuroimaging, neurostimulation, and stereotaxy. However, there is a danger that BS will fall unless acceptable strategies are adopted by BS providers.
Methods:A critical review of conditions leading to rise of psychosurgery (PS) and concerns resulting in its fall was conducted to learn lessons and safeguard BS of the future.
Results:PS rose and spread in 1960 like wildfire without adequate preclinical and clinical studies. Hundreds of patients had PS without adequate preoperative diagnosis or assessment, proper consent, and non-objective reporting of outcome. Furthermore, there was public opposition against PS because of its potential abuse to control violent behavior and dissidents. Advances in neurostimulation, neuroimaging, and stereotaxy, and emergence of treatment-resistant mental disorders led to increased interest in BS. Several recent studies have shown BS to be safe and effective. However, concerns related to strength of evidence, safety, efficacy, consent, and objectivity of studies have been raised. Unless clinical and regulatory governance structures are adopted in each jurisdiction, BS will face the same fate as that of PS in the past.
Conclusion:The future of BS as a safe and effective therapy is dependent upon adopting clear moral ethical and governance standards on the following lines: Patients must have failed adequate therapies; must be assessed by psychiatrist-led multidisciplinary teams; patients’ abilities to give consent and diagnosis must be verified by independent authorities designated for this purpose by the state; and the independent authority must also decide whether the teams were adequately trained to perform BS.
Keywords: Capsulotomy, cingulotomy, neurostimulation, psychosurgery, stereotaxy, vagus nerve stimulation
Behavioral disorders such as major depressive disorders (MDDs), anxiety disorders, obsessive compulsive disorders (OCD), and schizophrenias are associated with huge direct and indirect costs to sufferers, their families and communities, and countries as a whole. It is estimated that 20–40% of sufferers become either resistant or refractory to standard therapeutic options, leading to increased demands on finite healthcare resources and significant unmet need for alternative therapeutic options.[
This study is a critical review of the issues and concerns that led to the rise and fall of PS in 1960–1970 and a review of the advances and potential ethical issues that affect the emergence of BS in the 21st century.
Concerns that shrouded PS in the past
The most important central concern that surrounded PS in the past was the lack of scientific evidence to justify its use. The data upon which PS was introduced were at most inconclusive or contradictory.[
The second concern surrounding PS was informed consent and how informed consent was obtained, e.g. Can an appropriate candidate for PS give valid consent for PS or can a third party, family, or society who might benefit from PS give consent on behalf of a patient. Some argued that PS may produce irreversible change in behavior, self, or mind of the consenting individual on the same bar as mutilation.[
Finally, opponents of PS voiced their concern that PS had been, may be, or will be used or abused as a social or political tool to control and subdue those who are considered abnormal to justify controlling dissidents, minorities, or bothersome individuals.[
Recent changes that made behavioral surgery a safe, effective therapeutic reality
It is clear that current standard therapeutic options cannot help a significant number of mentally ill patients. For example, the prevalence of OCD is 2.5% with 30–40% of sufferers becoming treatment resistant (TRes).[
Contrary to the common belief of PS opponents, BS of today is based on scientific evidence. Positron emission tomography (PET) demonstrated reduced cerebral blood flow (CBF) in the prefrontal, premotor, dorsal anterior cingulate gyrus, and anterior insula of the cerebrum, and elevated CBF in the subgenu cingulate gyrus in patients with MDD.[
Preoperative diagnosis and selection of patients
In recent years, patients referred for BS are considered for surgery after thorough critical review of their diagnosis and adequacy of previous treatments. In my institution, prospective patients for BS are evaluated by a multidisciplinary team in the Advanced Interventions Service (AIS) led by experienced psychiatrists and psychotherapists in this field.[
Pre- and postoperative assessments
Recently, BS has been conducted with the most stringent ethical, moral, and regulatory approvals, and its outcome is assessed with validated objective scales, performed by those who do not perform the actual BS. In my institution and other centers, OCD patients are assessed by the Yale–Brown Obsessive-Compulsive scale (YBOCS)[
Accuracy and precision of BS
In contrast to PS where prefrontal lobotomy is performed by a leucotome or an ice-pick with no imaging guidance or postoperative imaging confirmation, current BS procedures are guided by stereotactic image guidance systems including stereotactic frames and robotic systems, with submillimetric accuracies and precision.[
Lesion versus deep brain simulation
One of the most controversial issues concerning PS is the fact that psychosurgeons make large irreversible permanent destructive brain lesions. If the lesion is made too small to be effective, repeat surgery is required, and if the lesion is made too large, it cannot be reduced in size. Furthermore, lesions made in non-responders cannot be reversed with the knowledge that surgery has not worked. With DBS and vagus nerve stimulation (VNS), the effects of stimulation can be reversed by switching off the implanted pulse generator (IPG) at the flick of a button, so in a way, the patient can decide before surgery to proceed or not and after surgery to continue with DBS/VNS or not. DBS/VNS provides a way of testing whether or not TRes-OCD or TRes- and TRef-MDD patients will respond. It gives them a chance of experiencing firsthand the effects of stimulation and how much function will they gain by this treatment.[
The issue of consent
BS today is performed in academic centers following specific treatment and research protocols with stringent and rigorous consenting processes. In my own institution, patients deemed to be candidates for BS by experienced dedicated psychiatrists at the academic center are referred to an independent mental healthcare commission (MHCC) consisting of independent psychiatrists and lay individuals. The MHCC reviews the diagnosis, the proposed BS, and whether the sufferer is able to give informed consent. The consenting process takes several consultations with the sufferer and his/her carer, and BS is carried out only after the referring psychiatrist and MHCC are satisfied that the sufferer understood the ins and outs of the proposed BS and the aftercare required thereafter. It is also of note that BS is only offered to patients who can give informed consent. When the patients in our institution were given the choice of ablative procedures, DBS, or VNS, they had a very clear idea about the procedure they preferred and it was not always DBS or VNS.[
The cry for PS was expressed by a schizophrenic adolescent in 1976: “Please give me an inhuman operation to take away the sacredness” – A schizophrenic adolescent, Philadelphia, USA, 1976. This was a cry of suffering, expecting relief from an impersonal inhuman procedure, recognizing there is something wrong with the operation.[
BS and the way it is practiced today is very different from that of PS of the past ; BS is accurate and precise, and it can allay most of the concerns encountered in the past in this field of neurosurgery. However, a review of the literature on DBS for mental disorders uncovers a plethora of articles on BS; a total of 90 publications during 2009–2011 compared to only 17 articles between 2002 and 2005 [
The main concerns surrounding BS are the same as those that surrounded PS in the past. If we do not develop and agree strategies, BS will face the same destiny as PS. These new strategies should include the following points to allay these concerns:
Patients considered for BS must have failed adequate therapies: In OCD failure of at least three adequate trials of SRIs including clomipramine and augmentation and behavioral therapies. In MDD failure of at least four adequate antidepressive therapies including medicines, psychotherapy, and ECT. Patients should be assessed by psychiatrist-led multidisciplinary team of experienced healthcare professionals, who must validate the diagnosis, adequacy of previous treatments, and the ability of patients to give consent. Ability of patients to give informed consent and the diagnosis must be verified by an independent authority designated for this purpose under jurisdiction of the state where BS will be carried out, e.g. MHCC or Behavioural Surgery Review Board. The independent body or authority must also decide whether the treating team is adequately trained to perform the procedure and provide aftercare. These procedures should only be performed within adequately resourced centers subject to annual inspections and robust clinical and regulatory governance frameworks.
Patients considered for BS must have failed adequate therapies:
In OCD failure of at least three adequate trials of SRIs including clomipramine and augmentation and behavioral therapies.
In MDD failure of at least four adequate antidepressive therapies including medicines, psychotherapy, and ECT.
Patients should be assessed by psychiatrist-led multidisciplinary team of experienced healthcare professionals, who must validate the diagnosis, adequacy of previous treatments, and the ability of patients to give consent.
Ability of patients to give informed consent and the diagnosis must be verified by an independent authority designated for this purpose under jurisdiction of the state where BS will be carried out, e.g. MHCC or Behavioural Surgery Review Board.
The independent body or authority must also decide whether the treating team is adequately trained to perform the procedure and provide aftercare.
These procedures should only be performed within adequately resourced centers subject to annual inspections and robust clinical and regulatory governance frameworks.
Publication of this manuscript has been made possible by an educational grant from
The author acknowledges the support of all staff at the AIS, the Neurosurgical Operating Room, the Neurosurgical Ward, and the Neuroradiology Department for their continued support of behavioral surgery service at Ninewells Hospital and Medical School.
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