Ablative surgery for neuropsychiatric disorders: Past, present, future

Abstract

Surgical interventions for the treatment of psychiatric disease have a long history. Before the availability of effective psychotropic drugs, the widespread practice of psychosurgery reached a dramatic peak in the mid 20th century, with the notorious era of the Freeman lobotomy. The practice of psychosurgery continued on a much smaller scale for medically-refractory psychiatric patients, continuing to develop with a concept of minimalism out of the school of stereotaxy in neurosurgery. The modern era of psychosurgery has established four procedures with extensive experience supporting their indications and efficacies in properly selected patients. All of modern intracranial psychosurgery is stereotactic in nature, though historically interventions have been lesion-based. More recently, the idea of psychosurgery has been met with renewed enthusiasm, favoring DBS to avoid the historic dependence on lesioning. While there are some advantages to DBS over ablative methods, it is important to keep in mind that the two modalities are neither functionally nor clinically equivalent. Furthermore, while DBS is a new and experimental modality with unproven long-term effects, there is extensive experience with lesioning that supports its benefit for carefully selected psychiatric patients. Furthermore, the theoretical and practical aspects of each modality, warrant continued consideration and research to determine their optimal roles in psychosurgical practice. However, it is clear that ablative methods play an important role in the surgical management of severe, intractable psychiatric disease today and will likely continue to do so in the future.