Current Literature

In Clinical Science

Psychosurgery, Epilepsy Surgery, or Surgical Psychiatry:

The Tangled Web of Epilepsy and Psychiatry as Revealed
by Surgical Outcomes

Psychiatric Lifetime Diagnoses are Associated With a Reduced Chance of Seizure Freedom After Temporal Lobe
Surgery.
Koch-Stoecker SC, Bien CG, Schulz R, May TW. Epilepsia 2017;58:983–993.
OBJECTIVE: To examine whether psychiatric comorbidity is a predictor of long-term seizure outcome following
temporal lobe epilepsy surgery. METHODS: A sample of 434 adult patients who received temporal lobe resection to
treat epilepsy between 1991 and 2009 and were psychiatrically assessed before surgery were followed for 2 years to
assess seizure outcome. Stepwise multivariate logistic regression analyses were used to assess the impact of psychiatric
variables on complete seizure freedom (Engel class IA), and freedom from disabling seizures (Engel class I). Lifetime
histories of three psychiatric syndromes (PS: psychosis; depression; other) and five personality disorders (PD: DSM-IV
Clusters A, B, and C; organic personality disorder; other) were considered as predictors, complemented by age at onset,
duration of epilepsy, type of lesion (mesiotemporal sclerosis vs. other), and year of surgery. RESULTS: Seizure-freedom
rates were significantly higher (p < 0.001) in patients with no history of PS or PD (N = 138; Engel class IA: 61.6%; Engel
class I: 87.7%) than in those with any PS or PD (N = 296; Engel class IA: 39.5%; Engel class I: 58.8%). Particularly low
seizure-freedom rates were found in patients with a diagnosis of psychosis (N = 32, Engel class IA: 21.9%; Engel class
I: 40.6%), organic PD (N = 48, Engel class IA: 25.0%; Engel class I: 35.4%) or a double diagnosis of PS plus PD (N = 97;
Engel class IA: 27.8%; Engel class I: 45.5%). No other variables emerged as significant risk factors in multivariate logistic
regression analyses. SIGNIFICANCE: Patients with and without psychiatric comorbidities can benefit from temporal lobe
epilepsy surgery; however, psychiatric comorbidities are negatively associated with postoperative seizure-freedom
rates. Surgical outcome is related to the type and extent of preoperative psychiatric morbidity, which underscores the
prognostic value of presurgical psychiatric evaluation. The data support the argument that there are common patho-
genetic mechanisms underlying both epilepsy and psychiatric conditions.

Commentary It is tempting, and perhaps necessary, to briefly revisit the

Have we reached a new age of psychosurgery? Unlikely,
because at this point, surgically treating psychiatric illness is
unsuccessful in all but a few clinical syndromes and unique
circumstances. But we may have reached a new age of
psychiatry and surgery, at least in understanding how psychi-
atric conditions complicate surgery. Although psychiatry and
surgery mentioned in the same breath brings forth unpleasant
recollections of flawed science and lack of reason, their men-
tion today may be an intuitive response after considering the
results of Koch-Stoecker et al. To be clear, psychosurgery was in
no way the focus of this paper or this study. The impact of this
paper is in vividly demonstrating the overlap between psychi-
atric illness and epilepsy in terms of surgical outcomes.
Epilepsy Currents, Vol. 17, No. 6 (November/December) 2017 pp. 351–352
© American Epilepsy Society
history of psychiatry and surgery. In 1949, the neurologist Egas
Moniz won the Nobel Prize for performing leucotomies. The
outcomes were initially intriguing and yielded improvement in
cases where there was little perceived hope for positive prog-
noses. Eventually the procedures were discredited because of
the lack of psychiatric specificity and the imprecision of surgi-
cal techniques. Lack of documented baseline function may
have also hampered assessment of the utility of the procedure,
and surely prevented appreciation of nuanced outcomes, posi-
tive or negative, that may have been ascertained.
Surgery for temporal lobe epilepsy was evolving in roughly
the same time frame, the 1960s and 1970s. In many ways, that
history parallels the evolution of psychiatric neurosurgery,
particularly with the presence of controversy. Contemplating
brain surgery for people with epilepsy who had aggressive
outbursts involved a serious ethical dilemma a half-century
ago. A profound debate about how much epilepsy surgery
could be construed as psychiatric neurosurgery, and vice versa

351
Psychosurgery
was agonizingly considered by Mark and Neville in their JAMA
editorial in 1973 (1).
The debate continues today, though the intersections of
epilepsy surgery and psychiatric impact are better under-
stood. Koch-Stoecker et al. present data from 434 patients
who underwent temporal lobectomies over a 17-year period.
Each patient had seizure localization in the temporal lobe,
though had varying pathology ranging from mesial tempo-
ral sclerosis (MTS) or tumors, to nonlesional. Each patient
received a psychiatric evaluation, which included a semistruc-
tured interview procedure that yielded “official” psychiatric
diagnoses according to the Diagnostic and Statistical Manual
of Mental Disorders (DSM). This in itself is remarkable given
that psychiatric evaluation prior to epilepsy surgery is still
uncommon in many surgery centers. Psychiatric syndromes
(depression, psychosis, other) or personality disorders
(clusters A, B, C, or organic) were not precisely specified, but
instead were aggregated to account for changes in categoric
criteria from differing DSM versions. Each patient received a
follow-up evaluation 2 years later when Engel outcomes were
established.
The results were profound. Surgical outcomes for epilepsy
depended heavily upon the presence or absence of psychiatric
syndromes and/or personality disorders identified prior to sur-
gery. Other factors such as age of onset, duration of epilepsy,
side of surgery, or presence of MTS were not associated with
postsurgical seizure freedom. The best outcomes by far were
in those with no history of psychiatric syndrome or personal-
ity disorder. The presence of both psychiatric syndrome and
personality disorder was associated with a markedly worse
outcome. Psychosis itself was a particularly strong predictor of
a poor outcome for epilepsy. The supposition is clear: psychi-
atric illness may have a powerfully negative impact upon the
efficacy of epilepsy surgery.
Ultimately, the blossoming paradigm of treating psychiat-
ric illness in order to treat epilepsy appears to be reinforced.
And with this data from Koch-Stoecker and colleagues, the
paradigm extends to surgical treatment as well. What if psychi-
atric illnesses were identified and treated prior to the surgical
procedures, or even within the 2-year follow-up period after
surgery? Would the epilepsy outcome be different? We cannot
answer these questions from this study, but clearly the psychi-
atric conditions matter. So it is curious to find that a recently
published practice guideline outlining requirements for high-
level epilepsy surgery centers did not insist upon inclusion
of a psychiatrist on the treatment team. The only reference
to psychiatric evaluation was that availability of “consultative
expertise in multiple fields” was necessary (2). A more recent
paper tracking surgical procedures performed and personnel
involved in surgery centers did not even measure the presence
of psychiatrists on treatment teams (3).
352
To be fair, questions still remain regarding the true impact
of psychiatric illness upon epilepsy surgery outcomes. As the
authors aptly point out, psychosocial stressors may be worse in
patients with psychiatric illness. In theory, a relative lack of social
support and potentially inconsistent treatment adherence may
also contribute to a worse outcome. Even with the authors’ well-
reasoned consideration of common pathogenetic mechanisms
for epilepsy and psychiatric conditions, it is unclear if surgical
procedures may actually have improved the psychiatric status in
some cases. Follow-up psychiatric evaluations were not done at
the 2-year mark, and literature reporting potential emergence of
de novo psychiatric illness after surgery cannot be ignored (4, 5)
Although the data and analyses are robust, the fact that
358/792 eligible patients were not assessed is also notable.
Even in this sophisticated center with an embedded psychia-
trist, 45% of patients did not receive psychiatric baseline assess-
ments. The reason was that the group only had one psychiatrist,
who obviously could not be available 100% of the time. That
perhaps is the most important lesson of this study, that psychi-
atric evaluation prior to epilepsy surgery is no longer optional.
It is essential, and this point has been made repeatedly (6, 7).
One can only hope that center directors and influential resource
allocators will take heed. In terms of understanding and improv-
ing outcomes for persons with medically refractory epilepsy,
psychiatry and surgery belong together, intuitively.
by Jay Salpekar, MD
References
1. Mark VH, Neville R. Brain surgery in aggressive epileptics. Social and
ethical implications. JAMA 1973;226:765–772.
2. Labiner DM, Bagic AI, Herman ST, Fountain NB, Walczak TS, Gumnit
RJ; for the National Association of Epilepsy Centers. Essential services,
personnel, and facilities in specialized epilepsy centers–revised 2010
guidelines. Epilepsia 2010;51:2322–2333.
3. Kaiboriboon K, Malkhachroum AM, Zrik A, Daif A, Schiltz NM, Labiner
DM, Lhatoo SD. Epilepsy surgery in the United States: analysis of
data from the National Association of Epilepsy Centers. Epilepsy Res
2015;116:105–109.
4. Macrodimitris S, Sherman EM, Forde S, Tellez-Zenteno JF, Metcalfe
A, Hernandez-Ronquillo L, Wiebe S, Jette N. Psychiatric outcomes of
epilepsy surgery: a systematic review. Epilepsia 2011;52:880–890.
5. D’Alessio L, Scevola L, Fernandez Lima M, Oddo S, Solis P, Seoane E,
Kochen S. Psychiatric outcome of epilepsy surgery in patients with
psychosis and temporal lobe drug-resistant epilepsy: a prospective
case series. Epilepsy Behav 2014;37:165–170.
6. Sawant N, Ravat S, Muzumdar D, Shah U. Is psychiatric assessment
essential for better epilepsy surgery outcomes? Int J Surg 2016;36(Pt
B):460–465.
7. Rayner G, Wilson SJ. Psychiatric care in epilepsy surgery: who needs
it? Epilepsy Curr 2012;12:46–50.