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Psychosurgery Review Board
The Psychosurgery Review Board (the Board) was established by s56 of the Mental Health Act 1986 (the Act). The Board was set up in October 1987 as a multidisciplinary tribunal whose 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 Mental Health and appointed by Governor-in-Council for a term of up to 5 years. Members are entitled to be re-appointed.
To protect confidentiality, Board hearings are closed to the public. The role of the Board is to determine applications by psychiatrists for a neurosurgeon to perform psychosurgery on a person. This involves deciding whether the person is capable of giving, and has given, informed consent (in accordance with the Act), that the proposed psychosurgery 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 Board for consent to the performance of the proposed psychosurgery by a neurosurgeon. Both the psychiatrist and the neurosurgeon have a responsibility to advise the Board of the patient’s response to the operation. At three months post-operatively, both the psychiatrist and the neurosurgeon must prepare a report as to the person’s response to the psychosurgery. At twelve months post-operatively, the psychiatrist is required to provide the Board with an additional updated progress report.
These legislative protections were introduced to provide appropriate safeguards to limit the use of psychosurgery to those who, it is considered, would benefit most from a psychosurgery procedure. Primarily, psychosurgery is a treatment of last resort. Patients must be capable of giving free and voluntary consent.
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 latest techniques involve stimulation with electrodes inserted in the patient’s brain by psychosurgery, and are potentially reversible.
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 and brain stimulation techniques. 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 Board is that surgery is only explored as an option of last resort. The Board 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 (mood) 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 may involve severing or otherwise disabling, or stimulating, specific 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 more 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 definition of psychosurgery appears in s54 of the Act as:
(a) |
Any surgical technique or procedure by which one or more lesions are created in a person's brain on the same or on seperate occasions primarliy for the purpose of altering the thoughts, emotions or behaviour of that person; or
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(b) |
the use of intracerebral electrodes to create one or more lesions 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; or |
(c) |
the use of intracerebral electrodes to cause stimulation though the electrodes on the same or on separate occassions without creating a lesion in the person’s brain for the purpose of influencing or altering the thoughts, emotions or behaviours of that person. |
The number of psychosurgery 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 restrictions.
Between 1988 and 2000, the Board received on average about one application per year, half of which have proceeded to surgery (click here for specific figures). No applications were received between 2001 and 2006. There have been 3 applications dealt with in 2007 and 2008. This change 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 ongoing research in the area of mental health contributes to the improved clinical knowledge and improvement in practice. Psychosurgery remains the intervention of last resort because it is currently seen as the most invasive of treatments.
However, psychosurgery today is seen as a safe, relatively effective treatment which is available for psychiatrists 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 Board in Victoria, are mandatory in order to ensure appropriate selection, adequate consent, and quality control are undertaken. 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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