Neurosurgery for mental disorder

Dr Persaud provides an ardent but ultimately flawed argument in favour of allowing neurosurgery for mental disorder (NMD) to die out (Persaud/Crossley & Freeman, 2003).

Patients who are considered for NMD are among the most severely ill and disabled who come into contact with any branch of the medical profession, and such presentations merit conceptualisation as rather more than having ‘psychological problems’.

It is also disingenuous to argue that ‘psychosurgery’ (sic) tries to locate complex psychiatric disorders in ‘one so-called “abnormal” brain region’. Such hangovers from Cartesian dualism fail to advance clinical neuroscience or the practice of psychiatry. Dr Persaud will, of course, be aware of the compelling evidence for changes in brain function and structure in both depression and obsessive-compulsive disorder, the main indications for NMD (Drevets, 1998; Szeszko et al, 1999).

The argument that there is a lack of randomised controlled trial (RCT) data to support NMD applies equally to a range of ‘cutting edge’ medical and surgical procedures. The proportions of medical and surgical treatments based on RCT data are 53% and 24%, respectively (Ellis et al, 1995; Howes et al, 1997). In such situations, prospective clinical audit becomes the tool of choice. If Dr Persaud demands that NMD cease because of the absence of robust RCT support, then he must surely demand the same rigour from other interventions such as heart transplantation or dynamic psychotherapy.

With respect to the issue of consent, in Scotland NMD does not take place unless the patient provides informed consent and the Mental Welfare Commission for Scotland agrees both that it is an appropriate treatment and that consent is valid. Regrettably, Dr Persaud continues to trade on the outdated image of patients receiving NMD against their wishes. Indeed, he implies that chronic intractable mental illness robs patients of their capacity to provide informed consent. It is demeaning to assert that individuals are incapable of evaluating the risks and benefits of a treatment simply because they have a mental illness. Perhaps it is the failure to appreciate this perspective that leads to excessive concern for the ‘stigmatised profession of psychiatry’? Believing ourselves to be persecuted perpetuates outdated views of psychiatry, and does nothing to reduce the stigma of mental illness.

Declaration of interest

K.M. has received payment for lectures on the management of depression from. various pharmaceutical companies. K.M. and M.S.E. run the Dundee Neurosurgery. for Mental Disorders Service.