The management of treatment-resistant affective disorder: clinical perspectives

Management of resistant depression

The inadequate assessment and management of depression can lead to the erroneous diagnosis of treatment resistance. After briefly considering the definition and diagnosis of resistant depression, the authors describe the principles and methods of antidepressant therapy, emphasizing the systematic use of medication and the importance of therapeutic drug monitoring. The application of these is then discussed in a clinical context, and illustrated with examples.

The frontal lobes and neurosurgery for psychiatric disorders

The frontal lobe has been the main target for surgical treatment of mental illness over the last 60 years. Initially the surgery was crude and performed on patients with many different psychiatric disorders. Contemporary surgery utilizes stereotactic lesions which interrupt fronto-thalamic and/or fronto-cingulate fibres. The findings of clinical, neurochemical, neuroimaging, neuropsychological and physiological research in this area are summarized. Current advances in clinical neuroscience methods should be used in patients with these lesions to elucidate the neural substrate of post-operative changes and optimize clinical practice.

Neurosurgery for mental disorders (NMD) A clinical worldwide perspective: past, present and future

The use of neurosurgery for mental disorders (NMD) is a clinical issue that involves many ethical considerations. It is a treatment that offers hope for many patients with severe and debilitating affective and anxiety disorders and should be widely available. Its current use worldwide (UK, Sweden, US, Australasia, Europe) is reviewed and the types of procedures currently used are explained (stereotactic subcaudate tractotomy, anterior capsulotomy, cingulotomy, limbic leucotomy). In addition, clinical strategies for the evaluation and management of patients both prior to and following NMD are discussed.