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Background: Current literature shows that the prevalence of depressive disorders (DD) is increasing in the United States. Patients with DD have worse outcomes after shoulder arthroplasty; however, properly defined inclusion and exclusion criteria evaluating the effects of DD on primary reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare the outcomes of patients with and without DD undergoing primary RSA, evaluating: (1) in-hospital length of stay (LOS), (2) medical complications, (3) emergency department (ED) utilizations, and (4) cost of care., Methods: A retrospective query was performed using a nationwide administrative claims database from 2010 to 2020 for all patients who underwent primary RSA for the treatment of glenohumeral osteoarthritis. The query yielded a total of 24,326 patients within the study (DD, n = 4084) and comparison (without DD, n = 20,242) cohorts. The primary end points were in-hospital LOS, 90-day medical complications, and total 90-day episode of care costs. Subanalyses compared whether DD diagnosis and preoperative ED utilization within 6 months of RSA were associated with increased incidence and odds of postoperative ED utilization within 90 days. P values less than .004 were considered statistically significant., Results: Patients with DD undergoing primary RSA had significantly longer LOS (3 vs. 2 days, P < .0001) compared with patients without DD. The study group also had higher frequency and odds ratio (OR) of complications (47.40% vs. 17.63%; OR: 2.27, P < .0001) such as pneumonia (10.04% vs. 2.15%; OR: 2.88, 95% confidence interval [CI]: 2.47-3.35, P < .0001), cerebrovascular accidents (3.13% vs. 0.86%; OR: 2.69, 95% CI: 2.09-3.46, P < .0001), myocardial infarctions (1.98% vs. 0.51%; OR: 2.54, 95% CI: 1.84-3.50, P < .0001), and other adverse events. Among patients who had a diagnosis of DD, preoperative ED utilization within 6 months of RSA was associated with increased odds of postoperative ED utilization within 90 days compared with those without ED utilization preoperatively (15.08% vs. 13.64%; OR: 1.16, 95% CI: 1.04-1.28, P = .003). Controlling for preoperative ED utilization and comorbidities, patients with DD experienced a 2- to 3-fold increase in postoperative ED use within 90 days after surgery (P < .0001). Patients with DD also incurred significantly higher episode of care costs ($19,363.10 vs. $17,927.55, P < .0001)., Conclusion: This retrospective study shows that patients with DD undergoing primary RSA for the treatment of glenohumeral osteoarthritis have longer in-hospital LOS, higher rates of complications, and increased costs of care. Preoperative health care utilization among patients with DD may be associated with increased utilization postoperatively., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Smartphone applications ("apps") may contribute to closing the treatment gap for depression by reaching large populations at relatively low costs. The general public seems open towards the use of apps for mental disorders but less is known about the attitudes of health care professionals. Therefore, the aim of this study was to examine the available evidence on the effectiveness of apps for depression and to explore the attitudes of health care professionals towards their use in practice. A systematic literature search was performed aimed at studies utilizing smartphone applications for depression. In addition, a survey was conducted to explore health care professionals' attitudes towards using these treatment apps in clinical practice. Twelve articles were identified in the systematic literature review. All included trials reported a decline in depressive symptoms after the intervention periods. In the survey, 72 health care professionals participated. Significant differences were found between the level of technology experience and how much the health care professional would consider the use of mobile applications in clinical practice. Survey participants reported openness towards therapeutic app use but very little knowledge and experience in the field. Apps appear to be a promising self-management tool for reducing depressive symptoms. Despite some concerns, health care professionals' attitudes towards the use of smartphone applications in clinical practice are quite positive. The provision of information on the potential benefits of e-health interventions as well as the training of professionals in the application of new technologies may increase health care professionals' awareness and knowledge about mobile apps for the treatment of mental disorders.

Purpose: Vagus nerve stimulation (VNS) is well established in the treatment of epilepsy and disorders of depression. The prevalence of depression is high in patients with epilepsy, but still it remains unclear how patients with a comorbidity of epilepsy and symptoms of depression respond to VNS., Methods: We investigated 59 patients with different subtypes of disorders of depression as a comorbidity of epilepsy, who underwent VNS-surgery. Before and one year after VNS surgery, the severity of symptoms of depression was evaluated by a psychiatrist using Montgomery-Åsberg Depression Rating Scale (MADRS) and Beck-Depressions-Inventory (BDI). Response towards epilepsy was measured by a seizure reduction of at least 50%., Results: Symptoms of depression ameliorated in response to VNS in the overall of all patients MADRS 29 to 18 (p < 0,001) and BDI 24 to 14 (p < 0,001) and all subtypes of disorders of depression. Seizure reduction of at least 50% was achieved in two out of three of all patients two years after VNS., Conclusion: We were able to show the beneficial effect of VNS in the treatment of patients with pharmacoresistant epilepsy and a comorbidity of symptoms of depression., (Copyright © 2019 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background and Case Presentation: Electroconvulsive therapy (ECT) is a common therapeutic procedure in psychiatry associated with a low rate of complications. We report a rare case of subdural hematoma (SDH) associated with ECT., Clinical Presentation: a 64 year old woman, with a medical history of persistent depression which required ECT six years previously, underwent ECT following a new acute episode. After four ECT sessions, a left hemiparesis occurred. Brain CT scan revealed a right SDH. The patient underwent surgery and fully recovered three months after the drainage of the hematoma. We conducted a review of all cases in which SDH was associated to ECT., Conclusion: Early stage brain imaging is indispensable prior to starting ECT. Moreover, a previous medical history of SDH may not be a contraindication to ECT. In these situations, a clinical and radiological follow-up by both the psychiatrist and the neurosurgeon during all the ECT sessions is highly recommended., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objective: Older people with depressive disorders access psychotherapy less frequently than younger ones. GPs play an important role in referring patients, particularly the elderly, to psychotherapeutic treatment. This paper presents the obstacles to and preconditions for referring older, depressed sick people to psychotherapy from the point of view of GPs., Methodology: Doctors who are training GPs were given a questionnaire on the care of the elderly (60+) with depressive disorders. In 2 open questions, they were requested to state their views on obstacles to and preconditions for referring older, depressed diseased people to psychotherapeutic treatment., Results: Most statements related to obstacles perceived by patients followed by barriers on the part of the supply system. Especially obstructive attitudes and emotions, but also functional limitations on the part of patients were referred to as barriers. With regard to the supply system, structural aspects, such as lack of psychotherapy places, but also the actions of care providers and insufficient cooperation were listed. As preconditions, specific therapy for the elderly were mentioned CONCLUSIONS: Dealing with reservations about psychotherapy on the part of older people takes time, which usually is not reimbursed in general practice. Collaborations with psychotherapists are seen as an important precondition for referral. Especially for people with multiple illnesses, access is considered difficult., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The presence of neuropathic pain can severely impinge on emotional regulation and activities of daily living including social activities, resulting in diminished life satisfaction. Unfortunately, the majority of patients with neuropathic pain do not experience an amelioration of symptoms from conventional therapies, even when multimodal therapies are used. Chronic refractory neuropathic pain is usually accompanied by severe depression that is prone to incur suicidal events; thus clinical management of chronic neuropathic pain and depression presents a serious challenge for clinicians and patients., Case Description: Two patients presented at our institution with neuropathic pain and severe depression. The patients had different pain symptoms emerging a few months after central or peripheral nervous system impairment. These symptoms were associated with the development of severe depression, social isolation, and a gradual inability to perform daily activities. Both patients were referred to our treatment center for bilateral anterior cingulotomy. After surgery, both patients showed significant progressive improvements in perceived pain, mental health status, and daily functioning., Conclusions: Bilateral anterior cingulotomy may serve as an alternative treatment for medically refractory neuropathic pain, especially for patients who also experience depression., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Psychiatric co-morbidity, in particular major depression and anxiety, is common in patients with Crohn's disease (CD) and ulcerative colitis (UC). Prior studies examining this may be confounded by the co-existence of functional bowel symptoms. Limited data exist examining an association between depression or anxiety and disease-specific endpoints such as bowel surgery., Aims: To examine the frequency of depression and anxiety (prior to surgery or hospitalisation) in a large multi-institution electronic medical record (EMR)-based cohort of CD and UC patients; to define the independent effect of psychiatric co-morbidity on risk of subsequent surgery or hospitalisation in CD and UC, and to identify the effects of depression and anxiety on healthcare utilisation in our cohort., Methods: Using a multi-institution cohort of patients with CD and UC, we identified those who also had co-existing psychiatric co-morbidity (major depressive disorder or generalised anxiety). After excluding those diagnosed with such co-morbidity for the first time following surgery, we used multivariate logistic regression to examine the independent effect of psychiatric co-morbidity on IBD-related surgery and hospitalisation. To account for confounding by disease severity, we adjusted for a propensity score estimating likelihood of psychiatric co-morbidity influenced by severity of disease in our models., Results: A total of 5405 CD and 5429 UC patients were included in this study; one-fifth had either major depressive disorder or generalised anxiety. In multivariate analysis, adjusting for potential confounders and the propensity score, presence of mood or anxiety co-morbidity was associated with a 28% increase in risk of surgery in CD (OR: 1.28, 95% CI: 1.03-1.57), but not UC (OR: 1.01, 95% CI: 0.80-1.28). Psychiatric co-morbidity was associated with increased healthcare utilisation., Conclusions: Depressive disorder or generalised anxiety is associated with a modestly increased risk of surgery in patients with Crohn's disease. Interventions addressing this may improve patient outcomes., (© 2013 Blackwell Publishing Ltd.)

There is increasing attention in the neurosurgical literature towards surgery, specifically deep brain stimulation (DBS), for psychiatric indications. Several positive trials have spurred intense investigation and research in this area, owing to rapid advances in the neurosciences. As a result, the scope of neurosurgical practice is evolving to now include disorders that weren't traditionally in the purview of the average functional neurosurgeon. Further, functional neurosurgeons are now being charged with taking care of patients as part of a multi-disciplinary group that includes psychologists and psychiatrists. As DBS for psychiatry continues to evolve, and as further indications are explored, it is incumbent on neurosurgeons who treat these disorders to familiarize themselves with current standards of diagnosis and treatment. Just as the movement disorder surgeon should be familiar with the biology, physiology, diagnosis and treatment of Parkinson's disease, so they should become familiar with similar aspects of commonly referred psychiatric conditions. Specifically, much of the interest in the DBS literature currently surrounds major depression, obsessive-compulsive disorder and Tourette's syndrome. Here, we review the epidemiology, diagnostic criteria, hypothesized neurocircuitry and current treatments, both medical and surgical of each of these conditions to serve as a centralized, introductory primer for the practicing functional neurosurgeon.

Objective: This study explored the association between long-term epilepsy surgery outcome and changes in depressive symptoms., Methods: Adults were enrolled between 1996 and 2001 in a multicenter prospective study to evaluate outcomes of resective epilepsy surgery. The extent of depressive symptoms and depression case status (none, mild, or moderate/severe) were assessed using the Beck Depression Inventory (BDI) preoperatively and 3, 12, 24, 48, and 60 months postoperatively. A mixed-model repeated-measures analysis was performed, adjusting for covariates of seizure location, gender, age, race, education, and seizure control., Results: Of the total 373 subjects, 256 were evaluated at baseline and 5 years after surgery. At baseline, 164 (64.1%) were not depressed, 34 (13.3%) were mildly depressed, and 58 (22.7%) had moderate to severe depression. After 5 years, 198 (77.3%) were not depressed, 20 (7.8%) were mildly depressed, and 38 (14.8%) were moderately to severely depressed. Five years after surgery, the reduction in mean change from baseline in BDI score was greater in subjects with excellent seizure control than in the fair and poor seizure control groups (p = 0.0006 and p = 0.02 respectively). Those with good seizure control had a greater reduction in BDI score than the poor seizure control group (p = 0.02) and borderline significant reduction compared with the fair seizure control group (p = 0.055)., Conclusion: Although study participants had initial improvement in depressive symptoms, on average, after resective surgery, only patients with good or excellent seizure control had sustained long-term improvement in mood.

Context: Patients with primary hyperparathyroidism (PHP) often report nonspecific symptoms including mood disturbances., Objective: The objective of the study was to determine the frequency of depression in PHP and assess its response to parathyroidectomy., Methods: A case-control study at a referral center in Rochester, MN, performed Patient Health Questionnaire-9 (PHQ-9) assessments in observed (n = 81) and surgical (n = 88) PHP and benign nontoxic surgical thyroid disease (n = 85) at baseline and 1, 3, 6, and 12 months after surgery or the initial questionnaire in observed PHP. Baseline PHQ-9 scores and their response to surgery were evaluated., Results: The groups were similar in gender and depression history, but PHP patients were older. Baseline PHQ-9 scores were 1.71 points higher in PHP than controls after adjusting for age and gender (P = .004). Clinically significant PHQ-9 scores (≥10) were twice as common in PHP (31.4%) compared with thyroid subjects (15.3%). Parathyroidectomy resulted in significant and sustained reductions in PHQ-9 scores, which were greater than observed PHP at all time points (P < .001). PHP patients with clinically significant PHQ-9 scores dropped to 7.4% (P < .001) and 7.6% (P < .001) at 1 month and 1 yr after parathyroidectomy. There were greater declines in PHQ-9 scores after parathyroidectomy at 1, 3, and 6 months (P < .001) and 1 yr (P = .061) compared with thyroid surgery., Conclusions: Depression is common in patients with PHP. Parathyroidectomy results in greater improvement in PHQ-9 scores compared with thyroid surgery or observation of PHP.

Background: The treatment of refractory epilepsy by vagus nerve stimulation (VNS) is a well-established therapy option for patients not suitable for epilepsy surgery and therapy refractory depressions., Objective: To analyze surgical and technical complications after implantation of left-sided VNS in patients with therapy-refractory epilepsy and depression., Methods: One hundred five patients receiving a VNS or VNS-related operations (n = 118) from 1999 to 2008 were investigated retrospectively., Results: At the time of operation, 84 patients were younger than 18 years, with a mean age of 10.5 years. Twenty (19%) patients had technical problems or complications. In 6 (5.7%) patients these problems were caused by the operation. The device was removed in 8 cases. The range of surgically and technically induced complications included electrode fractures, early and late onset of deep wound infections, transient vocal cord palsy, cardiac arrhythmia under test stimulation, electrode malfunction, and posttraumatic dysfunction of the stimulator., Conclusion: VNS therapy is combined with a wide spread of possible complications. Technical problems are to be expected, including electrode fracture, dislocation, and generator malfunction. The major complication in younger patients is the electrode fracture, which might be induced by growth during adolescence. Surgically induced complications of VNS implantation are comparably low. Cardiac symptoms and recurrent nerve palsy need to be taken into consideration.

Objective: To study the long-term effects of deep brain stimulation (DBS) of the bilateral subthalamic nucleus (STN) on depression in patients with Parkinson's disease (PD) and to discuss the mechanism., Methods: A STN-DBS group (n = 27) and anti-Parkinson's medication control group with paired designing were set up. The evaluation of the depression and motor function was performed a total of six times. Depression was evaluated by the Self-Rating Depression Scale (SDS) and Hamilton Rating Scale for Depression (HAMD). Motor function was evaluated by the third part of the Unified Parkinson's Disease Rating Scale (UPDRS-III)., Results: Compared with the preoperative and the medication control group, the UPDRS-III scores of the STN-DBS group decreased remarkably within 18 months postoperatively (P < or = 0.001), and the SDS scores decreased notably within 6 months postoperatively (P < or = 0.05), and the HAMD scores decreased notably within 3 months postoperatively (P < or = 0.05). The UPDRS-III scores were strongly correlated with their SDS scores within 6 months postoperatively (P < or = 0.05), especially at 5 weeks postoperation (P < or = 0.001). UPDRS-III scores were also strongly correlated with HAMD scores at 5 weeks postoperation (P < or = 0.05). The mean value of the bilateral voltages was obviously correlated with SDS and HAMD scores (P < or = 0.05) within 18 months postoperatively., Conclusion: The improvement in motor symptoms resulting from STN-DBS can improve depression in PD patients, but its long-term effects were unremarkable. Within the treatment range, the higher the mean value of bilateral voltages then the more severe was the depression in PD patients.

Drug refractory chronic daily headache (CDH) is a highly disabling condition. CDH is usually regarded as the negative evolution of chronic migraine (CM) and is characterized by high prevalence of psychiatric disorders, especially mood disorders. Vagal nerve stimulation (VNS) is an established treatment option for selected patients with medically refractory epilepsy and depression. Neurobiological similarities suggest that VNS could be useful in the treatment of drug-refractory CM associated with depression. The aim of the study was to evaluate the efficacy of VNS in patients suffering from drug-refractory CM and depressive disorder. We selected four female patients, mean age 53 (range 43-65 years), suffering from daily headache and drug-refractory CM. Neurological examination and neuroradiological investigations were unremarkable. Exclusion criteria were psychosis, heart and lung diseases. The preliminary results in our small case series support a beneficial effect of chronic VNS on both drug-refractory CM and depression, and suggest this novel treatment as a valid alternative for this otherwise intractable and highly disabling condition.

Purpose of Review: From its peak in the 1940s and 1950s, psychosurgery (or, neurosurgery for psychiatric disorders) has had a gradual decline, with only a few centers around the world continuing with the procedure into the 1980s and 1990s. With recent developments in brain stimulation techniques, the continuing relevance of psychosurgery in the treatment of psychiatric disorders is worthy of examination., Recent Findings: A review of databases (PubMed, Medline, Current Contents and Embase) suggests that psychosurgery in the form of stereotactic focal ablation is still practiced in a few centers, although the number has decreased further from the 1990s. Procedures have not changed substantively, although modern imaging and stereotaxy have made them more precise. No good predictors of treatment response have been identified. There is a major shift in interest to deep brain stimulation (DBS) instead of ablative surgery. Studies of DBS in resistant depression and obsessive-compulsive disorder have been few and have involved small numbers, but this field is growing rapidly., Summary: Although ablative psychosurgery using stereotactic procedures continues to be used to a small extent, psychiatrists remain ambivalent about this procedure. The baton of psychosurgery, however, appears to have been passed on to DBS, but more data are needed on technical details and outcomes before the possible therapeutic role of DBS can be established.

Introduction: Minimally invasive surgery was born out of recent advances in neuroimaging and stereotaxy, and the scale of future neurosurgical procedures will soon be so small that it will not be possible for the unassisted surgeons. Hence, neurosurgical robotics is a natural evolution in this field. The aim of this study was to evaluate the performance of a new robotic system in a wide range of neurosurgical applications., Methods: Patients undergoing image-guided surgical procedures were recruited to participate in this prospective ethically approved study from 2005. The PathFinder (Prosurgics, UK) is a neurosurgical robotic system with 6 degrees of freedom. It uses a fiducial system that is automatically detectable by the planning software and a camera system embedded in the robot's head. The registration procedure was performed automatically by photographing the fiducials from different angles. The robot then aligns its end-effector and tool holder along the specified path for the surgeon to pass the probe to the target. We recruited 37 consecutive patients to test the application accuracy and consistency of the system using three different fiducial fixation mechanisms: a double adhesive fixed to the skin, an ECG lead dot fixed to the skin, and a registration plate fixed to the skull., Results: Out of 37 consecutive patients, 17 were males and 20 were females, with a mean age of 46.6 years. The procedures were: transsphenoidal in 8, malignant tumour biopsies in 3 and resections in 5, benign tumour excisions in 6 and functional procedures in 15 [6 bilateral deep-brain stimulations (DBSs) of the subthalamic nucleus for Parkinson's disease, 3 bilateral anterior cingulotomies for depression, 3 bilateral DBSs of the ventral intermediate nucleus of the thalamus for tremor and 3 depth electrodes during epilepsy surgery]. We tested a total of 140 targets with an average of 3-4 targets per patient. The mean application accuracy was less than 1 mm and the application accuracy was consistent in all targets in the same patient., Conclusions: This robotic system was very accurate and consistent in practice as long as the robot had achieved acceptable registration., ((c) 2009 S. Karger AG, Basel.)

Deep brain stimulation (DBS) is the most focal method for stimulating the human brain. In contrast to lesions, DBS is nonablative, with the advantages of reversibility and adjustability. Thus, therapeutic effectiveness can be enhanced and stimulation-related side effects minimized during long-term patient management. While DBS is an approved adjunct therapy for severe, medication-refractory movement disorders, it remains investigational in neuropsychiatry. However, experience to date, though limited, suggests that DBS may offer a degree of hope to patients with severe and treatment-resistant neuropsychiatric illness. Thus far, work in obsessive-compulsive disorder (OCD), the first psychiatric condition studied using modern DBS devices, has shown consistently positive results across multiple small-scale studies. Work in treatment-resistant Major Depressive Disorder (MDD) also suggests therapeutic potential in preliminary studies, generating cautious optimism for this indication. With the increase in potential applications, a number of clinical and preclinical research efforts have now focused on understanding the mechanisms of action of DBS. Further development of DBS for these and other illnesses with primarily behavioral symptoms will require thoughtful collaboration among multiple disciplines.

Object: The author presents his personal perspective on ablative neurosurgical techniques used to perform bilateral anterior cingulotomy (BACI) and bilateral anterior capsulotomy (BACA) for ameliorating the symptoms of refractory obsessive-compulsive disorder (OCD) and treatment refractory depression (TRD). With depression predicted to be the second most common cause of disability in the world by the year 2020 and the birth of electric neurostimulation representing an attractive alternative treatment option for TRD and OCD, it is desirable to revisit the pros and cons of these treatment options., Methods: The author reviewed the surgical methods and outcome (including neuroimaging findings) in all cases in which ablative neurosurgery was performed at Ninewells Hospital and Medical School over the last 2 decades., Results: The advantages of ablative procedures (BACI and BACA) from patients' and psychiatrists' perspectives are that the ablative procedures are one-off procedures that do not require lifelong commitment to program the stimulation devices, fix hardware failures, or change exhausted batteries. From the perspective of healthcare funding bodies, the relatively low cost of these treatments is an advantage. The main disadvantages of BACI and BACA are the perceived higher complication rates, the irreversibility of the surgical lesions, and the stigma associated with brain destruction in psychiatric patients that are still unpalatable in the community at large. However, some patients still choose a one-off procedure in preference to any other options presented to them., Conclusions: There is still place for BACI and BACA in modern neurosurgery for mental disorders, at least in the short term for those who do not want to commit to lifelong device programming and maintenance.

Object: The goal of this study was to evaluate the definition of treatment-resistant depression (TRD), review the literature regarding deep brain stimulation (DBS) for TRD, and identify potential anatomical and functional targets for future widespread clinical application., Methods: A comprehensive literature review was performed to determine the current status of DBS for TRD, with an emphasis on the scientific support for various implantation sites., Results: The definition of TRD is presented, as is its management scheme. The rationale behind using DBS for depression is reviewed. Five potential targets have been identified in the literature: ventral striatum/nucleus accumbens, subgenual cingulate cortex (area 25), inferior thalamic peduncle, rostral cingulate cortex (area 24a), and lateral habenula. Deep brain stimulation electrodes thus far have been implanted and activated in only the first 3 of these structures in humans. These targets have proven to be safe and effective, albeit in a small number of cases., Conclusions: Surgical intervention for TRD in the form of DBS is emerging as a viable treatment alternative to existing modalities. Although the studies reported thus far have small sample sizes, the results appear to be promising. Various surgical targets, such as the subgenual cingulate cortex, inferior thalamic peduncle, and nucleus accumbens, have been shown to be safe and to lead to beneficial effects with various stimulation parameters. Further studies with larger patient groups are required to adequately assess the safety and efficacy of these targets, as well as the optimal stimulation parameters and long-term effects.

An estimated 20% of patients with major depression are refractory to existing therapies. The purpose of this review is to provide a theoretical and neuroscientific framework in which to interpret new work in the field of surgical treatment for depression. This review focuses on existing clinical and imaging data, current disease models, and results of recent case reports and patient series that together may inform the construction of appropriate clinical trials for the surgical treatment of refractory depression.

Although cognitive side effects may occur after electroconvulsive therapy (ECT), no structural brain abnormalities have been detected after ECT with conventional magnetic resonance imaging (MRI). Transient disturbances of memory function are common findings after ECT indicating functional compromise. Diffusion weighted imaging (DWI) has been shown to be sensitive to focal tissue changes associated with compromise of energy metabolism in cerebral ischemia and after prolonged ictal activity. We used conventional MRI and DWI in an exploratory study examining ten patients after treatment with ECT, eight of whom experienced short-lasting memory disturbances. MRI and DWI showed no definite signal abnormalities on qualitative and quantitative analysis. In three patients, equivocal marginal DWI hyperintensity was noted in the hippocampal formation. These findings are in line with previous negative studies using conventional MRI. Higher resolution DWI and serial imaging may be necessary to visualize possible minimal signal changes after ECT.

Objective: To investigate the long-term efficacy and adverse cognitive effects of stereotactic bilateral anterior cingulotomy as a treatment for refractory obsessive-compulsive disorder (OCD) patients., Materials and Methods: Seventeen patients suffering from refractory OCD underwent stereotactic bilateral anterior cingulotomies and were followed for 24 months. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Clinical Global Impression and other neuropsychological tests were used to assess the efficacy and cognitive changes of cingulotomy. The tests were taken before and 12 and 24 months after surgery., Results: The mean improvement rate of the Y-BOCS score achieved from the baseline was 48%. Eight patients out of 17 met the responder criteria. During the 24-month follow-up, there were no significant adverse effects observed after surgery., Conclusions: Bilateral anterior cingulotomy was effective for the treatment of refractory OCD, and no other significant adverse cognitive effects on long-term follow-up were found., (Copyright 2006 S. Karger AG, Basel.)

Background: Five patients underwent magnetic resonance imaging (MRI) following MRI-guided stereotactic bilateral anterior capsulotomy to detect lesion-related anatomic changes., Methods: Five disabled and treatment-resistant patients with major depression (n = 4) and obsessive-compulsive disorder (n = 1) underwent stereotactic bilateral anterior capsulotomy. All patients had postoperative MRI at 2 months and at 1-4 years after surgery. An additional patient who had a pure motor deficit following a spontaneous basal ganglia hemorrhagic stroke was imaged as a comparator., Results: The 2-month postcapsulotomy MRI showed a previously undescribed increase in T1-weighted signal within similar neural pathways for each patient. These pathways showed no changes in T2-weighted or fluid-attenuated inversion recovery sequences. The signal changes are different from the expected changes associated with anterograde Wallerian degeneration and identify retrograde changes in the proximal segment of the interrupted axon., Conclusion: Previously undescribed T1-weighted signal alterations following stereotactic surgery identify retrograde non-Wallerian changes in interrupted axons and provide a new method in identifying and tracing lesioned pathways., (Copyright 2006 S. Karger AG, Basel.)

Objective: To determine changes in depression and anxiety after resective surgery., Methods: Data from subjects enrolled in a prospective multicenter study of resective epilepsy surgery were reviewed with the Beck Psychiatric Symptoms Scales (Beck Depression Inventory [BDI] and Beck Anxiety Inventory [BAI]) and Composite International Diagnostic Interview (CIDI) up to a 24-month period. chi2 analyses were used to correlate proportions., Results: A total of 358 presurgical BDI and 360 BAI results were reviewed. Moderate and severe levels of depression were reported in 22.1% of patients, and similar levels of anxiety were reported by 24.7%. Postoperative rates of depression and anxiety declined at the 3-, 12-, and 24-month follow-up periods. At the 24-month follow-up, moderate to severe levels of depression symptoms were reported in 17.6 and 14.7% of the patients who continued to have postoperative seizures. Moderate to severe depression and anxiety were found in 8.2% of those who were seizure-free. There was no relationship, prior to surgery, between the presence or absence of depression and anxiety and the laterality or location of the seizure onset. There were no significant relationships between depression or anxiety at 24-month follow-up and the laterality or location of the surgery., Conclusions: Depression and anxiety in patients with refractory epilepsy significantly improve after epilepsy surgery, especially in those who are seizure-free. Neither the lateralization nor the localization of the seizure focus or surgery was associated with the risk of affective symptoms at baseline or after surgery.

Between 1973 and 1995, a total of 76 patients were treated with bilateral stereotactic, orbitomedial lesions for resistant severe depression at the Neuropsychiatric Institute, Sydney, Australia. On follow up after a mean 14.4 years, 24 (31.6%) subjects were confirmed dead, with six having committed suicide. Of the 52 patients still alive (mean age 62.9 years), 23 were interviewed in detail, and lesions verified in 18 with magnetic resonance imaging (MRI). On a 6-point global outcome rating scale, rated by consensus between two independent psychiatrists, five (22.7%) were judged to be completely recovered and another 11 (50%) showed significant improvement. The improvement was noted within days or weeks of the surgery. Adverse effects were epilepsy (2 subjects), marked personality change (1), weight gain (2), and mild personality change (5). Any reported cognitive impairment was mild. No definite predictors of improvement were identified.

Objective: The authors compared patients who underwent stereotactic subcaudate tractotomy for depression, who were still depressed or recovered from depression, to identify therapeutic mechanisms., Method: Ten depressed and eight recovered psychosurgery patients, along with nine never-depressed subjects and nine who had recovered from depression with medication, completed the Iowa Gambling Task, a measure of decision making in the face of feedback. Psychosurgery patients also completed general neuropsychological testing., Results: Recovered psychosurgery patients exhibited insensitivity to negative feedback on the Iowa Gambling Task compared to the other three groups. This difference between the groups remained when general neuropsychological performance was covaried out., Conclusions: These findings suggest acquired relative insensitivity to negative information as a specific mechanism mediating the antidepressant effect of stereotactic subcaudate tractotomy. Such insensitivity is not secondary to deficits in general neuropsychological functioning and is not a function of recovery from depression per se.

Spontaneous intracranial hypotension (SIH) is known to cause postural headache, often combined with auditory, and vestibular symptoms, nausea, vomiting, and diplopia. We report a 63-year-old male patient who for the first time developed a depressive episode followed by acute manic symptoms during the course of SIH, both relieved after treatment of the underlying organic disturbance.

While primary hyperparathyroidism (primary HPT) is recognized as a correctable cause of nephrolithiasis and osteoporosis, its role as an organic cause of major depression is less clear. The rate of major depression in primary HPT, response of symptoms to parathyroidectomy, and potential cost benefits were reviewed. From August 1994 to September 2002, 360 patients underwent parathyroidectomy for primary HPT. Thirty-five patients met Diagnostic and Statistical Manual of Mental Disorders IV-Text Revision (DSM IV-TR) criteria for major depression. Postoperatively, a modified form of the Outcomes Institutes Health Status Questionnaire 2.0 was used to evaluate patient mood and continued need for antidepressant medication (ADM). Cost analysis of ADM use was performed. Thirty-five of 360 patients (10%) with primary HPT met criteria for major depression. Thirteen of 35 (37%) required ADM preoperatively. Postoperatively, 29/35 (83%) patients responded to a phone survey: 90 per cent stated depression no longer impacted their ability to work or activities of daily living; 52 per cent reported an improved quality of life; 27 per cent discontinued preoperative ADM; and 27 per cent reduced their ADM dose. Reduction in ADM resulted in a savings of dollars 700 to dollars 3000 per patient per year. Major depression occurs in 10 per cent of patients undergoing parathyroidectomy for primary HPT. Parathyroidectomy reduces symptoms of major depression, improves quality of life, and can eliminate or reduce the need for antidepressant medication in up to 54 per cent of patients.

Background: Despite the application of ablative neurosurgical treatments for intractable mental disorder throughout most of the past century, unequivocal evidence for efficacy has not been provided., Aims: To review the status of ablative neurosurgery for mental disorder and to describe the activities of the Scottish national service., Method: Relevant literature is reviewed alongside a description of recent clinical activity., Results: Neurosurgical treatment is offered to a small number of patients severely disabled by otherwise intractable mental disorder. There are inequalities in the strength of evidence to support the use of some of these procedures. The frequency and severity of adverse effects remains unclear. We are collecting data that should inform future practice., Conclusions: Modern neurosurgery can offer clinically meaningful symptom relief and improved function for 'untreatable' patients with chronic, severe depression and obsessive-compulsive disorder. However, follow-up studies of greater rigour are required. The potential role of non-ablative alternatives remains unclear.

After providing an overview of depression this article briefly reviews the development of psychosurgery and outlines the current procedures in use world wide. Stereotactic subcaudate tractotomy (SST) is described in particular detail, and the rationale for its use in the treatment of resistant depression is then discussed by considering the findings of neuropsychological, neurophysiological and neuroimaging studies. The emerging evidence suggests that the prefrontal cortex subserves an essential function in emotion and that disruption of its connections modifies mood.

After its introduction 60 years ago, psychosurgery witnessed a remarkable rise followed by a decline. In the 1990s, it is a marginal treatment practised by a few psychiatrists in some specialised centres around the world. The psychiatric profession, however, continues to support it, and there is some evidence for a recent renewal of interest in the procedure. In this paper, the reasons for this reluctant acceptance of psychosurgery are examined, and the factors that are likely to determine its future are identified. The profession is urged to keep the interest in psychosurgery alive until further theoretical and empirical developments can either announce its death or lead to a resurgence of psychiatric neurosurgery in its present or modified form.

We describe the modern operative technique of magnetic resonance (MR) image-guided stereotactic cingulotomy and discuss the indications, results, and complications of this procedure. A retrospective analysis of psychiatric outcome was performed for 34 patients with intractable major affective disorder and/or obsessive-compulsive disorder who underwent MR image-guided stereotactic cingulotomy since 1991. Fourteen patients underwent multiple cingulotomies (50 total procedures). Overall, 38% of the patients were classified as responders, 23% as possible responders, and 38% as nonresponders. Of the patients who did not respond to initial cingulotomies and who underwent multiple cingulotomies, 36% became responders, 36% possible responders, and 28% nonresponders. There were no deaths or long-term side effects related to the procedure. The therapeutic results of MR image-guided stereotactic cingulotomy are similar to the results of earlier methods of cingulotomy, and the use of MR imaging offers substantial technical advantages. This procedure also compares favorably with other neurosurgical procedures performed for intractable psychiatric disease with a low rate of undesired side effects. Cingulotomy is safe and well tolerated, with over one-third of the patients demonstrating significant improvement; however, prospective long-term follow-up studies are needed to further define the role of surgery in treating intractable psychiatric disease.

This study describes a cohort of 23 patients undergoing stereotactic subcaudate tractotomy. Research Diagnostic Criteria indicated that 70% suffered major depressive disorder; the remainder mostly had a bipolar affective disorder. There were serial assessments pre-operatively and at 2 weeks and 6 months post-operatively using the Hamilton Rating Scale for depression, the Present State Examination (PSE), Newcastle Scale, the Beck Depression Inventory, and the Taylor Manifest Anxiety Scale. Neuropsychological assessment included tests thought to be sensitive to frontal lobe dysfunction, as well as tests of general intelligence, attention, memory, language and visuo-spatial function. Post-operatively, depression rating scale scores decreased significantly but most patients continued to exhibit a number of PSE syndromes. Depression rating scale scores were correlated with 1 year global outcome: there was no significant correlation except for the 6 month assessment when lower Hamilton scores were found to be associated with better global outcome. Correlations between the neuropsychological tests and the Hamilton and Beck depression scales at 2 weeks post-operatively suggested that an improvement in psychiatric condition was associated with greater efficiency on some tests of attention and verbal recall, as well as faster performance on a sorting task. By contrast, the changes at 6 months suggested an association between improvement in psychiatric condition and less efficient performance on certain neuropsychological tests including verbal recognition memory, attention and two tests of frontal lobe dysfunction.

The outcome of all psychosurgical operations (stereotactic subcaudate tractotomies) performed at the Geoffrey Knight National Unit for Affective Disorders in London since 1979 is reviewed. Of patients who had suffered severe mood or obsessive-compulsive disorders before surgery, 84 of 249 (34%) were well 1 year after. The effects of gender, psychiatric diagnosis, and age on outcome are assessed. The findings are compared with a 1975 outcome study, and explanations for apparent differences are proposed.

A 78-year-old man with a history of parathyroidectomy presented with hyperparathyroidism and tracheal obstruction. After excision of the mediastinal parathyroid cyst, his symptoms were completely relieved. The diagnosis, investigations, and management are discussed.

Samples of ventricular CSF were taken from 52 consecutive patients admitted for psychosurgery for intractable depression. Concentrations of asparagine, aspartate, glutamine, glutamic acid, and serine were determined. Glutamate and aspartate concentrations, implicated in excitotoxic brain damage, were not affected by various types of psychotropic drug treatment. Serine, a modulator of glutamate responses, was significantly elevated in samples from subjects receiving antidepressants. These subjects responded poorly to the operation. Psychotropic drugs are unlikely to be neurotoxic. Nevertheless, antidepressants may influence excitatory neurotransmission.

The psychosurgical operation of stereotactic subcaudate tractotomy can be a highly effective treatment for chronic and intractable affective disorders. We have lately given increasing attention to cases where the depressed mood appears to lift although there is little improvement in social function. In these cases there has been a failure of rehabilitation and the complexities of this process post-operatively are discussed. In addition, relatives report in some 10% of cases "personality changes" after the operation which are not perceived in this way by an independent medical assessor and these observations seem to depend upon relatives mis-interpreting the resumption of pre-morbid personality function after long illnesses as undesirable side-effects. Case histories illustrating the problems are described. Treatment and rehabilitation strategies are outlined.

Forty-two patients out of 300 who had undergone bilateral stereotactic cingulotomies were studied by means of computerized tomography (CT). The appearance showed bilateral encephalomalacia, measuring on the average 5 X 7 mm2, located in the cingulate gyrus. These induced lesions had attenuation values similar to cerebrospinal fluid and did not enhance with contrast. CT is a useful technique for initial evaluation, management, and follow up of these patients.

The growth hormone and hypotensive responses to clonidine have been measured in six drug free severely depressed patients before, and at two weeks after, the surgical procedure of stereotactic sub-caudate tractotomy. The responses were unaltered two weeks after operation, by which time a small clinical improvement was evident. These findings are discussed in relation to central alpha adrenoceptor functions in depression, and the effect upon this of antidepressant treatment.

A case of a 37-year-old patient, 10 years after bilateral amygdalotomy and subcaudate tractotomy for chronic self-mutilation, is described. The clinical picture revealed a complex mental state, including disorders of facial recognition, social behaviour, affect and elements of the Kluver-Bucy syndrome. Mild selective deficits were demonstrated psychometrically in the recognition of familiar and unfamiliar faces. Certain features have been described in rhesus monkeys, but have not previously been reported in humans. Primate studies are discussed, with particular reference to the role of the amygdala in facial recognition.

Plasma, cerebrospinal fluid and brain tissue amino acid levels were measured in 14 patients with affective illness and generally confirm previous findings. There was no correlation between these values and age, sex, family history and levels of anxiety. GABA levels measured in cortex tissue were negatively correlated with depressive mood (P less than 0.05), supporting a possible involvement of GABA in depressive illness.

An evaluation of 15 patients treated by subcaudate stereotactic tractotomy (SST) for treatment-resistant unipolar affective disorder was made for frequency and severity of recurrence of illness. One-third had died by the time of assessment, but none by suicide. Two-thirds of the sample experienced a reduction in the severity of depressive episodes after the operation; only one-third reported a reduction in frequency of episodes.