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Chandler JA, Cabrera LY, Doshi P, Fecteau S, Fins JJ, Guinjoan S, Hamani C, Herrera-Ferrá K, Honey CM, Illes J, Kopell BH, Lipsman N, McDonald PJ, Mayberg HS, Nadler R, Nuttin B, Oliveira-Maia AJ, Rangel C, Ribeiro R, Salles A, Wu H. International Legal Approaches to Neurosurgery for Psychiatric Disorders. Front Hum Neurosci 2021; 14:588458. [PMID: 33519399 PMCID: PMC7838635 DOI: 10.3389/fnhum.2020.588458] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Neurosurgery for psychiatric disorders (NPD), also sometimes referred to as psychosurgery, is rapidly evolving, with new techniques and indications being investigated actively. Many within the field have suggested that some form of guidelines or regulations are needed to help ensure that a promising field develops safely. Multiple countries have enacted specific laws regulating NPD. This article reviews NPD-specific laws drawn from North and South America, Asia and Europe, in order to identify the typical form and contents of these laws and to set the groundwork for the design of an optimal regulation for the field. Key challenges for this design that are revealed by the review are how to define the scope of the law (what should be regulated), what types of regulations are required (eligibility criteria, approval procedures, data collection, and oversight mechanisms), and how to approach international harmonization given the potential migration of researchers and patients.
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Affiliation(s)
| | - Laura Y. Cabrera
- Center for Ethics & Humanities in the Life Sciences and Dept. Translational Neuroscience, Michigan State University, East Lansing, MI, United States
| | - Paresh Doshi
- Department of Neurosurgery, Jaslok Hospital and Research Center, Mumbai, India
| | - Shirley Fecteau
- Department of Psychiatry and Neurosciences, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- CERVO Brain Research Center, Center Intégré Universitaire en Santé et Services Sociaux de la Capitale-Nationale, Quebec City, QC, Canada
| | - Joseph J. Fins
- Weill Cornell Medical College, Consortium for the Advanced Study of Brain Injury, Weill Cornell and the Rockefeller University, New York, NY, United States
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT, United States
| | | | - Clement Hamani
- Harquail Center for Neuromodulation, Sunnybrook Research Institute, Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | | | - C. Michael Honey
- Section of Neurosurgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian H. Kopell
- Departments of Neurosurgery, Neurology, Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nir Lipsman
- Division of Neurosurgery, Harquail Center for Neuromodulation, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Patrick J. McDonald
- Division of Neurosurgery, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Head, Vancouver, BC, Canada
| | - Helen S. Mayberg
- Departments of Neurology, Neurosurgery, Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roland Nadler
- Peter A. Allard School of Law, University of British Columbia, Vancouver, BC, Canada
| | - Bart Nuttin
- Neurosurgeon, Katholieke Universiteit (KU) Leuven, Universitair Ziekenhuis (UZ) Leuven, Leuven, Belgium
| | - Albino J. Oliveira-Maia
- Champalimaud Research and Clinical Center, Champalimaud Center for the Unknown, Lisbon, Portugal
- NOVA Medical School, NMS, Universidade Nova De Lisboa, Lisbon, Portugal
| | - Cristian Rangel
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Arleen Salles
- Center for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
| | - Hemmings Wu
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Smit JV, Pielkenrood BJ, Arts RAGJ, Janssen ML, Temel Y, Stokroos RJ. Patient Acceptance of Invasive Treatments for Tinnitus. Am J Audiol 2018; 27:184-196. [PMID: 29507954 DOI: 10.1044/2017_aja-17-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 09/28/2017] [Indexed: 01/28/2023] Open
Abstract
PURPOSE The field of neuromodulation is currently seeking to treat a wide range of disorders with various types of invasive devices. In recent years, several preclinical trials and case reports in humans have been published on their potential for chronic tinnitus. However, studies to obtain insight into patients' willingness to undergo these treatments are scarce. The aim of this survey study was to find out whether tinnitus patients are willing to undergo invasive neuromodulation when taking its risks, costs, and potential benefits into account. METHOD A Visual Analog Scale (VAS, 0-10) was used to measure the outcome. Spearman's rank-order correlation coefficients were computed to determine the correlation between patient characteristics and acceptance rates. RESULTS Around one fifth of the patients were reasonably willing to undergo invasive treatment (VAS 5-7), and around one fifth were fully willing to do so (VAS 8-10). Hearing aids, used as a control, were accepted most, followed by cochlear implantation, deep brain stimulation, and cortical stimulation. Acceptance rates were slightly higher when the chance of cure was higher. Patients with a history of attempted treatments were more eager than others to find a new treatment for tinnitus. CONCLUSIONS A considerable proportion of patients with tinnitus would accept a variety of invasive treatments despite the associated risks or costs. When clinical neuromodulatory studies for tinnitus are to be performed, particular attention should be given to obtaining informed consent, including explaining the potential risks and providing a realistic outcome expectation.
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Affiliation(s)
- Jasper V. Smit
- Department of Ear, Nose, and Throat/Head and Neck Surgery, Maastricht University Medical Center, The Netherlands
| | - Bart J. Pielkenrood
- Department of Ear, Nose, and Throat/Head and Neck Surgery, Maastricht University Medical Center, The Netherlands
| | - Remo A. G. J. Arts
- Department of Ear, Nose, and Throat/Head and Neck Surgery, Maastricht University Medical Center, The Netherlands
| | - Miranda L. Janssen
- Department of Methodology and Statistics, Maastricht University Medical Center, The Netherlands
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, The Netherlands
| | - Robert J. Stokroos
- Department of Ear, Nose, and Throat/Head and Neck Surgery, Maastricht University Medical Center, The Netherlands
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Jung HH, Kim SJ, Roh D, Chang JG, Chang WS, Kweon EJ, Kim CH, Chang JW. Bilateral thermal capsulotomy with MR-guided focused ultrasound for patients with treatment-refractory obsessive-compulsive disorder: a proof-of-concept study. Mol Psychiatry 2015; 20:1205-11. [PMID: 25421403 DOI: 10.1038/mp.2014.154] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 09/29/2014] [Accepted: 10/08/2014] [Indexed: 11/09/2022]
Abstract
Despite optimal pharmacotherapy and cognitive-behavioral treatments, a proportion of patients with obsessive-compulsive disorder (OCD) remain refractory to treatment. Neurosurgical ablative or nondestructive stimulation procedures to treat these refractory patients have been investigated. However, despite the potential benefits of these surgical procedures, patients show significant surgery-related complications. This preliminary study investigated the use of bilateral thermal capsulotomy for patients with treatment-refractory OCD using magnetic resonance-guided focused ultrasound (MRgFUS) as a novel, minimally invasive, non-cranium-opening surgical technique. Between February and May 2013, four patients with medically refractory OCD were treated with MRgFUS to ablate the anterior limb of the internal capsule. Patients underwent comprehensive neuropsychological evaluations and imaging at baseline, 1 week, 1 month and 6 months following treatment. Outcomes were measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A), and treatment-related adverse events were evaluated. The results showed gradual improvements in Y-BOCS scores (a mean improvement of 33%) over the 6-month follow-up period, and all patients showed almost immediate and sustained improvements in depression (a mean reduction of 61.1%) and anxiety (a mean reduction of 69.4%). No patients demonstrated any side effects (physical or neuropsychological) in relation to the procedure. In addition, there were no significant differences found in the comprehensive neuropsychological test scores between the baseline and 6-month time points. This study demonstrates that bilateral thermal capsulotomy with MRgFUS can be used without inducing side effects to treat patients with medically refractory OCD. If larger trials validate the safety, effectiveness and long-term durability of this new approach, this procedure could considerably change the clinical management of treatment-refractory OCD.
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Affiliation(s)
- H H Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - S J Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - D Roh
- Department of Psychiatry, Chunchon Sacred Heart Hospital, Hallym University College of Medicine, Chunchon, Korea
| | - J G Chang
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - W S Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - E J Kweon
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - C-H Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - J W Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Abstract
At the Paris Colloquium held forty years ago, and which this paper celebrates, the issue of psychosurgery had not been tackled yet. At that time psychosurgery was tainted by the controversial history of lobotomy and leucotomy. Supporters of psychosurgery at the time of the Colloquium were preparing their fourth International Conference, which was held in Madrid the following year. This represented a key characteristic of the collective, institutional and symbolic action of psychosurgery practitioners. At the end of the seventies, their strategy changed as noted below. Furthermore, we focus on the special importance of the results presented and commented on by psychosurgery supporters, including its conception and classification throughout the rhetoric historically involved (its supposed ventriloquism, its persuasive strength). Based on this view, we suggest a critical reflection encompassing old and new psychosurgery, while questioning the value of new rhetorical devices for the assessment and presentation of psychosurgery results after the surge of Deep Brain Stimulation.
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Luyck K, Luyten L. Can electrical stimulation of the human bed nucleus of the stria terminalis reduce contextual anxiety? An unanswered question. Front Behav Neurosci 2015; 9:69. [PMID: 25852509 PMCID: PMC4362315 DOI: 10.3389/fnbeh.2015.00069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/01/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kelly Luyck
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven Leuven, Belgium
| | - Laura Luyten
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven Leuven, Belgium ; Psychology of Learning and Experimental Psychopathology, Psychology and Educational Sciences, KU Leuven Leuven, Belgium
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Nuttin B, Wu H, Mayberg H, Hariz M, Gabriëls L, Galert T, Merkel R, Kubu C, Vilela-Filho O, Matthews K, Taira T, Lozano AM, Schechtmann G, Doshi P, Broggi G, Régis J, Alkhani A, Sun B, Eljamel S, Schulder M, Kaplitt M, Eskandar E, Rezai A, Krauss JK, Hilven P, Schuurman R, Ruiz P, Chang JW, Cosyns P, Lipsman N, Voges J, Cosgrove R, Li Y, Schlaepfer T. Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders. J Neurol Neurosurg Psychiatry 2014; 85:1003-8. [PMID: 24444853 PMCID: PMC4145431 DOI: 10.1136/jnnp-2013-306580] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/30/2013] [Accepted: 12/18/2013] [Indexed: 12/02/2022]
Abstract
BACKGROUND For patients with psychiatric illnesses remaining refractory to 'standard' therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups. METHODS To expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments. FINDINGS The proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered 'established' in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients. INTERPRETATION This consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.
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Affiliation(s)
- Bart Nuttin
- Research Group of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
- Chair of Committee of Neurosurgery for Psychiatric Disorders of the WSSFN and Department of Neurosurgery, UZ Leuven, Leuven, Belgium
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
| | - Hemmings Wu
- Research Group of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Helen Mayberg
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - Marwan Hariz
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Clinical Neuroscience, UCL Institute of Neurology, Queen Square, London, Umea University, Umea, Sweden
| | - Loes Gabriëls
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Chair of the Committee of Neurosurgery for Psychiatric Disorders, Belgium and Belgium and Department of Psychiatry, UZ Leuven, Leuven, Belgium
| | - Thorsten Galert
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Deutsches Referenzzentrum für Ethik in den Biowissenschaften, Bonn, Germany
| | - Reinhard Merkel
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Universität Hamburg/Juristische Fakultät Lehrstuhl für Strafrecht und Rechtsphilosophie, Hamburg, Germany
| | - Cynthia Kubu
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Osvaldo Vilela-Filho
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosciences, Institute of Neurology of Goiânia, Stereotactic and Functional Neurosurgery Service, Medical School, Federal University of Goiás, Medical School, Pontifical Catholic University of Goiás, Goiânia, Brazil
| | - Keith Matthews
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Advanced Interventions Service and Division of Neuroscience, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Takaomi Taira
- Past-president of WSSFN and Chair of Committee of Stereotactic and Functional Neurosurgery, World Federation of Neurosurgical Societies (WFNS), and Department of Neurosurgery, World Federation of Neurosurgical Societies (WFNS), Tokyo Women's Medical University, Tokyo, Japan
| | - Andres M Lozano
- Past-president of WSSFN and Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Gastón Schechtmann
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery and Clinical Neuroscience, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Paresh Doshi
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Stereotactic and Functional Neurosurgery Program, Jaslok Hospital and Research Centre, Mumbai, India
| | - Giovanni Broggi
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery, Instituto Neurologico C. Besta, Milano, Italy
| | - Jean Régis
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Functional Neurosurgery, Hôpital La Timone, Aix-Marseille Université, Marseille, France
| | - Ahmed Alkhani
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, AlFaisal University, Riyadh, Saudi Arabia
| | - Bomin Sun
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Center for Functional Neurosurgery, Shanghai Jiao Tong University Rui Jin Hospital, Shanghai, China
| | - Sam Eljamel
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Centre of Neurosciences Department of Neurosurgery, Ninewells Hospital and Medical School Dundee, Dundee, Scotland, UK
| | - Michael Schulder
- Department of Neurosurgery, Hofstra North Shore LIJ School of Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - Michael Kaplitt
- Member of the Psychiatric Surgery Committee of the ASSFN and Department of Neurological Surgery, Weill Cornell Medical College, NY, USA
| | - Emad Eskandar
- Member of the Psychiatric Surgery Committee of the ASSFN and Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Rezai
- Past President, American Society of Stereotactic and Functional Neurosurgery (ASSFN), Department of Neurosurgery, American Society of Stereotactic and Functional Neurosurgery (ASSFN), Ohio State University, Ohio, USA
| | - Joachim K Krauss
- President of ESSFN and WSSFN, Department of Neurosurgery, Medical University of Hannover, Hannover, Germany
| | | | - Rick Schuurman
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Pedro Ruiz
- President of WPA, Department of Psychiatry and Behavioral Sciences, Miami Miller School of Medicine, Miami, USA
| | - Jin Woo Chang
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- President of Asian Australasian Society for Stereotactic & Functional Neurosurgery Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Paul Cosyns
- Committee of Neurosurgery for Psychiatric Disorders, Belgium, Kortenberg, Belgium
| | - Nir Lipsman
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Juergen Voges
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University Magdeburg and Leibniz-Institute for Neurobiology, Magdeburg, Germany
| | - Rees Cosgrove
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery, Brown University, Providence, RI, USA
| | - Yongjie Li
- Department of Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Thomas Schlaepfer
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Chair of the Focus Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’, Chair of the Task Force on Brain Stimulation of the World Federations of Societies of Biological Psychiatry, Chair of the Section of Experimental Brain Stimulation Methods of the German Association of Psychiatry, Psychotherapy and Psychosomatics and member of the Operational Committee on Sections of the World Psychiatric Association. He is professor of Psychiatry and Psychotherapy at the University of Bonn, Germany, and Associate Professor of Psychiatry and Mental Health at The Johns Hopkins University, Baltimore, MD, USA
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Suetens K, Nuttin B, Gabriëls L, Van Laere K. Differences in metabolic network modulation between capsulotomy and deep-brain stimulation for refractory obsessive-compulsive disorder. J Nucl Med 2014; 55:951-9. [PMID: 24722531 DOI: 10.2967/jnumed.113.126409] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 01/01/2014] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Around 7%-10% of patients with obsessive-compulsive disorder (OCD) are refractory to first-line treatment. Neurosurgical approaches are available such as capsulotomy or deep-brain stimulation (DBS). There is strong evidence for central involvement of the corticostriatopallidothalamocortical (CSPTC) circuit in OCD, but the exact mechanism through which these interventions lead to clinical improvement and potential differences in network modulation are not fully understood. METHODS In total, 13 capsulotomy patients (aged 29-59 y, 10 men and 3 women) and 16 DBS patients (aged 25-56 y, 6 men and 10 women) were prospectively included. (18)F-FDG PET was performed before and after capsulotomy and before and after DBS in both stimulation-on and stimulation-off conditions. Presurgical scans were compared with scans of healthy volunteers using SPM8 and global scaling, and metabolic changes after DBS were compared with changes after capsulotomy. Correlations with clinical improvements were investigated using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Hamilton Depression Rating Scale (HAM-D). RESULTS Both groups had similar pretreatment clinical morbidity as assessed by Y-BOCS and the Hamilton Depression Rating Scale. Preoperative superior frontal and supplementary motor cortex hypometabolism was common to both patient groups, and the subgenual anterior cingulate, occipital cortex (cuneus), and posterior cerebellum were relatively hypermetabolic. Postoperative metabolic decreases were common to both interventions in the anterior cingulate and the prefrontal and orbitofrontal cortices. Compared with DBS, capsulotomy resulted in more intense metabolic changes, with additional significant decreases in the mediodorsal thalamus, caudate nucleus, and cerebellum as well as increases in the precuneus and the fusiform and lingual gyrus. The stimulation-off condition of DBS patients showed no significant differences from the preoperative state. Improvement in Y-BOCS scores correlated with metabolic changes in the occipital cortex. Baseline metabolism in the subgenual anterior cingulate and superior temporal cortices were related to postoperative improvement of depressive symptoms. CONCLUSION Capsulotomy and DBS lead to similar clinical improvement and similar metabolic network changes in the CSPTC circuit, with a prominent role for the subgenual anterior cingulate and other core structures of the CSPTC. However, metabolic changes are more pronounced and extended in capsulotomy than in DBS. Furthermore, cortical regions outside the CSPTC may also play an important role in OCD symptomatology.
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Affiliation(s)
- Kristin Suetens
- Nuclear Medicine and Molecular Imaging, University Hospital and KU Leuven, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, University Hospital and KU Leuven, Leuven, Belgium; and
| | - Loes Gabriëls
- Department of Psychiatry, University Hospital and KU Leuven, Leuven, Belgium
| | - Koen Van Laere
- Nuclear Medicine and Molecular Imaging, University Hospital and KU Leuven, Leuven, Belgium
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8
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Garnaat SL, Greenberg BD, Sibrava NJ, Goodman WK, Mancebo MC, Eisen JL, Rasmussen SA. Who qualifies for deep brain stimulation for OCD? Data from a naturalistic clinical sample. J Neuropsychiatry Clin Neurosci 2014; 26:81-6. [PMID: 24515679 PMCID: PMC4093791 DOI: 10.1176/appi.neuropsych.12090226] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A few patients with obsessive-compulsive disorder (OCD) remain severely impaired despite exhausting best-practice treatments. For them, neurosurgery (stereotactic ablation or deep brain stimulation) might be considered. The authors investigated the proportion of treatment-seeking OCD patients, in a naturalistic clinical sample, who met contemporary neurosurgery selection criteria. Using comprehensive baseline data on diagnosis, severity, and treatment history for adult patients from the NIMH-supported Brown Longitudinal OCD Study, only 2 of 325 patients met screening criteria for neurosurgery. This finding prompts consideration of new models for clinical trials with limited samples as well as methods of refining entry criteria for such invasive treatments.
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Affiliation(s)
- Sarah L. Garnaat
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
| | - Benjamin D. Greenberg
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
| | - Nicholas J. Sibrava
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
| | - Wayne K. Goodman
- Department of Psychiatry, Mt. Sinai Hospital, New York, NY 10029, USA
| | - Maria C. Mancebo
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
| | - Jane L. Eisen
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
| | - Steven A. Rasmussen
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02906, USA
- Butler Hospital, Providence, RI 02906, USA
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Tierney TS, Abd-El-Barr MM, Stanford AD, Foote KD, Okun MS. Deep brain stimulation and ablation for obsessive compulsive disorder: evolution of contemporary indications, targets and techniques. Int J Neurosci 2013; 124:394-402. [PMID: 24099662 DOI: 10.3109/00207454.2013.852086] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Surgical therapy for treatment-resistant obsessive compulsive disorder (OCD) remains an effective option for well-selected patients managed within a multidisciplinary setting. Historically, lesions within the limbic system have been used to control both obsessive thoughts and repetitive compulsions associated with this disease. We discuss classical targets as well as contemporary neuromodulatory approaches that have been shown to provide symptomatic relief. Recently, deep brain stimulation (DBS) of the anterior limb of the internal capsule/ventral striatum received Conformité Européene (CE) mark and Food and Drug Administration (FDA) approvals for treatment of intractable OCD. Remarkably, this is the first such approval for neurosurgical intervention in a strictly psychiatric indication in modern times. This target is discussed in detail along with alternative targets currently being proposed. We close with a discussion of gamma knife capsulotomy, a modality with deep historical roots. Further directions in the surgical treatment of OCD will require better preoperative predictors of postoperative responses, optimal selection of individualized targets, and rigorous reporting of adverse events and standardized outcomes. To meet these challenges, centers must be equipped with a multidisciplinary team and patient-centered approach to ensure adequate screening and follow up of patients with this difficult-to-treat condition.
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Affiliation(s)
- Travis S Tierney
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Deep-brain stimulation for anorexia nervosa. World Neurosurg 2012; 80:S29.e1-10. [PMID: 22743198 DOI: 10.1016/j.wneu.2012.06.039] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 05/25/2012] [Accepted: 06/21/2012] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Anorexia nervosa (AN) is a complex and severe, sometimes life-threatening, psychiatric disorder with high relapse rates under standard treatment. After decades of brain-lesioning procedures offered as a last resort, deep-brain stimulation (DBS) has come under investigation in the last few years as a treatment option for severe and refractory AN. METHODS AND RESULTS In this jointly written article, Sun et al. (the Shanghai group) report an average of 65% increase in body weight in four severe and refractory patients with AN after they underwent the DBS procedure (average follow-up: 38 months). All patients weighed greater than 85% of expected body weight and thus no longer met the diagnostic criteria of AN at last follow-up. Nuttin et al. (the Leuven group) describe other clinical studies that provide evidence for the use of DBS for AN and further discuss patient selection criteria, target selection, and adverse event of this evolving therapy. CONCLUSION Preliminary results from the Shanghai group and other clinical centers showed that the use of DBS to treat AN may be a valuable option for weight restoration in otherwise-refractory and life-threatening cases. The nature of this procedure, however, remains investigational and should not be viewed as a standard clinical treatment option. Further scientific investigation is essential to warrant the long-term efficacy and safety of DBS for AN.
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Barbier J, Gabriëls L, van Laere K, Nuttin B. Successful Anterior Capsulotomy in Comorbid Anorexia Nervosa and Obsessive-Compulsive Disorder: Case Report. Neurosurgery 2011; 69:E745-51; discussion E751. [DOI: 10.1227/neu.0b013e31821964d2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE:
State-of-the-art treatment of anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) often proves ineffective. Both disorders have common features, and anterior capsulotomy is a last-resort treatment for OCD. We document the effect of bilateral anterior capsulotomy in a patient with comorbid AN and OCD.
CLINICAL PRESENTATION:
A 38-year-old woman with life-threatening, chronic, treatment-refractory AN and OCD underwent anterior capsulotomy. Psychiatric and neuropsychological evaluations at baseline and at follow-up document the severity and progress of the case. Bilateral anterior capsulotomy resulted in normalization of eating pattern and weight and a significant decrease of food-related and overall obsessive-compulsive symptoms. Psychiatric evaluations and exposure to food cues confirmed the clinical improvement that was evident immediately after surgery and sustained at 3-month follow-up.
CONCLUSION:
This case report suggests that bilateral anterior capsulotomy can be a therapeutic option for patients with comorbid AN and OCD. However, a well-controlled study is warranted.
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Affiliation(s)
- Johan Barbier
- Departments of Neurosciences and Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Loes Gabriëls
- Departments of Neurosciences and Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Koen van Laere
- Departments of Medical Imaging and Nuclear Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bart Nuttin
- Departments of Neurosciences and Experimental Neurosurgery and Neuroanatomy, Katholieke Universiteit Leuven, Leuven, Belgium
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Invasive circuitry-based neurotherapeutics: stereotactic ablation and deep brain stimulation for OCD. Neuropsychopharmacology 2010; 35:317-36. [PMID: 19759530 PMCID: PMC3055421 DOI: 10.1038/npp.2009.128] [Citation(s) in RCA: 268] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Psychiatric neurosurgery, specifically stereotactic ablation, has continued since the 1940s, mainly at a few centers in Europe and the US. Since the late 1990s, the resurgence of interest in this field has been remarkable; reports of both lesion procedures and the newer technique of deep brain stimulation (DBS) have increased rapidly. In early 2009, the US FDA granted limited humanitarian approval for DBS for otherwise intractable obsessive-compulsive disorder (OCD), the first such approval for a psychiatric illness. Several factors explain the emergence of DBS and continued small-scale use of refined lesion procedures. DBS and stereotactic ablation have been successful and widely used for movement disorders. There remains an unmet clinical need: current drug and behavioral treatments offer limited benefit to some seriously ill people. Understandings of the neurocircuitry underlying psychopathology and the response to treatment, while still works in progress, are much enhanced. Here, we review modern lesion procedures and DBS for OCD in the context of neurocircuitry. A key issue is that clinical benefit can be obtained after surgeries targeting different brain structures. This fits well with anatomical models, in which circuits connecting orbitofrontal cortex (OFC), medial prefrontal cortex (mPFC), basal ganglia, and thalamus are central to OCD pathophysiology and treatment response. As in movement disorders, dedicated interdisciplinary teams, here led by psychiatrists, are required to implement these procedures and maintain care for patients so treated. Available data, although limited, support the promise of stereotactic ablation or DBS in carefully selected patients. Benefit in such cases appears not to be confined to obsessions and compulsions, but includes changes in affective state. Caution is imperative, and key issues in long-term management of psychiatric neurosurgery patients deserve focused attention. DBS and contemporary ablation also present different patterns of potential benefits and burdens. Translational research to elucidate how targeting specific nodes in putative OCD circuitry might lead to therapeutic gains is accelerating in tandem with clinical use.
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Rabins P, Appleby BS, Brandt J, DeLong MR, Dunn LB, Gabriëls L, Greenberg BD, Haber SN, Holtzheimer PE, Mari Z, Mayberg HS, McCann E, Mink SP, Rasmussen S, Schlaepfer TE, Vawter DE, Vitek JL, Walkup J, Mathews DJH. Scientific and ethical issues related to deep brain stimulation for disorders of mood, behavior, and thought. ACTA ACUST UNITED AC 2009; 66:931-7. [PMID: 19736349 DOI: 10.1001/archgenpsychiatry.2009.113] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT A 2-day consensus conference was held to examine scientific and ethical issues in the application of deep brain stimulation for treating mood and behavioral disorders, such as major depression, obsessive-compulsive disorder, and Tourette syndrome. OBJECTIVES The primary objectives of the conference were to (1) establish consensus among participants about the design of future clinical trials of deep brain stimulation for disorders of mood, behavior, and thought and (2) develop standards for the protection of human subjects participating in such studies. RESULTS Conference participants identified 16 key points for guiding research in this growing field. CONCLUSIONS The adoption of the described guidelines would help to protect the safety and rights of research subjects who participate in clinical trials of deep brain stimulation for disorders of mood, behavior, and thought and have further potential to benefit other stakeholders in the research process, including clinical researchers and device manufactures. That said, the adoption of the guidelines will require broad and substantial commitment from many of these same stakeholders.
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Affiliation(s)
- Peter Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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Neurosurgical treatment of mood disorders: traditional psychosurgery and the advent of deep brain stimulation. Curr Opin Psychiatry 2009; 22:25-31. [PMID: 19122531 DOI: 10.1097/yco.0b013e32831c8475] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW From its peak in the 1940s and 1950s, psychosurgery (or, neurosurgery for psychiatric disorders) has had a gradual decline, with only a few centers around the world continuing with the procedure into the 1980s and 1990s. With recent developments in brain stimulation techniques, the continuing relevance of psychosurgery in the treatment of psychiatric disorders is worthy of examination. RECENT FINDINGS A review of databases (PubMed, Medline, Current Contents and Embase) suggests that psychosurgery in the form of stereotactic focal ablation is still practiced in a few centers, although the number has decreased further from the 1990s. Procedures have not changed substantively, although modern imaging and stereotaxy have made them more precise. No good predictors of treatment response have been identified. There is a major shift in interest to deep brain stimulation (DBS) instead of ablative surgery. Studies of DBS in resistant depression and obsessive-compulsive disorder have been few and have involved small numbers, but this field is growing rapidly. SUMMARY Although ablative psychosurgery using stereotactic procedures continues to be used to a small extent, psychiatrists remain ambivalent about this procedure. The baton of psychosurgery, however, appears to have been passed on to DBS, but more data are needed on technical details and outcomes before the possible therapeutic role of DBS can be established.
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