Despite decades of opposition from medical ethicists, brain surgery for psychiatric disorders is resurfacing as a treatment option.
A new Canadian study has concluded that one type of psychosurgery – bilateral anterior capsulotomy – is "an effective and safe technique" for treating severe obsessive compulsive disorder.
In the study, published Monday in the Journal of Neurology, Neurosurgery and Psychiatry, researchers at Laval University in Quebec City found that 37 per cent of patients responded fully to the surgery, while 11 per cent were partial responders.
"We were able to help [nearly] 50 per cent of the patients," said lead author Myreille D'Astous. She added that all the patients had suffered from severe OCD along with other conditions, such as anxiety and depression, that had not improved with psychiatric drugs or psychotherapy.
Clinical OCD involves persistent thought and behaviours, including hoarding, that interfere with normal life. A patient may be tormented by unwanted preoccupations with cleanliness and order, or unable to stop compulsive behaviours such as hand-washing.
One patient in the study was incapacitated by her compulsion to check the stove and turn the lights on and off for hours at a time. After surgery, the patient went back to university, D'Astous said.
Of the 19 patients in the study, however, 10 did not improve after surgery. The researchers reported adverse events such as deep vein thrombosis and urinary incontinence in 60 per cent of all patients, including permanent complications in two individuals. (One patient experienced paralysis of one side of the body; another suffered cognitive impairment, including memory and concentration problems.)
The surgery involved drilling a hole on either side of the patient's skull and pushing a narrow metal shaft called a leucotome through the brain. Four times on each side, the surgeon rotated the leucotome to cut through soft brain tissue using a wire at the end.
Peter Breggin, a New York psychiatrist who has devoted much of his career to combatting psychosurgery, described the procedure used in the study as barbaric. "This is old-fashioned lobotomy," he said. "They are mutilating normal brain tissue in the interests of modifying behaviour and feeling."
The surgical objective, D'Astous said, was to destroy pathways in the frontal lobes of the brain that are believed to be overactive in patients with severe OCD.
D'Astous and co-authors noted that 10 to 27 per cent of OCD patients attempt suicide at some point in their lives. Up to 30 per cent of patients do not respond to conventional treatments, they wrote.
Patients in the study underwent surgery between 1997 and 2009. The researchers measured their OCD symptoms at three, six, 12 and 24 months after the surgery, with a final follow-up by phone three to 11 years later. At the last follow-up, three of the patients were considered recovered from OCD and three had minimal symptoms. The others showed marginal or no improvement.
Psychosurgery has been controversial since the 1930s, when it was first developed. By the mid-1970s – due to public outcry – lobotomies had all but disappeared in Canada, Breggin said. But in recent decades, there has been a resurgence. Newer forms of psychosurgery are being conducted at centres including the University of Alberta Hospital in Edmonton, Vancouver General Hospital and Toronto Western Hospital.
D'Astous acknowledged that the surgical technique used in the Laval study has become less common. Deep brain stimulation and radiosurgery, which uses radiation to target specific brain areas, are considered less invasive, she said.
The renewed interest in psychosurgery is alarming, Breggin said. Few studies adequately measure patients' overall well-being or quality of life after surgery, he explained. Any improvements in psychiatric symptoms are achieved "by damaging the humanity of the patient," he said.
A major review of psychosurgery side effects, published in 1982 in the Danish journal Acta Psychiatrica Scandinavica, found that patients who underwent psychosurgery tended to be apathetic and emotionally shallow. Other studies have shown that psychosurgery patients were at increased risk for addictions and suicide, and could not cope except in protected, managed environments, Breggin said.
When the frontal lobes are partially cut off from the rest of the brain, he said, executive functions such as judgment, creativity, complex analyses, social awareness, self-reflection and emotional expression "are damaged or obliterated," he said.
D'Astous, however, said the Laval researchers were in contact with psychiatrists who had continued to treat the patients before and after the study period. The psychiatrists had not reported significant decreases in the patients' quality of life, she added.
"Most of the patients, when we asked, said they would have the surgery again," she said.