A prospective clinical study of stereotactic subcaudate tractotomy

This study describes a cohort of 23 patients undergoing stereotactic subcaudate tractotomy. Research Diagnostic Criteria indicated that 70% suffered major depressive disorder; the remainder mostly had a bipolar affective disorder. There were serial assessments pre-operatively and at 2 weeks and 6 months post-operatively using the Hamilton Rating Scale for depression, the Present State Examination (PSE), Newcastle Scale, the Beck Depression Inventory, and the Taylor Manifest Anxiety Scale. Neuropsychological assessment included tests thought to be sensitive to frontal lobe dysfunction, as well as tests of general intelligence, attention, memory, language and visuo-spatial function. Post-operatively, depression rating scale scores decreased significantly but most patients continued to exhibit a number of PSE syndromes. Depression rating scale scores were correlated with 1 year global outcome: there was no significant correlation except for the 6 month assessment when lower Hamilton scores were found to be associated with better global outcome. Correlations between the neuropsychological tests and the Hamilton and Beck depression scales at 2 weeks post-operatively suggested that an improvement in psychiatric condition was associated with greater efficiency on some tests of attention and verbal recall, as well as faster performance on a sorting task. By contrast, the changes at 6 months suggested an association between improvement in psychiatric condition and less efficient performance on certain neuropsychological tests including verbal recognition memory, attention and two tests of frontal lobe dysfunction.

Psychosurgery: stereotactic subcaudate tractomy. An indispensable treatment

BACKGROUND

Stereotactic subcaudate tractotomy (SST) is the only type of psychosurgery performed at the Geoffrey Knight Unit, London, where nearly 1300 operations have been done since 1961. Statistically reliable data are not available to prove the effectiveness of SST. A detailed statement about contemporary psychosurgery is given.

METHOD

Relevant publications from the Unit and via Medline are discussed. The outcome figures are reviewed. The outcome is assessed at the Unit in global and clinical terms, associated with results of self-completed questionnaires.

RESULTS

SST allows 40-60% of patients to live normal or near-normal lives, perhaps with continuation of medication. A reduction in suicide rate to 1% post-operatively, from 15% in cases of uncontrolled affective disorders is seen.

CONCLUSION

As a treatment of last resort, no controlled trial against a comparable treatment is possible. It appears reasonable to offer SST to patients with suicidal and deluded depression or with frequently swinging moods, not responding to other treatments.

Current state of psychosurgery

This article considers aspects of the contemporary practice of psychosurgery in Britain including the numbers of operations, operative procedures and the assessment and indications for surgery. The evaluation of outcome and possible adverse consequences are discussed in the light of some recent research.

Altered magnetic resonance white-matter T1 values in patients with affective disorder

The MRI T1 proton relaxation values were assessed in 14 patients with bipolar affective disorder and 10 with a unipolar disorder and a matched normal control group. The T1 values in the frontal white matter of patients significantly exceeded those of the controls. This difference was accounted for by an increase in T1 values in the frontal white matter of unipolar patients: the values for bipolar patients alone did not differ from those for controls. These preliminary findings support a hypothesis of frontal lobe dysfunction mediating pathological changes in mood.

Psychiatric liaison referrals of elderly in-patients in a teaching hospital

A retrospective review of 131 psychiatric referrals of hospital in-patients aged 65 years and older was made to examine the referral rate, the characteristics of referred patients, and the pattern of diagnoses and recommendations made by the psychiatrist. The referral rate was much less than the estimated prevalence of psychiatric morbidity in similar populations. The majority of referrals received a psychiatric diagnosis, most commonly an organic psychiatric syndrome (37%) or depression (23%). Comparison of various aspects of referral for the periods before and after the introduction of a specific psychiatric liaison service for the elderly showed little change apart from a small increase in referral rate.