Neurological

Do ablative neurosurgical procedures work in treatment-resistant psychiatric diseases?

Research published in the Journal of Neurology, Neurosurgery and Psychiatry found that modern ablative neurosurgical procedures significantly improve symptoms of major depression (MDD), obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD).

Pharmacological and psychotherapeutic approaches have helped improve symptoms in patients with psychiatric disorders over the past 60 years. However, patients with treatment-resistant psychiatric illnesses continue to struggle with a reduced quality of life and an increased risk of suicide. Researchers at the University of Toronto conducted a study to assess whether modern ablative procedures lead to significant improvement in symptoms of MDD, OCD, and GAD.

The researchers searched publication databases for psychiatric or psychological results from patients undergoing ablative neurosurgical procedures.

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A total of 43 studies evaluating the results of capsulotomy (n = 26), cingulotomy (n = 7), limbic leukotomy (n = 5), and subcaudatic tractotomy (n = 5) for the treatment of patients with obsessive-compulsive disorder (n = 24), MDD (n = 5), bipolar disorder (n = 3), GAD (n = 2), anorexia nervosa (n = 1), or mixed indications (n ​​= 8) were included in this analysis.

The study cohort included 1414 patients with a mean age of 38 (standard deviation 7.2) years and 52.5% were women.

Overall, the effects of ablative methods were associated with a significant decrease in MDD symptoms (effect size 1.27; 95% CI 0.94-1.60; P <0.0001), with significant heterogeneity among the included studies (I2, 78 %; P <.01). After stratification by surgical procedure, the effect size on improvement in MDD symptoms was 1.42 (95% CI, 1.00-1.84) for capsulotomy, 0.68 (95% CI, 0.13-1.23 ) for cingulotomy, 1.22 (95% CI, -0.06.) indicated to 2.49 for the limbic leukotomy and 1.37 (95% CI, 0.68-2.06) for the subcaudatal tractotomy.

Similar to MDD symptoms, the overall effect of the ablative procedures significantly reduced OCD symptoms (effect size 2.25; 95% CI 1.79-2.71; P <0.0001), and there was also heterogeneity between the included studies significant (I2, 88%; P <.01). The effect sizes on the improvement in OCD symptoms were 2.28 (95% CI, 1.75-2.81) for capsulotomy, 1.92 (95% CI, 0.52-3.32) for cingulotomy, 3, 58 (95% CI, 0.94–6.21) for limbic leukotomy and 0.62 (95% CI, -1.04 to 2.28) for subcaudatal tractotomy.

In addition, the meta-analysis showed that ablative procedures significantly reduced the symptoms of GAD (effect size 1.76; 95% CI 1.24-2.29; P <0.0001), with significant heterogeneity found between the included studies ( I2, 89%; P <.01). After stratification by surgical procedure, the effect sizes on improvement in GAD symptoms were 2.02 (95% CI, 1.37-2.68) for capsulotomy, 1.21 (95% CI, 0.56-1, 86) for cingulotomy, 1.00 (95% CI, 0.26-1.74) for limbic leukotomy, and 0.73 (95% CI, 0.09-1.37) for subcaudatal tractotomy.

This study was limited because studies included in the analysis were published between 1968 and 2020 and the development of diagnostic criteria for some of the causative disorders may have introduced additional bias.

These data showed that some modern ablative neurosurgical procedures may still be effective in treating symptoms associated with some treatment-resistant psychiatric disorders.

The researchers noted that “there is currently not enough evidence to favor one procedure over the other, despite the capsulotomy” [was] associated with the greatest improvement in anxiety levels. “

reference

Davidson B, Eapen-John D, Mithani K, et al. Lesional Psychiatric Neurosurgery: Meta-Analysis of Clinical Outcomes Using a Transdiagnostic Approach. J Neurol Neurosurg Psychiatry. Published online July 14, 2021. doi: 10.1136 / jnnp-2020-325308

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