True to an ignoble tradition of lending its "authoritative" front page to promote psychiatry’s most radical experimental approaches to dealing with patients disabled by mental illness, today’s front and center article in The New York Times, "Surgery for Mental Ills Offers Both Hope and Risk," by Benedict Carey, sends an optimistic positive spin on psychiatry’s current spade of experimental brain surgeries.
A large photograph–rather than compelling evidence–attempts to lend the story significance.

The article acknowledges that the new surgeries are not backed by new scientific evidence of their benefit to justify the serious risks involved:

"The great promise of neuroscience at the end of the last century was that it would revolutionize the treatment of psychiatric problems. But the first real application of advanced brain science is not novel at all. It is a precise, sophisticated version of an old and controversial approach: psychosurgery, in which doctors operate directly on the brain."

Indeed, Paul Root Wolpe, a medical ethicist at Emory University, acknowledges the high risk experimental procedures that patients are being put through:

“We have this idea — it’s almost a fetish — that progress is its own justification, that if something is promising, then how can we not rush to relieve suffering?” 

But, Dr. Wolpe reminds readers, "It was not so long ago, he noted, that doctors considered the frontal lobotomy a major advance — only to learn that the operation left thousands of patients with irreversible brain damage. Many promising medical ideas have run aground, and that’s why we have to move very cautiously.”

Despite "large gaps" in the neurosurgeons’ understanding of the brain circuits they are operating on,  several surgeries are currently being promoted:
cingulotomy, capsulotomy, brain stimulation (DBS), and radiation (gamma knife surgery)
–all pose high risk for patients with little demonstrable evidence of success.

In cingulotomy, doctors drill into the skull and thread wires into an area of the brain called the anterior cingulate.
"There they pinpoint and destroy pinches of tissue that lie along a circuit in each hemisphere that connects deeper, emotional centers of the brain to areas of the frontal cortex, where conscious planning is centered."

"This circuit appears to be hyperactive in people with severe O.C.D., and imaging studies suggest that the surgery quiets that activity."
The evidence to justify the risks does not exist: neurosurgeons proceed on what  "appears" and imaging studies that "suggest" but do not demonstrate.
 
In capsulotomy, "surgeons go deeper, into an area called the internal capsule, and burn out spots in a circuit also thought to be overactive."

Surgeons who perform DBS, sink wires into the brain but leave them in place. "A pacemaker-like device sends a current to the electrodes, apparently interfering with circuits thought to be hyperactive in people with obsessive-compulsive disorder (and also those with severe depression). The current can be turned up, down or off, so deep brain stimulation is adjustable and, to some extent, reversible."

In the technique described in the Times article, called gamma knife surgery,
"Doctors place the patient in an M.R.I.-like machine that sends beams of radiation into the skull. The beams pass through the brain without causing damage, except at the point where they converge. There they burn out spots of brain tissue…"

Underscoring the danger these latest neurosurgical procedures pose, Dr. Darin D. Dougherty, director of the division of neurotherapeutics at Massachusetts General Hospital and an associate professor of psychiatry at Harvard, put it more bluntly.

" Given the history of failed techniques, like frontal lobotomy,  if this effort somehow goes wrong, it’ll shut down this approach for another hundred years.”

The evidence, from a small long-term follow-up study, reported by the respected Swedish Karolinska Institute in the Archives of General Psychiatry, [1]  found that 50% of 25 patients treated with any of the commonly used surgeries for OCD, showed that response rates did not differ significantly between surgical methods.

"Only 3 patients were in remission without adverse effects at long-term follow-up."

"One of the 9 patients undergoing radiosurgery (patient 20) developed a right-sided radiation necrosis with subsequent apathy, memory problems, and executive dysfunction. Another (patient 10) developed a brain edema that reached its peak size 1 year after surgery; the patient was hospitalized with symptoms of apathy, incontinence, and seizures. At long-term follow-up, urinary incontinence, apathy, and executive problems persisted. In both cases, complications may have been caused by too high a radiation dose. Another patient who underwent multiple thermocapsulotomies (patient 8) had persistent urinary incontinence at long-term follow-up. Symptoms of apathy and poor self-control for years afterward." 

"A mean weight gain of 6 kg was reported in the first postoperative year. Ten patients were considered to have significant problems with executive functioning, apathy, or disinhibition. Six of these 10 patients had received high doses of radiation or had undergone multiple surgical procedures."

Conclusions:  "Capsulotomy is effective in reducing OCD symptoms. There is a substantial risk of adverse effects, and the risk may vary between surgical methods. Our findings suggest that smaller lesions are safer and that high radiation doses and multiple procedures should be avoided."

The invariably positive claims made by proponents of neurosurgery are likely explained by the inherent bias of these stakeholders. As Dr. Christian Ruck, the lead author of the Swedish paper, published in the Archives of General Psychiatry correctly notes:

"An inherent problem in most research is that innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid."

So why, did the New York Times once again, see fit to publicize admittedly high risk, radical surgical procedures that demonstrably cause at least half of the patients serious long-term debilitating adverse effects that undermine their quality of life? [2]

**The answer to that question comes to us from an expert academic in the field:

"Because psychiatry is the religion of modern America, and as faith in psychiatry has eroded lately, our  thought leaders are dredging up old psychiatric idols who might re-energize the faithful…"

Reference:

1. Christian Rück, MD, PhD; Andreas Karlsson, MS; J. Douglas Steele, MD, PhD, MRCPsych; Gunnar Edman, PhD; Björn A. Meyerson, MD, PhD; Kaj Ericson, MD, PhD; Håkan Nyman, PhD; Marie Åsberg, MD, PhD; Pär Svanborg, MD, PhD
Capsulotomy for Obsessive-Compulsive Disorder: Long-term Follow-up of 25 Patients
Arch Gen Psychiatry . 2008;65(8):914-921.

2. See NYT Archive on psychosurgery:
For example, in 1948, the Times reported: "A revolutionary discovery about mental illness, which has already resulted in surgical cures with no apparent ill effects for a group of asylum inmates who had been considered hopelessly insane, was revealed to a specially called meeting at the New York Society of Neuro-surgery yesterday."
SURGERY RESTORES ‘INCURABLY’ INSANE: Revolutionary Brain Operation Called Topectomy Removes Tissues in Certain Areas Mar 19, 1948.

Posted by Vera Hassner Sharav