Neurosurgical treatment of mood disorders: traditional psychosurgery and the advent of deep brain stimulation

Radiofrequency ablation of the centromedian thalamic nucleus in the treatment of drug-resistant epilepsy

OBJECTIVE

To determine the usefulness and efficacy of radiofrequency ablations (RFA) of the Centromedian thalamic nucleus (CMN) to control primarily generalized or multifocal seizures in refractory epilepsy.

METHODS

Six patients with clinical diagnosis of multifocal or primarily generalized drug-resistant epilepsy were included. Bilateral RFA of the CMN was performed through a monopolar 1.8 mm. tip electrode with a temperature of 80 °C during 90 seconds. Patients were followed in every 3 months visit for 20 to 36 months and kept a monthly seizure count calendar. We also compared maximal paroxysmal electroencephalogram (EEG) activity and neuropsychological evaluation pre and 6 months postoperatively.

RESULTS

A significant reduction in the number of generalized seizures was observed in all subjects in the range of 79-98%, starting the first post-operative month. Although focal aware seizures remained unchanged throughout follow-up, there was an important reduction on paroxysmal activity between the pre and postoperative EEG. No major changes on cognitive status were detected. There was post-operative dysphagia and odynophagia lasting one week and there was no mortality in this group of patients.

CONCLUSION

Preliminary results of CMN RFA suggest safety and a trend toward reduction of some seizure types, it may reduce the seizure frequency like other palliative procedures since the first post-operative month, but a larger, controlled study would be needed to establish the value of this therapy.

Should DBS for Psychiatric Disorders be Considered a Form of Psychosurgery? Ethical and Legal Considerations

Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community's interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS-though a much more precise and refined treatment than its predecessors-is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS.

'A matter for conjecture': leucotomy in Western Australia, 1947-70

Very little has been published on the rise and fall of psychosurgery in Australia. In the mid-twentieth century, Western Australia was the largest but most sparsely-populated of the six Australian States, and its local psychiatry practice was, as one commentator put it, 'backward'. Nonetheless, electroconvulsive therapy was introduced in 1945, and leucotomy in 1947. This paper will explore the introduction of leucotomy to Western Australia in the context of wider national and international trends in psychiatry, and posit some reasons for its decline and abandonment in the 1970s. It will present a narrative reconstruction of the local introduction and practice of leucotomy, using retrieved, reconstructed and previously unpublished data.

Sing the mind electric - principles of deep brain stimulation

The remarkable efficacy of deep brain stimulation (DBS) for a range of treatment-resistant disorders is still not matched by a comparable understanding of the underlying neural mechanisms. Some progress has been made using translational research with a range of neuroscientific techniques, and here we review the most promising emerging principles. On balance, DBS appears to work by restoring normal oscillatory activity between a network of key brain regions. Further research using this causal neuromodulatory tool may provide vital insights into fundamental brain function, as well as guide targets for future treatments. In particular, DBS could have an important role in restoring the balance of the brain's default network and thus repairing the malignant brain states associated with affective disorders, which give rise to serious disabling problems such as anhedonia, the lack of pleasure. At the same time, it is important to proceed with caution and not repeat the errors from the era of psychosurgery.

Mental health legislation and psychiatric treatments in NSW: electroconvulsive therapy and deep brain stimulation

OBJECTIVE

The aim of this paper is to discuss the restriction of electroconvulsive therapy (ECT) to the treatment of psychiatric disorders and the prohibition of psychosurgery and deep brain stimulation (DBS) in the NSW Mental Health Act 2007 (MHA), and to examine these restrictions from clinical and human rights perspectives.

METHOD

Sections of the NSW MHA regulating the use of ECT, psychosurgery and DBS were reviewed. These were compared with corresponding regulations in mental health legislation in other Australian states. Reasons for discrepancies were explored.

RESULTS

Restrictions in the MHA on the use of ECT, psychosurgery and DBS are not in line with current clinical evidence of their efficacy and safety. The prohibitions aim to ensure safeguards are in place but the legislation fails to balance these objectives with the potential clinical benefit offered by these treatments.

CONCLUSIONS

By imposing restrictions which are not justifiable in terms of the clinical evidence available, the MHA discriminates against those with neurological disorders responsive to psychiatric treatments, and those with psychiatric disorders who would benefit from the development of DBS as a treatment.

Diagnosis and treatment of neuropsychiatric disorders

Neuropsychiatry is the subspecialty of psychiatry that deals with disorders at the intersection of neurology and psychiatry. Neuropsychiatric disorders are complex and incompletely understood. Neuroscience research is beginning to elucidate the biological underpinnings of many of these disorders. These advances have the potential to improve diagnosis, inform treatment selection, and facilitate development of new and better interventions.