Psychiatric Neurosurgery: A Survey on the Perceptions of Psychiatrists and Residents.

OBJECTIVES: To evaluate the attitudes and perceptions of psychiatrists and psychiatry residents regarding neurosurgical procedures for treating psychiatric disorders and to identify potential barriers to patient referral. METHODS: A survey consisting of 25 questions was created using SurveyMonkey and was distributed to psychiatrists and psychiatry residents in Quebec. The study was approved by the McGill University Health Center's Research Ethics Board. Descriptive statistics and Friedman's test were performed using SPSS software. RESULTS: A total of 99 participants, including 64 residents and 35 psychiatrists, completed more than 75% of the survey and were included in data analysis. Overall, participants were significantly (p < 0.0005) more comfortable in referring patients suffering from treatment-resistant obsessive-compulsive disorder than from treatment-resistant major depressive disorder and preferred to refer patients for deep brain stimulation (DBS) rather than for anterior cingulotomy/capsulotomy (AC). Only 11.43% of psychiatrists had ever referred a patient for AC or DBS, and 34.69% of respondents felt that these procedures were dangerous. Lack of knowledge (82.83%) was viewed as the principal limiting factor, and 57.58% of respondents identified ≥6 different barriers to patient referral. The majority of participants (69.39%) were interested in improving their knowledge on psychiatric neurosurgery, and 82.65% felt that this subject should be included in the psychiatry residency curriculum. CONCLUSION: Overall, participants acknowledged having many limitations to referring patients for neurosurgical interventions. While informative conferences discussing neuromodulation/neuroablation could easily address many barriers, further studies are required to assess how these could change attitudes and patterns of referral.

The contemporary practice of psychiatric surgery: results from a global survey of functional neurosurgeons.

BACKGROUND: Interest in neurosurgery for psychiatric diseases (NPD) has grown globally. We previously reported the results of a survey of North American functional neurosurgeons that evaluated general attitudes towards NPD and the future directions of the field. OBJECTIVES: The purpose of this study was to expand on our previous work and obtain a snapshot in time of global attitudes towards NPD among practicing functional neurosurgeons. We measure general and regional trends in functional neurosurgery and focus specifically on surgery for mind and mood, while exploring the future prospects of the field. METHODS: We designed an online survey and distributed it electronically to 881 members of the following international organizations: World Society for Stereotactic and Functional Neurosurgery, European Society for Stereotactic and Functional Neurosurgery, Asian-Australasian Society for Stereotactic Functional Neurosurgery and the South and Latin American Society for Stereotactic and Functional Neurosurgery. Subsequent statistical and thematic analysis was performed on the data obtained. RESULTS: Of 881 surveys distributed, 106 were returned (12.8%). Eighty-two percent of functional neurosurgeon respondents were fellowship trained, with movement disorders and pain making up the majority of their practice. Psychiatric indications are the most frequently treated conditions for 34% of survey respondents, and over half of participants (51%) perform epilepsy surgery. Of the psychiatric conditions, obsessive-compulsive disorder and depression are the most common disorders treated. The majority of respondents (90%) felt optimistic about the future of NPD. Two thirds cited the reluctance of psychiatrists to refer patients as the greatest obstacle facing the field, and a majority reported that a cultural stigma surrounding psychiatric diseases exists in their community. In response to hypothetical situations involving cognitive and personality enhancement, opinions varied, but the majority opposed enhancement interventions. Regional variations were examined as well and uncovered distinct attitudinal differences depending on geographic location. CONCLUSIONS: Surgery for psychiatric conditions is an expanding field within functional neurosurgery. The opinions of international functional neurosurgeons were largely in line with those of their North American colleagues. Optimism regarding the future of NPD predominates, and future editions of this survey can be used to track the evolution of neurosurgeons' attitudes towards NPD and neuroenhancement.

Clinical reasoning and investigations for resective surgery for medically refractory epilepsies in children.

The article presents results of a UK survey of pediatric neurologists' views regarding resective surgery for medically refractory epilepsies in children. In contrast to surveys with adult neurologists, the findings indicate that delays to surgery in the pediatric field are not likely to be due to clinicians' views. There is, however, variability in clinicians' opinions as to what constitutes medically refractory epilepsy, variability in the factors reported as necessary for surgery eligibility, and uncertainty as to how these concepts should be defined. The survey highlights the need for elucidation of the epilepsy surgery process for pediatric patients, clear communication between epilepsy surgery centers and referring neurologists, and dissemination of consensus guidelines relating to the criteria for both medically refractory epilepsy and surgery eligibility.

Long-term outcome of leucotomy on behaviour of people with schizophrenia.

BACKGROUND: Prefrontal leucotomy was widely used from the late 1930s to early 1950s as a treatment for disorders involving obsessive agitation. Comparatively few studies of the enduring behavioural effects of such surgery exist, while data on mortality and cognition have been better reported. AIMS: We contrast the psychosocial functioning of older individuals with schizophrenia who had undergone prefrontal leucotomy with two groups of their peers who had not undergone such surgery. METHOD: A total of 87 individuals (one female) with a mean age of 70.3 years (SD = 6.84) were evaluated twice 25 months apart using a standardized rating scale. Twenty of the residents, all with schizophrenia, had undergone prefrontal leucotomy approximately 45 years previously. All diagnoses of schizophrenia were confirmed by multiple psychiatrists using DSM-III criteria at the time of the ratings, which were completed by two care staff who knew the residents well. RESULTS: Repeated measures comparisons with schizophrenia and non-schizophrenia patient groups showed no significant differences between the leucotomy and unoperated comparison groups on four of the five Multidimensional Observation Scale for Elderly Subjects (MOSES) scales. CONCLUSIONS: These results are consistent with reports of compromised function among individuals who had undergone leucotomy and contrast with some reports of positive changes in behaviour.

A survey of neurologists' views on epilepsy surgery and medically refractory epilepsy.

There is a 20-year delay between the diagnosis of epilepsy and surgical treatment. The aim of this study was to describe the different views held by neurologists regarding refractory epilepsy that may contribute to the delay in referring patients for epilepsy surgery. Neurologists in Michigan were mailed a 10-item survey inquiring about their definition of medically refractory epilepsy and their decision-making process in referring patients for epilepsy surgery. Eighty-four neurologists responded (20%). The majority defined medically refractory epilepsy as failure of three monotherapy antiepileptic drug (AEDs) trials and at least two polytherapy trials. Nineteen percent responded that all approved AEDs had to fail before a patient could be defined as medically refractory. Eighty-two percent of the respondents had referred patients for epilepsy surgery. Almost 50% were not satisfied with the level of communication from epilepsy centers. One-third reported serious complications resulting from surgery. These findings suggest that further education and improved communication from comprehensive epilepsy centers may shorten the time to referral and ultimately improve the lives of patients with epilepsy.

[Analysis of the results of a short-stay thoracic surgery program (2001-2005)]. / Análisis de los resultados del programa de corta estancia en cirugía torácica en el período 2001-2005.

INTRODUCTION: A short-stay thoracic surgery program was implemented and a prospective study was initiated to evaluate its results. OBJECTIVE: To analyze the results of the short-stay thoracic surgery program. PATIENTS AND METHOD: The results of 350 procedures (283 lobectomies and 67 pneumonectomies) performed between 2001 and 2005 were analyzed. The variables analyzed were: a) mean length of stay, b) mortality, c) complications, and d) readmission rate. RESULTS: The mean length of postoperative stay was 5.8 +/- 2.8 days for lobectomy and 5.36 +/- 1.8 days for pneumonectomy. Mortality was 3.5% in lobectomy and 3% in pneumonectomy. Complications occurred in 17.3% of lobectomies and 23.8% of pneumonectomies. The readmission rate was 7%. CONCLUSIONS: The results obtained show that, as expected, the short-stay thoracic surgery program reduces the mean length of hospital stay. Moreover, this program is safe, since mortality and morbidity were lower than or similar to the mean and the readmissions rate was similar to the national average. These results have encouraged us to continue the program started in 1998.

Lobotomy in Norwegian psychiatry.

Lobotomy is still a hidden chapter in the history of Norwegian psychiatry. The main reasons, which are discussed here, may have been the role of Ørnulv Ødegård at Gaustad Hospital in Oslo and the links between health authorities and the power élite in Norwegian psychiatry.

Psychosurgery.

The author describes the three commonly practiced surgical methods in the treatment of mental illness, i.e., cingulotomy, anterior capsulotomy, and posteromedial hypothalamotomy.

Regional cerebral blood flow changes in patients with intractable obsessive compulsive disorders treated by limbic leukotomy.

The object of this study is to assess the changes in regional cerebral blood flow (rCBF) following stereotactic limbic leukotomy in patients with medically intractable Obsessive-Compulsive Disorder (OCD). Technetium-99-Hexa Methyl Propylene Amine Oxime (99mTc-HMPAO) Single Photon Emission Computed Tomography (SPECT) data obtained before and after limbic leukotomy were subjected to image fusion with MRI images. Eight samples were obtained from healthy voluteers. After localization of the ROI (Region Of Interest) in anatomical area, rCBF measurements were obtained by METLAB. The results of this study show a change of rCBF following limbic leukotomy in intractable OCD. Postoperative 99mTc-HMPAO SPECT findings implicate the medial frontal cortex, cingulate and striatum, which culd be linked to limbic leukotomy that blocks the functional connection of corticolimbic loop.

SPECT-based tailoring of psychosurgical procedures: is it possible?

In contrast to the other areas of functional neurosurgery, psychosurgery has remained basically empiric and unchanged since the seventies, except for the recent suggestion to use chronic stimulation instead of ablative surgery. In this study, the authors investigated the value of SPECT abnormalities to guide psychosurgery and correlated the surgical results with the postoperative SPECT. This new approach, SPECT-based tailored psychosurgery, was applied in 4 of 11 patients referred for surgery, who fulfilled the inclusion criteria adopted. Excellent results were obtained in all of them after a follow-up of 30-52 months. Postoperative SPECT normalized in every case. We conclude, based on this small series, that it is possible to individualize and lateralize (tailor) psychosurgical procedures for every patient and that, to achieve this goal, SPECT is a rather impressive means and that postoperative SPECT closely correlated with the surgical results.

[The unknown history of lobotomy: women, children and idiots were lobotomized]. / Lobotomins okända historia: kvinnor, barn och idioter opererades.

The history of prefrontal lobotomy is an interesting example of medicine regarding as useful a treatment method which present-day consensus evaluates in a contrary fashion. A pilot study of archives from the Swedish state mental hospital Umedalen shows that the frequency of lobotomies as well as postoperative mortality were higher than what has earlier been assumed. The majority of the 704 patients who underwent lobotomy at Umedalen hospital were women. One unexpected finding concerns the numbers of mentally retarded patients and children who were subjected to lobotomy. Case records and other documents from the hospital archives indicate that the operation was performed largely for the benefit of the hospital rather than the patient, with an eye to engendering calm and order on the unruly wards.

[Lobotomy at the Gaustad hospital]. / Lobotomipraksis ved Gaustad sykehus.

The case records of 300 patients who were lobotomized, and 19 patients who had stereotaxic brain surgery during the period 1941-72 at Gaustad Hospital have been studied. The investigation shows that the practice of lobotomy was quite widespread. During the 1950s, lobotomy was carried out on broader indications than normally thought to be the case. Relatives were usually asked for their consent, but the information they received was often questionable. Many of the operations were fatal, particularly in the initial years, and this result can be traced to one specific surgeon.

The present status of psychosurgery in Australia and New Zealand.

OBJECTIVES: To assess the extent and nature of psychosurgery currently being performed in Australia and New Zealand, and the present status of legislation regulating its practice. METHODS: Details of current legislation were obtained through inspection of statutes and direct communication with Departments of Health. All full and associate members of the Neurosurgical Society of Australasia were surveyed by postal questionnaire. Ninety-eight neurosurgeons were surveyed, of whom 72 (73%) replied. RESULTS: In the 1980s a mean of nine (SD, 5.9) operations were performed per year; about two were performed per year in the late 1980s. Ninety per cent of these operations were performed at one centre in Sydney. The most common indications were severe and medically intractable depression and obsessive-compulsive disorder. Surgery is now exclusively stereotactic and involves the creation of lesions in the orbitomedial frontal or cingulate tracts or a combination of the two. The nature and type of surgery are comparable to those in other centres in the Western world. Regulatory legislation is in place in most, but not all, States in Australia and in New Zealand. CONCLUSIONS: Further developments of other forms of psychiatric treatments may make psychosurgery, in its present form and at its present level of validation, redundant. If it is to have a resurgence, it would have to be based on a much sounder theoretical premise, and a stronger demonstration of efficacy and predictability of effect.

Physical treatments in psychiatry: current and historical use in the southern United States.

Several surveys during the 1970s showed a decline in the use of electroconvulsive therapy (ECT). Psychosurgery, insulin coma, and continuous sleep treatment are widely assumed to be in total disuse. This is the first comprehensive survey on the use of physical treatments in psychiatry in the southern United States. Seventy-five percent of 315 surveys sent to psychiatric medical directors and chief residents were returned. ECT was used in 89% of training hospitals, 57% of Veterans Administration hospitals, and 44% of private hospitals, but only 19% of state hospitals within the last year. None of the 19 state hospitals begun since 1970 had started ECT services. Moreover, state hospitals abandoned ECT at a higher rate than private hospitals. The lack of this service in the public sector is a result of sociolegal pressure rather than lack of confidence or enthusiasm for ECT. The other physical treatments were reported to be in almost total disuse.