Concerns About Psychiatric Neurosurgery and How They Can Be Overcome: Recommendations for Responsible Research

Abstract

Background Psychiatric neurosurgery is experiencing a revival. Beside deep brain stimulation (DBS), several ablative neurosurgical procedures are currently in use. Each approach has a different profile of advantages and disadvantages. However, many psychiatrists, ethicists, and laypeople are sceptical about psychiatric neurosurgery. Methods We identify the main concerns against psychiatric neurosurgery, and discuss the extent to which they are justified and how they might be overcome. We review the evidence for the effectiveness, efficacy and safety of each approach, and discuss how this could be improved. We analyse whether and, if so, how randomised controlled trials (RCTs) can be used in the different approaches, and what alternatives are available if conducting RCTs is impossible for practical or ethical reasons. Specifically, we analyse the problem of failed RCTs after promising open-label studies. Results The main concerns are: (i) reservations based on historical psychosurgery, (ii) concerns about personality changes, (iii) concerns regarding localised interventions, and (iv) scepticism due to the lack of scientific evidence. Given the need for effective therapies for treatment-refractory psychiatric disorders and preliminary evidence for the effectiveness of psychiatric neurosurgery, further research is warranted and necessary. Since psychiatric neurosurgery has the potential to modify personality traits, it should be held to the highest ethical and scientific standards. Conclusions Psychiatric neurosurgery procedures with preliminary evidence for efficacy and an acceptable risk–benefit profile include DBS and micro- or radiosurgical anterior capsulotomy for intractable obsessive–compulsive disorder. These methods may be considered for individual treatment attempts, but multi-centre RCTs are necessary to provide reliable evidence.

Clinical outcomes of deep brain stimulation for obsessive‐compulsive disorder: Insight as a predictor of symptom changes

“…Thus, sham methods were necessary in earlier investigations to establish a level of efficacy. However, we contend that a sufficient level of evidence has been reached to consider DBS an established therapy for TR-OCD, [9][10][11]67,68 and that closed label conditions do not satisfy ethical or validity requirements. The overall goal of DBS therapy is to improve outcomes for patients.…”

Therapiemöglichkeiten der Depression nach Non-Response

“…Eine Erklärung für die fehlende Wirksamkeit im Vergleich zu einer Sham-Stimulation (neben Publikationsbias, Designproblemen und Placeboeffekten) könnte sein, dass die Läsion durch die Operation einen Effekt hat, die auch bei Sham-Stimulation erfolgt. Und in der Tat werden zunehmend wieder Läsionsverfahren bei schweren depressiven Erkrankungen diskutiert [57]. Für die DBS als Therapie der Depression kann mit der möglichen Ausnahme neuer Studien damit keine Empfehlung ausgesprochen werden.…”

Call to revise the Royal Australian and New Zealand College of Psychiatrists’ clinical memorandum on deep brain stimulation for obsessive-compulsive disorder

“…Thus, the efficacy of DBS is comparable, or rather beyond that of pharmacological interventions for OCD. These reported outcomes have led several experts to argue that DBS is now an established therapy for refractory OCD ( Acevedo and Rossell, 2022 ; Gadot et al, 2022 ; Mosley et al, 2021 ; Müller et al, 2022 ; van Wingen et al, 2022 ). Although the memorandum identifies DBS as a potential treatment option for refractory OCD patients, it encourages applications solely within investigational contexts (clinical trials) and classifies DBS as an emerging therapy.…”