Radioactive rods in your brain can eliminate depression. That is the claim of the science of psychosurgery. As Roger Dobson reports, it used to be better known as ...; LOBOTOMY
Monday 18 December 1995
The rods are still there, deep inside the frontal lobe of the brain, which controls emotion, but they are not now radioactive and, after years of severe, crippling depression, the 59-year-old Mrs Lee says she is no longer depressed.
Mrs Lee is one of about two dozen people a year who have psychosurgery in the UK. Banned in Oregon and several other US states, long since abandoned in Germany, Spain, Russia and Norway, psychosurgery (or lobotomy, as the operation is more popularly - though inaccurately - known) remains highly controversial. One of the few medical treatments worldwidewhich has a protection for patients enshrined in a United Nations resolution banning its use on involuntary patients, it may also only be performed with a patient's informed consent.
Psychosurgery, like the less-refined practice of lobotomy that preceded it and with which it is nevertheless still associated, has an image problem. It was the realisation of the enormity of the horrific damage done by lobotomies to thousands of patients in the Forties, largely in the US and Britain, that led to the rigorous controls on psychosurgery, an area of medicine where the UK is now the world leader. Images of lobotomy patients as shaven-headed, dull-eyed zombies pacing the white-tiled corridors of bleak asylums, immortalised by harrowing films such as One Flew Over the Cuckoo's Nest, still haunt the popular imagination.
But more and more clinicians are convinced of the effectiveness of psychosurgery and the number of such operations is expected to increase as a team of specialists, recently transferred from the Brook Hospital to the Maudsley Psychiatric Hospital, both in south London, begin to co-ordinate operations early in the new year. This will be the fourth and possibly most prestigious centre to offer psychosurgery in the UK and practitioners forecast an increase,thanks to patients' worries over the possible side effects of long-term medication.
In the 10 years from 1940, at least 10,000 people in Britain (and probably many more) had lobotomies where large parts of their brains were removed. They were performed by surgeons who, as the Lancet admitted 20 years later, took up a new fashion with more enthusiasm than caution, and with more surgical skill than neurophysiological understanding. The fashion started largely as the result of pioneering operations performed in the US, reported in 1935, on two chimpanzees, Becky and Lucy, which changed their behaviour patterns.
The human lobotomies which followed - British surgeons preferred to call them leucotomy, which literally means cutting the white matter - were largely carried out on people suffering with schizophrenia. It is claimed that 18 per cent of lobotomised patients left asylums as a result of the surgery, but side-effects were frequent and devastating - convulsions, incontinence, personality changes, loss of inhibition, vegetable status and, in up to 6 per cent of cases, death.
In the Fifties, surgery for schizophrenia became obsolete with the arrival of the drug chlorpromazine. Psychosurgery continues to be used in the treatment of severe depression where drugs and ECT have failed and, in the past few years, two additional centres - Cardiff and Dundee - have begun to carry out psychosurgeries.
Practitioners emphasise that the techniques used today are light years away from the old lobotomies. They believe psychosurgery offers a genuine treatment to seriously ill patients and they stress that surgery is controlled by the Mental Health Act Commission. This vets each individual application, including assessments by independent clinicians.
Dr Paul Bridges, consultant psychiatrist at the Maudsley, is regarded as the world leader on psychosurgery. Dr Bridges ran the Sir Geoffrey Knight Unit at the Brook Hospital, the UK's most active centre. Since 1961, 1,300 operations had been carried out up until last year, when the high cost and low availability of the radioactive rods then used forced a halt to surgery. Dr Bridges is in no doubt about its value. "A society without psychosurgery available is rendering untreatable some of its most severely ill and desperate people," he says.
Opponents, however, still see it as a bizarre, barbaric, unscientific assault on patients, a procedure which belongs more in a museum than a modern hospital. Claimed successes for operations are, they say, based on small numbers and are unproven, and no one really knows how it works or what the long-term effects are.
Psychosurgery is now carried out mostly for severe depression. This affects only a tiny proportion of the one in four individuals estimated to have some kind of depressive symptom during his or her life.
At the Maudsley, Dr Bridges and surgical colleagues will use their own modified psychosurgical technique to destroy brain tissue. In the 90-minute operation (called a stereotactric subcaudate tractotomy), a frame is mounted on the head and two holes are made in the forehead through which rods pass inside tubes that have been inserted into the holes. The frame allows far greater accuracy and reduces risk of operator error.
The rods are targeted at parts of the frontal lobe of the brain, the region known to control emotion. When radioactivity was used, up until last year, all living tissue in the brain to within 2mm of the rods was destroyed. In the new technique, rods emitting radio waves will be used in the same way to have a similar lethal effect on tissue.
Mrs Lee, for one, says her life was changed by the procedure: "I had a very deep depression for a number of years and all sorts of things had been tried, including drugs and ECT. I wasn't able to do anything, I wouldn't answer the phone or talk to anyone and I walked around like a zombie. I was like a vegetable.
"It was not a hard decision to have the operation. At that stage, as far as I was concerned, they could have chopped my head off. Nothing worked until the operation. There have been no side-effects."
It is known, however, that there can be post- operative side effects, including headaches for several days and muddled thinking. It is known, too, that one man died as a result of the operation when rods were misplaced in the brain. There is also some risk of epilepsy and fits, and patients are warned of the possibility of a cerebral haemorrhage which could produce a demented state, paralysis similar to a stroke, or even death.
According to Dr Bridges, the operation allows 40 to 60 per cent of patients to live normal or near-normal lives. Critics, however, say there is no real objective measure of any improvement in such patients. It is also acknowledged that, despite 60 years of psychosurgery, the mechanisms involved in the operations remain unclear.
"We do now know that severe depression has a biochemical basis," says Dr Bridges, "and we know it is a neuro-transmission disorder, like Parkinson's disease. The operation is in known tracts in the limbic system that are to do with the emotions and seem to be located in the lower frontal lobe. We interrupt that tract by making a lesion with the rods and somehow that stops the illness and normality follows. We know no more detail than that."
At Cardiff, consultant psychiatrist Dr Roger Thomas and his surgical colleagues have treated between nine and 12 patients in the last few months, some of them referrals from the Brook. "The patients we see have been severely ill, usually for many years," says Dr Thomas, "and they are the people who, in a sense, have nothing to lose because they don't wish to carry on living the way they are.
"People think of One Flew Over the Cuckoo's Nest, but modern psychosurgery is as far away from that as keyhole surgery is from open surgery."
Consultant Dr Sashi Sashidharan is one of many psychiatrists who remains sceptical. "The effectiveness of psychosurgery for what are essentially psychological disorders is unproven," he says. "There is a tendency for people who practise psychosurgery to argue not only on the basis of very small figures but also on selective samples.
"I would treat psychosurgery as a museum piece and I have yet to see any clinical condition that could be defined as responsive to such a traumatic intervention in the structure of the brain."
It is a sentiment echoed by the mental health pressure group MIND. "We are not happy with its continued use and believe there should be a rigorous review to see whether any use is justified," said policy officer Alison Cobb.
As the Maudsley unit gets ready to organiseoperations, the sudden arrival of lobotomy victims of the Forties, now seeking treatment in psychiatric hospitals, is grist to the sceptics' mill. While there are no records of numbers, one unit estimated it sees a dozen cases a year.
When these patients were younger and more mentally active, their depleted brains were able to compensate for the surgery carried out. Loss of intellect with age, however, means they no longer have any spare capacity to make up for the damage. At the Institute of Psychiatry in London, an 80-year- old woman was admitted suffering with self-neglect and other problems. When she was scanned it was found that a large area of her frontal lobe had been destroyed.
As reports of such cases increase, it may not be the scepticism of other psychiatrists or a bad public image which halt the renaissance of psychosurgery, but the re-emergence of these victims of those devastating lobotomies half a century ago.
HOW PSYCHOSURGERY WORKS
ABOVE: an X-ray of the brain of a woman in her fifties during psychosurgery at the Brook Hospital, Woolwich. A steriotactic or targeting frame is temporarily attached to the head to enable the introduction of the radioactive yttrium rods (7mm long and 1mm in diameter) which destroy all surrounding brain tissue within 2mm of the rods. The rods are only radioactive for up to two or three days but are left in place.
A cannula [narrow tube] within the frame itself is inclined by the surgeon using callibrations on the frame so the rod will enter at the precise location desired. It is then locked into position. The cannula is withdrawn once the rod is in the desired location and the rod remains. Two rows of five yttrium rods are inserted in each of the frontal lobes.
LEFT: Maureen Lee had suffered severe depression until the operation. 'There have been no side-effects,' she says
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