Psychosurgery
Review Board (PRB)
In
Victoria, the Psychosurgery Review Board (PRB) was established following
the introduction of the Mental Health Act 1986 (Vic)(the Act). Set up
as a multidisciplinary tribunal, the members include a lawyer, a neurosurgeon,
two psychiatrists and a Nominee of the Victorian Council of Civil Liberties,
all being recommended by the Minister for Health and appointed by Governor-in-Council
for a term of years. Since amendment passed in the 2004, the maximum term
is five years. Members are entitled to be re-appointed.
The
role of the PRB is to determine that the patient is capable of giving,
and has given, informed consent (in accordance with the Act), that the
proposed operation has clinical merit and is appropriate, that the doctors
involved are properly qualified and experienced in the field, and that
the hospital nominated to perform the procedure is an appropriate place
for the procedure to be performed, and that all other reasonable treatments
have already been adequately and skilfully administered without sufficient
and lasting benefit.
Only
a neuropsychiatrist or psychiatrist can apply to the PRB for consent to
the performance of the proposed psychosurgery by a neurosurgeon. They
have a responsibility to advise the PRB of the patient’s response
to the operation, firstly at three months post operatively, and then again
at twelve months post operatively. To protect confidentiality, PRB hearings
are closed to the public. These legislative protections were introduced
to provide appropriate safeguards to limit the use to those who, it is
considered, would benefit most from the procedure. Patients must be capable
of giving free and voluntary consent. Also persons who are convicted or
awaiting criminal charges are not permitted to have psychosurgery.
PSYCHOSURGERY EXPLAINED
Psychosurgery
remains subject to a range of controls around the world, and indeed is
a procedure no longer practised in many parts of the world. Legislation
was introduced as it was deemed necessary to provide protections that
ensured that appropriate and sufficient criteria were established and
followed in patient selection. A great deal of attention was also placed
on consideration of patients’ rights. The other important consideration
was the need for adequate follow-up to demonstrate the efficacy of interventions
and patients’ sense of well being.
Since
its introduction as a treatment for severe mental illness in 1936, psychosurgery
has at various times been enthusiastically embraced and resoundingly rejected
by both the medical profession and society at large. It is also fair to
say that psychosurgery has been a misunderstood and controversial treatment
in medicine and psychiatry. Much of the controversy surrounding the use
of psychosurgery may be attributed to its indiscriminate application and
the high incidence of side effects that accompanied the early procedures.
Modern stereotactic techniques have minimised the side effects of surgery
and for many patients have offered significant improvement to their mental
state.
The
selection of suitable candidates for the procedure is now a rigorous clinical
process with major therapeutic interventions tested and found unsatisfactory
before patients are considered. Currently, the accepted therapeutic approach
to most psychiatric illness involves a combination of well-supervised
pharmacotherapy, psychological and other interventions and, in some instances,
electroconvulsive therapy. However, despite improving drug treatment and
more responsive interventions, some patients fail to respond adequately
and remain severely disabled by their mental illness. For these patients,
surgical intervention is considered appropriate if, as a result of such
surgery, the therapeutic outcome and overall level of functioning of the
patient undergoing such a procedure can be improved. The major consideration
for the PRB is that surgery is only explored as an option of last resort.
The PRB must be satisfied that all other possible options have been tried
and demonstrated not to bring lasting relief from the debilitating illness
that motivates the patient to seek surgery as an option.
The
literature indicates that surgical treatment of psychiatric illness can
be helpful in certain cases. In the last decade, the range of psychiatric
illness deemed suitable for psychosurgery has become more restrictive
and is now confined to severe and intractable affective disorders, obsessive
compulsive disorder (OCD) and chronic anxiety states. The selection of
individual candidates for these operations is becoming more exacting and
is carried out by an expert multidisciplinary team with experience in
these disorders, and patients undergo rigorous screening processes to
ensure all possible non-surgical treatment options have been explored.
Psychosurgery is performed only with the patient’s informed consent.
Surgery is considered as one part of an entire treatment plan and is followed
by an appropriate psychiatric rehabilitation program.
What
does psychosurgery involve
Modern
psychosurgery involves severing, or otherwise disabling, areas of the
brain to treat a narrow range of psychiatric disorders. Modern psychosurgical
techniques target the pathways between the limbic system (the portion
of the brain on the inner edge of the cerebral cortex that is believed
to regulate emotions) and the frontal cortex, where thought processes
are seated. The surgery has become precise and restricted with the use
of stereotactic techniques, thus minimising morbidity and unwanted personality
change, and the follow up evaluation of patients has become more objective
and comprehensive. The practice of psychosurgery has been placed on a
much more scientific footing. Many patients are greatly improved after
surgery and the complications or side effects are few. Therefore surgical
intervention still remains an important therapeutic option for disabling
psychiatric illness.
A
standard working definition of psychosurgery is provided in the Oregon
statute (1971):
“Any
operation designed to irreversibly lesion or destroy brain tissue for
the primary purpose of altering the thoughts, emotions or behaviour of
a human being. Psychosurgery does not include procedures which may irreversibly
lesion or destroy brain tissue when undertaken to cure well-defined disease
states such as brain tumour, epileptic foci and certain chronic pain syndromes.”
A
similar definition of psychosurgery appears in s54 of the Act as:
“Any
surgical technique or procedure by which one or more lesions are created
in a person’s brain on the same or on separate occasions primarily
for the purpose of altering the thoughts, emotions or behaviour of that
person.”
Victorian
legislation is in line with the United States’ National Commission
on Psychosurgery which recommended that there is a limited but definite
role for psychosurgery and that it should be seen as the effective treatment
of last resort in selected psychiatric disorders. Modern psychosurgery
now rests on stronger scientific foundations and appears to have a definite
place in the treatment of intractable OCD, major affective disorders and
chronic anxiety states. The practice standards and ethical principles
that apply to the rest of medicine are applicable to the decisions in
relation to psychosurgery. The important decision to perform this delicate
and complicated procedure must be undertaken with the best interests of
the patient being paramount. The number of procedures performed has fallen
significantly in the last three decades owing to greater efficacy of pharmacotherapy
and other psychiatric treatment, increasingly narrow clinical indications
and severe judicial and governmental strictures.
The
PRB, since it was established in 1987, has received 16 applications, 10
of which have proceeded to surgery. This in part reflects the major advances
in psychiatric treatment generally with the introduction of more refined
and responsive psychotherapeutic treatments available. Individuals with
a psychiatric illness are now generally treated as outpatients with their
stays in hospital being less frequent and of shorter duration. It is acknowledged
that in psychiatry there remain many unanswered questions, and on going
research in the area of mental health contributes to the improved clinical
knowledge and improvement in practice. That psychosurgery remains the
intervention of last resort is because it is currently seen as the most
invasive of treatments.
Psychosurgery
today is seen as a safe, relatively effective treatment which is available
for psychiatrist to consider as an option of last resort for patients
with major affective disorders. As shown, careful safeguards, such as
vetting and approval of the independent, multidisciplinary and legally
constituted PRB in Victoria, are mandatory in order to ensure appropriate
selection, adequate consent, and quality control are undertaken. Though
the intervention is offered as a last resort, it is a therapeutic intervention
that is rigorously and extensively examined by a body of experts before
being performed. This rigorous process is not undertaken with other therapeutic
interventions and should therefore provide confidence to the community
and patients that it can be considered as an option that will for some
patients make life more tolerable as a result.
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