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Neurosurgical Intervention for Treatment-Resistant Psychiatric Disorders

  • Daniel E. Nijensohn
  • Teodoro Forcht Dagi
Chapter

Abstract

Despite the introduction of newer and more specific psychotropic medications, there remain a significant number of patients with refractory psychiatric disease that might be candidates for neurosurgical treatment. Because of the history and the ethical, legal, and social implications of psychosurgery, only a limited number of these procedures are done today. Nevertheless, the tremendous progress in the neurosciences over the past decades has led to the availability of new technologies such as neuromodulation and the revival of focused ultrasound lesioning, and these, in turn, bring neurosurgical interventions once again to the forefront of medicine. The infamous past of psychosurgery, as well as current standards of practice, requires screening by experienced multidisciplinary teams, strict ethical conduct, and careful patient selection. Voluntary fully informed consent, impeccable preoperative and postoperative care and oversight, and careful and open reporting of effects and side effects are essential. Although neurosurgical intervention is best considered for patients with severe, disabling, and chronic psychiatric illness, this important therapeutic option should no longer be relegated to a position of last resort.

Image-guided stereotactic ablative surgical procedures have been researched and performed for decades. The advent of MR image-guided high-intensity focused ultrasound (MR-HIFU or MRgFUS) lesioning, stereotactic radiosurgery, deep brain stimulation (DBS), and cerebral neuromodulation has been revolutionary. Among other things, DBS offers reversibility and the possibility of implanting closed-loop systems.

DBS for treatment of several psychiatric and behavioral disorders, whether performed with or without concomitant neurophysiological cerebral recording and stimulation, is perhaps currently underutilized. Well-planned randomized studies are needed to determine the correct indications and techniques, the most appropriate surgical target(s) for each psychiatric condition, and the optimal surgical approaches. The trend is towards minimally invasive outpatient therapies with a leaning towards lesions over DBS since patients perceive them as less invasive. Several new indications are presently in development.

Keywords

Neurosurgery for treatment-resistant psychiatric illness Psychosurgery Cerebral targets Stereotactic surgical ablation Deep brain stimulation Neuromodulation Closed loops 

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Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Daniel E. Nijensohn
    • 1
    • 2
    • 3
    • 4
  • Teodoro Forcht Dagi
    • 5
    • 6
    • 7
  1. 1.Neurosurgery DepartmentYale University School of MedicineNew HavenUSA
  2. 2.Neurosurgery DivisionSt. Vincent’s Medical CenterBridgeportUSA
  3. 3.Neurosurgery SectionBridgeport HospitalBridgeportUSA
  4. 4.Yale Gamma Knife Center & Yale New Haven HospitalNew HavenUSA
  5. 5.HLM Venture PartnersBostonUSA
  6. 6.Dentistry and Biomedical SciencesQueen’s UniversityBelfastUK
  7. 7.Anglo Scientific LTDThe Royal Institution of Great BritainLondonUK

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