Neurosurgery for intractable obsessive-compulsive disorder and depression: critical issues Benjamin D. Greenberg, MD, PhD a, * , Lawrence H. Price, MD a , Scott L. Rauch, MD c , Gerhard Friehs, MD b , Georg Noren, MD b , Donald Malone, MD e , Linda L. Carpenter, MD a , Ali R. Rezai, MD d , Steven A. Rasmussen, MD a a Department of Psychiatry and Human Behavior, Brown Medical School, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA b Department of Clinical Neuroscience, Brown Medical School, Providence, RI, USA c Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA d Department of Neurosurgery, The Cleveland Clinic Foundation, Cleveland, OH, USA e Department of Psychiatry, The Cleveland Clinic Foundation, Cleveland, OH, USA The effectiveness and tolerability of treatments for obsessive-compulsive disorder (OCD) and depression have seen impressive improvements over past decades. Nonetheless, some patients with either disorder continue to manifest severe chronic illness that is refractory to treatment. For them, modern neurosurgical procedures remain a therapeutic option. Psychiatric neurosurgery remains controversial, largely because indiscrim- inate use of prefrontal lobotomy in the middle of the twentieth century frequently produced signif- icant deficits in emotional responsiveness and motivation, sometimes with little or no therapeu- tic benefit. Although the historical experience remains an enduring caution, current stereotactic methods using considerably smaller and more precisely located targets have much lower mor- bidity. Moreover, an increasingly specific neuro- biologic rationale for psychiatric neurosurgery is being developed. Neuroimaging research has focused attention on the relations between activity in specific neuroanatomic networks and psychiat- ric symptoms and on changes in such relations after effective treatment. A small number of prospective studies support the view that neuro- surgery may be of benefit to patients who fail to improve with the best available conventional treatment. This article considers the efficacy and safety of lesion procedures. The evidence has important limitations but sheds light on critical issues in assessing the long-term effectiveness and morbidity associated with existing procedures, including anterior cingulotomy, anterior capsu- lotomy, subcaudate tractotomy, and limbic leu- kotomy. The same methodologic issues arise when considering the newer nondestructive techniques that are currently in development for the treat- ment of intractable psychiatric illness, including deep brain stimulation. Determining the effective- ness and side effect burden of neurosurgery for intractable psychiatric illness is a task primarily for psychiatrists, collaborating closely with neuro- surgeons, neurologists, and neuropsychologists in specialized multidisciplinary teams. Treatments for OCD and depression have come a long way in recent decades. Even so, some patients with either disorder have severe chronic illness that the best conventional methods are unable to improve. For this reason, there has been continuing work aimed at developing what might be termed neuroanatomically-based treat- ments. For example, there has been considerable interest in transcranial magnetic stimulation, a noninvasive method for stimulating the cerebral * Corresponding author. E-mail address: bdg@butler.org (B.D. Greenberg). 1042-3680/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1042-3680(03)00005-6 Neurosurg Clin N Am 14 (2003) 199–212