Things that have given psychiatry a bad name #1 – lobotomy

This is the first in an occasional series of posts examining aspects of psychiatric practice which have given shrinks a bad name. As always comments and suggestions are welcome and if you can think of a candidate then let me know.

Anyone who has seen the film ‘One Flew Over the Cuckoo’s Nest’ will remember McMurphy’s fate; having tried to strangle Nurse Ratched and subsequently restrained, he comes back to the ward where Chief Bromden discovers that he has been given a lobotomy. Previously sparky and defiant, he appears subdued and submissive.

Evidence for the use of surgical techniques, such as trepanation of the skull, in people has been found from skulls dating from the middle ages. Famously Phineas Gage underwent a non-surgical lobotomy following an accident during railroad construction. His subsequent personality change played a role in the understanding of the localisation of brain function.

Neurosurgery for psychiatric problems was introduced in modern times by the Portuguese neurologist Egas Moniz and his neurosurgical colleague Almeida Lima, when in 1935 they sought to damage connections to and from the frontal lobes in patients with symptoms of mental disorders. At this time there were no effective therapies for these conditions and the surgery was received positively, Moniz receiving the 1949 Nobel prize for medicine. Moniz’s technique was to drill holes in the skull and inject alcohol into the frontal lobes.

Walter Freeman and James Watts in America modified Moniz’s operative technique and introduced the standard prefrontal leucotomy, which is what we are normally referring to when we say ‘prefrontal lobotomy’. This however required trained neurosurgeons and Freeman was concerned that this restriction would mean that those patients who needed the procedure most, those in asylums, would not be able to access it. As a result he developed the transorbital lobotomy, a terrifying technique whereby a pick like instrument was driven through the thin bone at the top of the eye socket and into the brain at which stage it was blindly manipulated. This procedure could be undertaken anywhere, without surgical training; beforehand the patient was rendered unconscious by electroshock. Dr Freeman was a showman, who would occasionally like to show off in front of an audience of doctors by lobotomizing both sides of a patient at the same time. Dr Freeman alone peformed over 3,000 lobotomies during his career, the results of which, due to its imprecision, were very variable.

Overall between 1936 and 1961 50,000 patients underwent surgery in the United States and about 10,000 in the United Kingdom. No controlled studies were performed and many people who received this treatment did not have a mental health disorder. It is stated that about 20 per cent of patients with schizophrenia and between one-half and two-thirds of patients with affective disorder derived who underwent the procedure derived some benefit. There was a very high mortality (up to 4%), as well as severe abulia and amotivation (up to 4%), personality change (up to 60%), and postoperative epilepsy (up to 15% – all figures for success and side effects are from the Oxford Textbook of Psychiatry). Due to a lack of other effective treatments these were accepted by many psychiatrists as worthwhile risks.

The use of surgery declined rapidly following the introduction of antipsychotic and antidepressant medication during the late 1950s. Since then, neurosurgery has only been used for severe treatment-resistant affective, obsessional, and anxiety disorders. These operations are used only rarely there having been, on average, no more than 20 operations a year in the United Kingdom over the last 20 years.

Howard Dully, one of Dr Freeman’s youngest patients has written a book about his experiences called My Lobotomy (which I haven’t read), the subject of this Observer article

Dr Elliot Valenstein has written a book called Great and Desperate Cures!: Rise and Decline of Psychosurgery and other Radical Treatments for Mental Illness. (Which I haven’t read either)

Jack El-Hai has written a biography of Walter Freeman. I have read this, and it’s very interesting and detailed. It’s called The Lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness

15 Responses to “Things that have given psychiatry a bad name #1 – lobotomy”

  1. April says:

    We listened to something about Walter Freeman on NPR a couple years ago, told from the perspective of the patients and their families. It was heartbreaking. Looks like it (the radio program) was related to Howard Dully’s book.

  2. Interesting…it makes you wonder what people will be saying about how we approach mental health care in 50 years time doesn’t it.

  3. Howard Dully says:

    I did the piece on NPR in Nov, 2005 and it was only 22 minutes yet we had hundreds of hours of tape.
    Those that have bought and read my book Thank You very much. Waiting patiently for Oprah :)

    Much Luv
    Howard

  4. Paul says:

    “Interesting…it makes you wonder what people will be saying about how we approach mental health care in 50 years time doesn’t it.”

    Yes I suppose it does.

    For instance people may look at the death rates associated with long-term high-dose poly-prescribing of antipsychotic medication with a degree of astonishment as well… Given there is the same utter lack of evidence for the effectiveness of high-dose polypharmacy as there is for putting ice-picks in people’s brains.

    http://bjp.rcpsych.org/cgi/content/abstract/173/4/325

    They may also ask why – given the side-effects* and risk associated with antipsychotics are so serious that if they were being given to people for physical health problems there would be great public concern and much much tighter regulation – psychiatric patients are compelled to take them.

    *http://content.nejm.org/cgi/content/abstract/353/12/1209

    The cost to the individual of taking antipsychotics (typical or atypical) is significant (while not denying of course the benefits may be considerable) while the cost associated with MMR is negligible or illusory, yet the public response to these issues (both of which involve giving medication without full informed consent) is of course, vastly different.

    Back to the issue though…

    Frontier, do you think psychiatry ‘should’ have been given a bad name because of neurosurgery?

  5. deClerambault says:

    “http://bjp.rcpsych.org/cgi/content/abstract/173/4/325″

    Paul did you read the same paper as me? It doesn’t really have the Ronseal factor does it?
    88 people in a prospective study – in rural Ireland.
    No control for obvious confounders such as sedentry lifestyle, cardiovascular risk and SMOKING.
    You’re looking at a population who are somewhat neglecting in their physical health either due to disabling negative symptoms such as apathy, or plain and simple lifestyle choice.
    On the one hand the use of drugs such as Olanzapine and Clozapine often cause significant weight gain and a metabolic syndrome leading to diabetes. On the other hand patients with schizophrenia may be more prone to diabetes anyway (Dinan T. BJPsych 2004 147 supplement 72-75).

    You’ve got to remember Paul (I don’t know if you’re medically trained or not) that for every condition, physical or mental (a distinction that I actually think is irrelevant, but that’s another debate!) one must weigh up the risks of treatment vs non-treatment,with the patient, primarily for the patient themselves, but also where necessary with a public health perspective in mind – humans are social animals.

    So I’m not really sure if your point is a medical one ie. medical intervention doesn’t really work. Which I dispute, and can be proven one way or another.
    Or is it a philosophical one ie. that all people have agency and capacity and deontological ethics therefore always trump utilitarian concerns. Which is essentially an endless and rather circular debate depending on your own model of ethics.

  6. As a trainee psychiatrist, I do feel a compulsion to stand up for the profession, but one of the great things about doing this blog is getting opinions from outside the profession, as there are a lot of people not medically qualified who read and comment here.

    To address Paul’s comments (in reverse order). I do think that psychiatry suffers from the weight of its history, and of the things done in psychiatry’s name, psychosurgery is one of the more regrettable.

    However, as I say in the post we should bear in mind the total lack of effective treatments for serious mental illness at the time of Moniz’s work. I was surprised in my research to learn that a substantial number of people appeared to improve with the procedure. I wasn’t so surprised to learn of the high rate of side effects, but without any sort of trail, we’ll never know whether the treatment was actually effective or not. I don’t think that Dr Freeman’s cavalier approach can be defended in anyway.

    Overall though, an incredibly invasive and permanent procedure undertaken on extremely vulnerable people cannot be looked back at with any sort of pride. The best thing we can hope to do is learn the lessons of the past. Other disciplines in medicine have done comparable things to people in the name of affecting cures and we shouldn’t beat ourselves up any more than they do. Times have moved on and so has society and psychiatry too.

    As for psychiatric medication. Most psychiatric medication has serious side effects. We shouldn’t single out psychiatry in this – there are few if any drugs which are ‘silver bullets’ in any part of medicine and steroids, which are used in a very large number of diseases, have a side effect profile as long as your arm. With psychiatric medication, as with all treatments its then a matter of balancing risk with the positive effects that the medication can bring. This risk benefit analysis is complicated in psychiatry in that some people consider that people with psychiatric disorders don’t have anything wrong with them in the first place – a least not anything that can be treated with drugs. I don’t hold with this and I refer you to
    Trevor Turners article
    about the effect of Chlorpromazine in clearing out the asylums

    Out of the total number of people taking antipsychotic medication, only a small number are compelled to take it, most do so of their own free will.

    The papers you cite are interesting. The BJP paper appears to suggest that prescribing two antipsychotics affects a patient’s longevity. Whether this is true or not, this is not recommended practice and it is relatively rare to find a patient treated in this way. deClerambault is right to say that the study is small and they don’t appear to control for other factors that might lead to this reduced lifespan. The thrust of NEJM paper isn’t really about side effects of medications, although I grant that this is an important factor in it. It’s about comparing the relative effectiveness of first and second generation antipsychotics given the claims made that second generation are superior.

    We do need better psychiatric medications, and I hope we look back upon our treatments now and models of psychiatric illness as being primitive in years to come.

  7. Paul says:

    Thank you for your responses which I appreciate and largely agree with. However I’m worried you think I’m arguing something I’m not!

    First of all – no, I’m not medically qualified – I’m a trainee clinical psychologist. I currently attempt to provide cognitive therapy to people at high risk of psychosis and I’m conducting research with people across the spectrum, from people at first episode to those with chronic and severe problems. I support a minimum medication / maximum kindness approach to understanding and treating psychotic complaints as advocated by the likes of psychologist Richard Bentall and psychiatrist Loren Mosher.

    My main points were simply:

    1. Long-term high dose polypharmacy is significantly associated with increased mortality.

    I certainly was not arguing antipsychotic medication, when prescribed at BNF recommended levels or in accordance with NICE guidelines, is linked to increased mortality.

    I hardly think it’s controversial or unorthodox to acknowledge the increased risks associated with the prescribing practices I was criticising, and to acknowledge that the gains of such practice are actually minimal. I believe the burden of proof lies with someone who advocates long-term high dose polypharmacy to prove the benefits! I expect this is not something either of you advocate in your practice? However if so I’d be interested in studies supporting the efficacy, effectiveness and ethics of such an approach.

    The paper I cite was illustrative of this point, not exhaustive. Anyway here’s another one:

    http://bjp.rcpsych.org/cgi/content/full/188/2/122

    Anecdotally, my guess would be that if you go into any inner city ICU and ask the consultant if he or she thinks there’s a link between antipsychotic use of the sort described and increased mortality, they’ll give you a much firmer answer.

    2. I believe there is a relative disregard (at a societal level, not necessarily a medical one) of the impact of antipsychotic medication on people who are compelled to take it.

    You’ll note this was a point levelled at the “public response”, not necessarily psychiatry and the law – although I feel you read it as such. My awareness of the literature is that many people operate with a highly stigmatising view of people who have received a diagnosis of schizophrenia, believing them to be out of control and dangerous, and probably aren’t even aware of the side-effects people have to endure if they take their meds. I’m also aware that there is little media interest in the cost to people of taking such medication, but disproportionate attention given to rare acts of violence.

    I believe this has a knock-on effect in that the prescription of antipsychotic medication is less tightly regulated than a comparable drug in physical health – which is one reason long-term, high dose polypharmacy is tolerated. When was the last time you heard a public outcry over the sudden death of a psychiatric patient linked to such practice?

    Anyway, those were my points. I don’t identify with anti-psychiatry or radicalism, but I do feel criticial of reductionistic approaches and I do identify with a recovery model where psychotic symptoms are not the only measure used of whether something ‘works’.

    In addressing some of the points you made I’m assuming that neither of you deny that the side-effects of such medication are considerable for many, and a key factor in non-compliance. I for one am certainly NOT denying that for many people such side-effects are less of a problem than the distress they are experiencing in relation to their psychotic experiences. I also agree only a small number are legally compelled to take this medication, but whether this implies people are then taking it of their own free will is controversial. Many do I’m sure, but equally many are cajoled and pressured into compliance by health professionals who, keen to manage risk, minimise the side-effects and maximise the possibility of compulsion if they don’t ‘comply’.

    Frontier, you rightly say polypharmacy is not recommended but then say it is relatively rare to find a patient treated in this way. However according to an audit by Harrington et al., (2002) 48% of 3132 UK patients were being prescribed more than one antipsychotic.

    http://pb.rcpsych.org/cgi/content/abstract/26/11/414

    DeClerambault, you dispute the argument that these medications don’t work. I wasn’t actually making such a point but I certainly agree that with you that they ameliorate psychotic symptoms, if this is what you mean by working? But I’m sure you’ll agree that perhaps the best outcome measures to use are those identified by service-users? Unusual experiences often do feature here, but other things carry equal if not greater weight (e.g., the young man or woman for whom weight-gain is more distressing than risk of relapse).

    Regarding your points on the ethical analysis of medication. I completely agree with both of you on the need for careful weighing up of all factors and I certainly wasn’t intending to open a debate on deontological ethics versus consequentialism!

  8. Frontier Psychiatrist says:

    Paul, thanks for your thoughtful reply. I stand corrected on polypharmacy – although I hope that things have improved since that paper in 2002. It’s interesting to think about patient complicance with medication and whether the positive outcome measures of a psychiatrist would be the same as those of a patient.

    I don’t have a reference, but one of my consultants likes to quote a study where the adherence to medication was examined for people on anti-rejection drugs for kidney transplants. We might think that given the life-or-death nature of this then people might be very diligent in taking these. Not so apparently and adherence rates were not much better than any other drugs.

  9. I’m afraid to say that I have met many people on multiple drug therapies – and having worked with numerous psychiatrists and in teams where the consultant psychiatrist has changed (I don’t know what it is – but when I join teams, the psychiatrist leaves), I think what drugs a person gets is more of a function of the psychiatrist than their actual condition!

    Some psychiatrists are very drug happy – if one doesn’t work, they’ll add another, then another, then another and before you know it the individual is on quite a cocktail. Others will tend to switch between drugs and find one that best suits the individual (probably a better practice).

    However, you are right about non-adherence. My background in health psychology tells me that most people don’t take most medications as prescribed. I blether on about it constantly, but I think Leventhal’s model of self-regulation is the best model we have for understanding what people do with the health advice they’re given – they do what fits their broader understanding and goals, not what makes best medical sense to their doctors.

    This is a brilliant paper if you can get hold of it:
    http://psycnet.apa.org/?fa=main.doiLanding&uid=1986-01915-001

    It would be fascinating to find out more about people who take antipsychotic’s perceptions and narratives around the role of medication. Paul, you seem to be quite the expert – do you know of anything?

  10. Paul says:

    “you seem to be quite the expert”

    Well I’m not sure about that, but it is an issue I find interesting and relevant to some work I’m doing at the moment.

    Thanks for the Leventhal reference and the Conrad paper looks very interesting. How self-regulation theory sheds light on antipsychotic medication adherence is discussed here:

    http://linkinghub.elsevier.com/retrieve/pii/S0277953698002093

    The idea that antipsychotic non-compliance is about the same as other physical conditions is controversial, given that Lieberman et al (2005) found discontinuation rates of 74% in their research trial. I struggled to find any recent audit data on UK antipsychotic compliance and there was nothing recent comparing adherence rates in psychosis versus those in physical health, so that remains a moot point I suppose.

    http://content.nejm.org/cgi/content/abstract/353/12/1209

    With respect to antipsychotics in particular I think the evidence shows that when people are (1) properly educated about the mechanism, efficacy and side-effects of medication; (2) genuinely encouraged to weigh up the pro’s and con’s in a collaborative manner; (3) encouraged to make a properly free decision, and (4) there is a trusting positive relationship between user and provider, then those who choose to take antipsychotics will actually continue to take them despite the side-effects.

    There is some evidence that (1) is not always the case, e.g:

    http://linkinghub.elsevier.com/retrieve/pii/S0277953605005848

    For the importance of (4) see:

    http://archpsyc.ama-assn.org/cgi/content/abstract/62/7/717

    Unless there is a risk to others, those who express a rational choice not to take antipsychotics should be offered alternatives in my view. If there is a clear risk to others (directly linked to psychotic experiences and mitigated by medication) then I suppose it is not unprecedented to compel people to take medication where there is a public health concern (i.e., tuberculosis).

    Where there are doubts regarding a person’s capacity to make such a decision, and where there is only a low risk to others, I think this should be assessed according to the spirit of the new Mental Capacity Act, i.e., people are allowed to make bad decisions, and capacity is presumed unless proven otherwise*.

    Regarding the qualitative experience of taking antipsychotic medication, I found this:

    http://www.ingentaconnect.com/content/bpsoc/paptrap/2004/00000077/00000001/art00002

    I’ve not read it though so not sure how good it is.

    Finally, do we need to ask whether a prescription of antipsychotics can cause harm? I’m not sure about this, but if we don’t accept the brain disease model of psychosis, if we start to appreciate that the anxiety, trauma and catastrophic appraisals (“These voices mean I’m going mad”) created by being given a diagnosis of schizophrenia can themselves lead to relapse**, and if more evidence emerges demonstrating links between being told one has a degenerative brain disease and hopelessness***, then it is not an unreasonable question to ask. That is, a prescription of antipsychotics could be interpreted by a young person as good evidence for the catastrophic appraisals that he or she is going mad and that he or she has a degenerative brain disease and so on.

    *This is the opinion of psychiatrist and philosopher Bill Fulford in his Oxford Textbook of Philosophy and Psychiatry (2007)

    ** http://journals.cambridge.org/action/displayAbstract?aid=48627
    http://journals.cambridge.org/action/displayAbstract?aid=80756
    linkinghub.elsevier.com/retrieve/pii/S000579670700006X

    ***www.ncbi.nlm.nih.gov/pubmed/18091189

  11. Paul, sorry that you had trouble posting this – my spam program for picking out spam comments doesn’t like you. Please continue posting, but you could try a slightly different name or email address. Otherwise I check the spam section every other day or so, so your comments will appear fairly quickly!

  12. Paul says:

    “my spam program for picking out spam comments doesn’t like you.”

    Oh dear, your spam program has probably rumbled my tenuous arguments! I suspect it’s the number of links I’m putting in. Sorry if flooding your blog with these. I’m afraid I’m immersed in all this stuff at the moment and engaging in stimulating dialogue makes it easier to remember – hope you don’t mind!

  13. Thank you for this post Paul (and FP for the discussion – it seems your blog is being ambused by trainee clin psychs – ha ha ha – we will be taking over the world soon).

    Very interesting stuff! Unfortunately all completely unrelated to my current placement so I don’t have much time to read up on it :( . I’m hoping to work with psychosis in some of my specialist placements. It wasn’t something that really grabbed me until I started training, but now I find myself utterly fascinated by it.

  14. Anon says:

    “However, as I say in the post we should bear in mind the total lack of effective treatments for serious mental illness at the time of Moniz’s work.”

    Not quite total. The first person to undergo a leucotomy in Britain (a young woman in Bristol in December 1940) had already had insulin treatment, ‘endocrine’ treatment and 77 electroconvulsive treatments before her operation.

    I think by the way you underestimate the number of leucotomies carried out in Britain. Per head of the population, the use of leucotomy was probably higher than in the US.

  15. Mark Leo says:

    I was a nursing student and we were given an assignment to work an afternoon at a local psychiatric facility. At this facility I observed a few older women who had been lobotomized. Most were mute. One, who strangely enough was a women who might otherwise be considered attractive, was sitting in a soaked pajama bottom; her aides didn’t bother to change her, an illegality by the way. The aides were simian in appearance.

    What a legacy. The little creepy guy who was the doctor in charge wore a dopey tweed jacket, like he was Mr Chips or something.
    This activity by doctors doesn’t surprise. The history of the rise of Nazism reveals a disproportionate membership amongst physicians.
    As far as I am concerned psychiatry is a twisted and evil matter.
    Recently in Minnesota we had a sponsored bike ride called the MS150, a fundraiser for Multiple Sclerosis. The Noran Neurological Clinic offered to sponsor but they were turned down because of their history of lobotomy; I believe approximately 5000 in Minnesota were murdered.

    Fuck them and fuck you.

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