Neurosurgery is only used for treatment-resistant cases. Thus the patients who undergo surgery are those who have not responded to aggressive treatment strategies, which, depending on the diagnosis, include a combination of pharmacotherapy, electroconvulsive treatment, and cognitive-behavioural psychotherapy. The definition of treatment resistance is not universal, but there is consensus about the necessary therapeutic steps required for treating these patients. (l°il)

Patients who do undergo surgery have severe intractable illnesses. For instance, the average profile of 68 patients with pure affective disorder referred for stereotactic subcaudate tractotomy in the United Kingdom between 1988 and 1989 was as follows:(9)

• more than two serious suicide attempts

• 18 years since the illness was first reported

• 7 years without a remission of at least 6 months

• over 30 electroconvulsive treatments

• over 200 mg of tricyclic antidepressants prescribed

• a Hamilton 17 score of 22 (most patients were on intensive treatment regimens). Major depressive disorder

Most of the reported instances of stereotactic subcaudate tractotomies have been carried out for this indication, although cingulotomy and stereotactic limbic leucotomy have also been used. Up to 15 per cent of patients with severe chronic depression eventually commit suicide. (12.> However, postoperative suicide rates in those who have had neurosurgery have been reported as 2 to 3 per cent (stereotactic subcaudate tractotomy), (13> 5 per cent (stereotactic limbic leucotomy),(14> and 9 per cent (cingulotomy).(1.5)

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