PSYCHOSURGERY AND THE TREATMENT OF
RESISTANT DEPRESSION
PSYCHOSURGERY
(Neurosurgery for some psychiatric
illnesses)
Operations in UK now for psychiatric disorders.
|
|
Approximate Number over year |
|
Stereotactic limbic leucotomy, |
4 |
|
Stereotac- subcaudate
tractotomy(SST) |
20 |
|
Other |
2 |
All SST are done at the Geoffrey Knight
National Unit for Disorders, Brook General Hospital, London.
Amygdalotomy
is done for pathological aggression.
Stereotactic
limbic leucotomy is for obsessional-compulsive disorders and one reported case of Gilles de la Tourette has
been treated.
Stereotactic subcaudate tractotomy is for
unipolar and bipolar ~ affective
disorders, obsessive compulsive disorder with affective
symptoms,
and intractable anxiety and phobic disorder, and tension states which do
not respond to conventional treatments.
Resistant Affective Disorder:
1. What
is resistance?
2. Is
the diagnosis right?
3. Have
other organic illnesses been excluded?
4. Has
patient received adequate therapy? For
how long?
Adequate
Therapy:
1.Tricyclic antidepressants or monamine
oxidase inhibitors; alone or in combination as below. The dose should be limited by side effects and not by
recommended doses in these intractable cases.
2. Lithium and Carbamazepine - antimanic
and prophylactic on their own. They
have antidepressant properties especially in combination with drug
from 1 (above)
3. Other
Augmentors
L-tryptophan (now restricted to named
patients only)
5 Hydroxytryptophan (Van Praag)
Thioridazine
L-triiodothyronine (said to be best in rapid cycling illnesses)
Thyroxine
4. New
Antidepressants
5HT reuptake blockade:
Fluvoxamine
Fluoxetine
Sertraline
Paroxetine
5. MAOI
and TCA combinations
6. Psychotherapy - behavioral very
important for obsessional illness.
Cognitive/behavioral for anxiety states.
7. ECT - Preferably two courses at
least should have failed with an interval of months between before
consideration of psychosurgery.
Referral:
Consider
- Lack of response
- Severity
of illness
- Life
threat
- Stupor
- Cycling
of illness
Unfortunately
no marker exists for 'biological depression' and even less for 'likelihood of
response' since outcome may not be related to diagnoses, at least as they are
conceptualized at present.
Other
Concepts:
- Double
depression
- Cognitive
lag
- Unipolar depression
developing early may
lead to chronicity/inability of
developing coping strategies
- Secondary
disability
For all
these reasons rehabilitation post-operatively is very important in order to
complement post-operative improvement and rebuild life.
Mental
Health Act:
Surgery
needs:
a) The
patients freely giving consent
b)
Second opinion under Section 57.
Three
Commissioners (one being a psychiatrist) visit and interview:
i) Patient
ii) Relative if possible
iii) RMO*
iv) Nurse*
v) Non-nurse, non-doctor* (*Involved with
case)
They
certify that the patient is giving informed consent and the medical member also
certifies that the treatment is likely to alleviate the condition or stop it
worsening.
History:
In 1935 a paper
was presented reporting on the effects of ablation of the frontal brain areas
of chimpanzees. One of the observations
was that some of the more excitable animals became much calmer following the
surgery.
That year
Moniz and Lima, in Portugal, started by injecting alcohol in the frontal lobes
and then they cut cores out of the frontal white matter.
Freeman
and Watts in the next year popularized standard prefrontal lobotomy in the US.
Side effects and complications were high but this was balanced against 20% of
schizophrenic patients being discharged from hospital when there were no other treatments
available.
However,
prefrontal leucotomy became obsolete in the 1950's when chlorpromazine became
available. since then the indications for subsequent psychosurgery has not
include schizophrenia but has been largely and related disorders.