Neurosurgery for mental disorder (psychosurgery)

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Introduction
What is neurosurgery for mental disorder?
What happens during the operation? 
      Subcaudate tractotomy
      Bilateral capsulotomy
      Anterior cingulotomy
Post-operative
      What are the side effects?
Where is neurosurgery for mental disorder practised?
Who decides on the treatment?
Can NMD be given without the patient's consent?
Consent and the Law
      In England and Wales
      In Scotland
Statistics
How many people are treated with neurosurgery for mental disorder?
The cost of neurosurgery for mental disorder
What is the success rate?
What is Mind's view on neurosurgery for mental disorder?
Are there any alternative techniques?
References

Introduction

This factsheet is written for people who are considering neurosurgery for mental disorder and their friends and relatives, professionals, and students.

What is neurosurgery for mental disorder?

Neurosurgery for mental disorder (NMD), is a neurosurgical treatment on the frontal lobes of the brain (the part behind the forehead), involving the limbic system. The limbic system is a part of the brain concerned with functions not under conscious control, and with emotional response. NMD is not generally carried out to alter behaviour. It is usually used to treat severe, incapacitating, non-schizophrenic mood disorders when all other attempts at treatment have failed and the alternative is continuing suffering for the patient. Nowadays, it is most commonly used to treat severe depression and obsessive compulsive disorder. It is not considered to be curative, and people who undergo NMD will probably continue to need psychiatric support following the procedure even if it is considered to be a success.[1]

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What happens during the operation?

As there is no international consensus on the best target site for the operation, a variety of techniques are in use at different treatment centres. Most procedures aim to interrupt the nerve circuits within the limbic system.[2] All of the different types of NMD are irreversible.

The following operations have been used in the UK:

• stereotactic subcaudate tractotomy
• stereotactic anterior cingulotomy
• stereotactic bilateral capsulotomy.

The techniques are all called 'stereotactic' because they involve the use of specially constructed frames which are attached to the patient's skull and hold the probes which are put into the brain. Used together with neuro-imaging (computerised tomography (CT) or magnetic resonance imaging (MRI) scans) and dedicated computer software, stereotactic techniques allow the probes to be guided precisely (to within one millimetre) to any desired target within the brain. The stereotactic frame means that the siting of the probe is fixed and mechanical, and there is no error due to faltering hand movements.

Most modern procedures use an electrical current to generate heat (radiofrequency thermocoagulation) or use gamma radiation to destroy target areas (the "Gamma Knife").

The NMD procedure is carried out under general anaesthetic and lasts about one and a half hours, most of this time being taken up with X-rays to monitor the position of the probe. The hair is not shaved.

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Subcaudate tractotomy
In subcaudate tractotomy, two incisions are made in the forehead - within a skin crease if possible - and two burr-holes are then made in the frontal bone above the air sinuses (i.e. in the forehead). The stereotactic frame is then attached, and then any part of the frontal lobe of the brain can be targeted with the probe, where a lesion is produced using radio-frequency (heat). The wounds are stitched after removal of the stereotactic apparatus.[3] 

Bilateral capsulotomy
In bilateral capsulotomy, incisions are made, one on each side of the midline on top of the head, and probes are passed into the part of the brain called the internal capsule. A small electric current is passed, which destroys a small part of the brain tissue. The electrodes are then removed and the wounds stitched.[4]

Anterior cingulotomy
Anterior cingulotomy uses a similar technique to produce lesions in an area of the brain called the anterior cingulate gyrus.

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Post-operative

With all of the above techniques, patients sit out of bed on the second day and are mobile on the third day after the operation.

What are the side effects?
Some of the side effects that may occur can be associated with any brain operation, and some are specific to NMD. The risks associated with brain surgery are damage to the blood vessels (for example, causing stroke - this is very rare in NMD), confusional states, and epilepsy. Immediately after the operation, fluid in the tissues may cause pressure in the front of the brain (post-operative frontal oedema) leading to confusion; this may last up to a month.

The adverse effects associated specifically with NMD include headaches, which may be severe and may last for some days, and, in the long term, weight gain, and apathy. Weight gain is associated with anterior capsulotomy and subcaudate tractotomy, but not with cingulotomy; the reason for it is not known. Some personality change has been reported following NMD in some people, but this is considered to be rare. There is no evidence that NMD causes intellectual impairment, and in some cases, IQ scores have been raised, probably because of relief of symptoms which had severely impaired concentration before treatment.[5]

Rehabilitation must be gradual because recovery is a slow process.

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Where is neurosurgery for mental disorder practised?

At present, there is no centre for NMD in England. NMD is carried out in centres in Whitchurch Hospital, Cardiff and Ninewells Hospital, Dundee. Dundee uses anterior cingulotomy for resistant depressive disorder, and anterior capsulotomy or anterior cingulotomy for intractable OCD.[6]

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Who decides on the treatment?

British practice in NMD involves a referral from a local psychiatrist to the psychosurgical team, and not just to the neurosurgeon alone.

Good practice guidelines state that the full hospital notes are always needed for assessment, and a close relative should accompany the patient and be interviewed as well. In cases where a patient has never responded to medication or ECT (electroconvulsive therapy), there is the possibility that all physical treatments, including surgery, are inappropriate. Psychiatric conditions that will not be helped include personality disorders, uncomplicated schizophrenia, and anorexia nervosa.[7]   NMD is not performed on people under the age of 20.

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Can neurosurgery for mental disorder be given without the patient's consent?

Not usually. It cannot be given without consent under the Mental Health Act 1983 in England and Wales. In Scotland, under the Mental Health (Care and Treatment) (Scotland) Act 2003, NMD may be given without consent in cases where the patient is not capable of giving consent and does not object. The Court of Session must make an order declaring that the treatment may be lawfully given before it can proceed.

Consent and the Law

The United Nations resolution on The protection of persons with mental illness and the improvement of mental health care  (A/RES/46/119), [8] passed on 17 December 1991, includes the following statement:

14. Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility and, to the extent that domestic law permits them to be carried out, they may be carried out on any other patient only where the patient has given informed consent and an independent external body has satisfied itself that there is genuine informed consent and that the treatment best serves the health needs of the patient.

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In England and Wales
In England and Wales, NMD (psychosurgery) is covered by section 57 of the Mental Health Act 1983, which covers all patients, whether voluntary or detained under another section of the Act. Under section 57, psychosurgery and treatments specified in Department of Health regulations as giving rise to special concern, can only be given if:
       a) the patient consents and
       b) a multidisciplinary panel appointed by the Mental Health Act Commission confirms that his/her consent is valid and
       c) the doctor on the multidisciplinary panel certifies that the treatment should be given. Before doing so he must consult two people, one a nurse and the other neither a nurse nor a doctor, who have been concerned with the patient's treatment.

The following is taken from the Code of Practice to the Mental Health Act 1983:

Treatments requiring Consent and a Second Opinion
Section 57 reflects public and professional concern about particular forms of treatment; such treatments need to be considered very carefully in view of the possible long-term effects and the ethical issues that arise. Procedures for implementing this Section must be agreed between the Mental Health Act Commission and the hospitals concerned.

Before the responsible medical officer (rmo) or doctor in charge of treatment refers the case to the Mental Health Act Commission:

a) the referring doctor should personally satisfy himself that the patient is capable of giving valid consent and has consented;
b) the patient and (if the patients agrees) his family and others close to him should be told that the patient's willingness to undergo treatment does not necessarily mean that the decision to proceed has yet been taken. The patient should be made fully aware of the provisions of Section 57;
c) for psychosurgery, the patient's case should be referred to the Commission prior to his transfer to the neurosurgical centre for the operation. The Commission will usually visit and interview the patient at the referring hospital at an early stage in the procedure.

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In Scotland  

Those operations that are performed in Scotland come under the provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003, which came into effect in October 2005. They are overseen by the Mental Welfare Commission for Scotland, who provide independent clinical assessments for all patients. NMD can only be carried out after a designated medical practitioner (appointed by the Mental Welfare Commission) gives an independent opinion that it will be beneficial to the patient. Two lay people appointed by the Commission must then certify whether or not the patient is capable of consenting and, if the person is capable, that he or she consents, and if not, that he or she does not object to the treatment. Where the person is incapable of consenting, the Court of Session must make an order declaring the treatment may be lawfully given before it can proceed.[9]

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Statistics

How many people are treated with neurosurgery for mental disorder?

The Mental Health Act Commission panel authorised seven operations to go ahead in England and Wales in 1999-2000 and two in 2000-2001.[10] Prior to that:

There has been one death associated with NMD in over 3,000 procedures.[11]

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The cost of neurosurgery for mental disorder
The cost of the operation and perioperative care was between £6,000 and £7,000 in 1997. When post-operative care is included, this increases to about £13,000.

The alternative to NMD would in most cases be a high-cost, protracted period of high-dependency inpatient care.

What is the success rate?
Most reports on results of NMD relate to a form of operation which is no longer performed: a method of subcaudate tractotomy using radioactive yttrium rods which was discontinued because it became impossible to obtain the yttrium.

Of 42 patients on whom data was available, doctors reported significant improvement in 12 cases and some improvement in 22. Six cases showed no change, two showed some deterioration and none of the patients showed any significant deterioration.[12]

During the period when the Geoffrey Knight Unit (now closed), at the Maudsley Hospital in south London, was forced to suspend operations for technical reasons, they continued to admit patients for trials of high dose and combined antidepressants, which has reduced the need for NMD in recent years.[13] This suggests that, at least for some people, other treatment options have not always been fully tried before resorting to NMD.

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What is Mind's view on neurosurgery for mental disorder?

Mind's Policy on Physical Treatments[14]makes the following statements about NMD:

'Psychosurgery is a neurosurgical operation occasionally used where no other treatments have helped, in particular for severe obsessive-compulsive problems or depression. The techniques are more precise than in the past and it is no longer used to control aggression.

It involves the destruction of brain tissue or function, is irreversible and carries a risk of apathy, excessive weight gain, loss of inhibition and epilepsy. Although follow up studies show the majority of patients seem to improve, these uncontrolled studies have been said to provide 'virtually no scientific support for the efficacy of the treatment at all'.

The research has been criticised for failing to assess adverse effects adequately, especially the effect on personality; neither does it adequately assess users' views of outcome.

In England and Wales the treatment can only be given with consent, and authorisation by an independent doctor and two other people appointed by the Mental Health Act Commission.

Mind is concerned that failure to relieve suffering may lead inexorably towards increasingly invasive procedures. Psychosocial and other alternative forms of healing should always be explored and kept open. Mind is particularly concerned at the use of an irreversible procedure which carries serious risks when so little is known about its action.

Mind is not happy with the continued use of psychosurgery and believes that there should be a rigorous review to determine whether any continued use is justified.'

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Are there any alternative techniques?

A short paper from Sweden in The Lancet, October 1999,[15] reported an alternative procedure which was tried on four patients with long-standing treatment-resistant obsessive compulsive disorder (OCD). In this operation, electrodes were implanted using a stereotactic frame, as in the standard neurosurgical operations, but they were left in place and used to stimulate a small area of the brain, and not to destroy cells. The target cells were those aimed for in capsulotomy. Beneficial effects were seen in three of the four patients. In one patient, anxiety and obsessional thinking were relieved when the stimulation was on, but returned when it was turned off. During continuous stimulation, for a period of two weeks, her compulsive behaviour and rituals reduced by 90 per cent. The paper does not indicate how long the experimental treatment was continued for, but concludes that long-term stimulation may be useful in the management of severe OCD.

This factsheet was written by Katherine Darton, Mind Information Officer.

Revised May 2007.

References

[1]. Matthews K. and Eljamel M.S. 2001, 'Neurosurgery for Mental Disorder in Dundee Report', Dundee NMD Service.
[2]. National Health Service for Scotland Working Group on Mental Illness July 1996, 'Neurosurgery for Mental Disorder', The Scottish Office.
[3]. Bridges, P.K., Bartlett, J.R., Hale, A.S., Poynton, A.M., Malizia, A.L., & Hodgkiss, A.D. 1994, 'Psychosurgery: Stereotactic Subcaudate Tractotomy, an Indispensable Treatment', Br J Psychiatr, vol. 165, pp. 599-611.
[4]. 'New-style "lobotomy" arrives', Western Mail, 14 June 1994.
[5] Matthews, K. and Eljamel M.S. 2001.
[6] Matthews, K. and Eljamel, M.K. 2003, 'Status of neurosurgery for mental disorder in Scotland', Br J Psychiatry, vol. 182, pp. 404-411.
[7] Bridges et al 1994.
[8]  www.un.org/documents/ga/res/46/a46r119.htm
[9] NHS Education for Scotland, Mental Health (Care and Treatment) (Scotland) Act 2003, www.nes.scot.nhs.uk/mha/safeguards1f.htm
[10] The Mental Health Act Commission Ninth Biennial Report 1999-2001, The Stationery Office.
[11] Mental Health Act Commission and Ninewells Hospital, Dundee, quoted by the CRAG/SCOTMEG Working Group on Mental Illness.
[12] Mental Health Act Commission.
[13] Bridges, P.K. 1997, Correspondence, Psychiatric Bulletin vol. 21, pp. 121-122.
[14] Cobb, A. 1995, Mind's Policy on Physical Treatments, Mind.
[15] Nuttin, B., Cosyns, P., Demeulemeester, H., Gybels, J. and Meyerson, B. 1999, 'Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder', The Lancet, vol. 354, pp. 1526.