Do Ablative Neurosurgical Procedures Work for Treatment-Resistant Psychiatric Illness?

Contemporary ablative neurosurgical procedures were found to significantly improve symptoms of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD), according to study findings published in the Journal of Neurology, Neurosurgery and Psychiatry.

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

The researchers searched publication databases for psychiatric or psychological outcomes of patients who underwent ablative neurosurgical procedures.

A total of 43 studies that assessed outcomes of capsulotomy (n=26), cingulotomy (n=7), limbic leucotomy (n=5), and subcaudate tractotomy (n=5) for the treatment of patients with OCD (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 comprised 1414 patients with a mean age of 38 (standard deviation, 7.2) years, and 52.5% were women.

Overall, the effects of ablative procedures were associated with a significant decrease in MDD symptoms (effect size, 1.27; 95% CI, 0.94-1.60; P <.0001), with significant heterogeneity among the included studies (I², 78%; P <.01). After stratification by surgical procedure, the effect size on MDD symptom improvement was reported as 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 to 2.49) for limbic leucotomy, and 1.37 (95% CI, 0.68-2.06) for subcaudate tractotomy.

Similar to MDD symptoms, the overall effect of ablative procedures significantly decreased OCD symptoms (effect size, 2.25; 95% CI, 1.79-2.71; P <.0001), and heterogeneity among the included studies was also significant (I², 88%; P <.01). The effect sizes on OCD symptom improvement 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 leucotomy, and 0.62 (95% CI, -1.04 to 2.28) for subcaudate tractotomy.

In addition, the meta-analysis found that ablative procedures significantly decreased symptoms of GAD (effect size, 1.76; 95% CI, 1.24-2.29; P <.0001), with significant heterogeneity noted among the included studies (I², 89%; P <.01). After stratification by surgical procedure, the effect sizes on GAD symptom improvement 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 leucotomy, and 0.73 (95% CI, 0.09-1.37) for subcaudate tractotomy.

This study was limited as studies included in the analysis were published between 1968 and 2020, and the evolution of diagnostic criteria for some of the causative disorders may have introduced additional biases.

These data indicated that some contemporary ablative neurosurgical procedures may still be an effective treatment for symptoms associated with some treatment-resistant psychiatric disorders.

The researchers noted that “there is currently insufficient evidence to recommend one procedure over the others, although capsulotomy [was] associated with the greatest improvement in anxiety scores.”

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