Severe Refractory Obsessive Compulsive Disorder and Depression: Should We Consider Stereotactic Neurosurgery?

Abstract

Functional neurosurgery involves modulation of activity within neural circuits that drive pathological activity. Neurologists and neurosurgeons have worked closely together, advancing the field for over a century, such that neurosurgical procedures for movement disorders are now accepted as “standard of care”, benefiting hundreds of thousands of patients. As with movement disorders, some neuropsychiatric illnesses, including obsessive compulsive disorder and depression, can be framed as disorders of neural networks. Over the past two decades, evidence has accumulated that stereotactic neurosurgery can help some patients with mental disorders. Nevertheless, despite the availability of class I evidence for some interventions, there is a huge mismatch between the prevalence of severe refractory mental disorders and the number of referrals made to specialised functional neurosurgery services. This paper examines the historical trajectory of neurosurgery for movement and mental disorders. A review of neurosurgical techniques, including stereotactic radiofrequency ablation, gamma knife, deep brain stimulation, and magnetic resonance imaging guided focused ultrasound, explains the high degree of safety afforded by technological advances in the field. Evidence from clinical trials supporting functional neurosurgery for mental disorders, including obsessive compulsive disorder and depression, is presented. An improved understanding of modern functional neurosurgery should foster collaboration between psychiatry and neurosurgery, providing hope to patients whose symptoms are refractory to all other treatments.

Keywords:

• stereotactic neurosurgery
• deep brain stimulation
• obsessive compulsive disorder
• major depression
• stereotactic ablation
• focused ultrasound

Abbreviations

ACAPS, anterior capsulotomy; ACING, anterior cingulotomy; ALIC, anterior limb of the internal capsule; amSTN, anteromedial subthalamic nucleus; DBS deep brain stimulation; FUS, Focused Ultrasound; GK, gamma knife; GPi, globus pallidus pars internus; GTS, Gilles de la Tourette Syndrome; MDD, Major depressive disorder; MRI, magnetic resonance imaging; NHS, National Health Service; OCD, obsessive compulsive disorder; RCT, randomized controlled trial; RFA, radiofrequency ablation; TRD, treatment-refractory depression; UK, United Kingdom; Y-BOCS, Yale-Brown Obsessive compulsive score.

Ethics Statement

Written informed consent was obtained for publication of the images in Figure 2.

Acknowledgments

This paper is based on the International Neuropsychiatry Association Lishman Lecture, delivered at the Royal College of Psychiatrists, London, UK, on September 16, 2022. The Functional Neurosurgery Unit is supported by the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre.

Disclosure

The author acts as a Consultant for Boston Scientific, Insightec, and Medtronic. The authors also reports Honoraria for educational activities from Medtronic, Boston Scientific, BrainLab, and InoMed. The author reports no other conflicts of interest in this work.