The Association of Mental Illness With Outcomes of Emergency Surgery for Bowel Obstruction.

INTRODUCTION: Bowel obstruction is one of the most common surgical emergencies. The management of SBO is variable and influenced by numerous confounding factors. Recent studies have identified mental health as a health disparity that affects surgical outcomes. We aim to assess whether mental illness is a health disparity and its association with postoperative complications and secondary outcomes for bowel obstruction in Emergency General Surgery (EGS). METHODS: This was a retrospective study utilizing the National Inpatient Sample. Individuals aged 18-64 who underwent emergency adehesiolysis or bowel resection from 2015 to 2017 were identified. Postoperative complications, in-hospital mortality, length of stay, and total cost for surgical patients with and without mental illness were recorded. Univariate and multivariate analyses were used to evaluate the association between mental health and bowel obstruction. RESULTS: 20,574 patients who underwent surgery for bowel obstruction were identified. 3756 of these patients had mental illness and 16,998 patients did not. Patients with mental illness did not have significantly worse outcomes compared to patients without mental illness. Among 3576 patients with mental illness, sex, race, patient location, insurance, location/teaching status of hospital, hospital control and procedure type were significant predictors of prolonged length of stay, higher cost, and increased postoperative complications. CONCLUSIONS: Mental health does not appear to be a health disparity in outcomes for bowel obstruction procedures. However, the intersection of mental health with race and insurance status predicts worse outcomes. This essential area should be further explored to determine how marginalized populations are affected in emergency surgical care.

Happy Birthday "One Flew Over the Cuckoo's Nest": A Momentous Tale in the Quest for an Effective and Ethical Approach to Psychosurgery.

The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We used a narrative, historical and dialectical method to deliver an account of the controversial subject. A balanced representation of the negative and positive aspects, acknowledging some of the questionable ethical practices while describing well-reasoned applications is provided. It includes neurosurgeons, psychiatrists who have embraced these procedures with unwarranted enthusiasm and those who have opposed. Neurosurgical techniques for the treatment of severe mental disorders have evolved from rudimentary procedures which were used to 'correct' unwanted behaviours associated with a wide range of severe mental disorders to more refined and selective approaches used as a last resort to treat specific mental health conditions. In the absence of specific aetiological models to guide ablative surgical targets, non-ablative, stimulatory techniques have more recently been developed to allow reversibility when surgical treatment fails to obtain a sizeable improvement in quality of life. The subject is concretely illustrated by two eloquent clinical images: one on a series of brain computed tomography scans carried out on a Canadian population of subjects, who underwent leukotomy decades ago, and the other more contemporary on an implantation surgery to epidural stimulation. Alongside technical advances in psychosurgery, a regulatory framework has gradually developed to ensure vigilance in the appropriateness of patients' selection. Nevertheless, harmonisation of protocols around the world is necessary to ensure consistency in obtaining and maintaining the highest possible ethical standards for the benefit of patients. If the neurosciences promise today, in their new, better framed, and reversible applications, to provide answers to unmet therapeutic needs, we still must remain attentive to drifts linked the introduction of intrusive technologies for purposes of domination or behaviour modification that would impede our individual freedom.

Future directions in psychiatric neurosurgery: Proceedings of the 2022 American Society for Stereotactic and Functional Neurosurgery meeting on surgical neuromodulation for psychiatric disorders.

OBJECTIVE: Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients. Neuromodulation, including deep brain stimulation (DBS), has emerged as a potential therapy for persistent disabling disease, however it has not yet gained widespread adoption. In 2016, the American Society for Stereotactic and Functional Neurosurgery (ASSFN) convened a meeting with leaders in the field to discuss a roadmap for the path forward. A follow-up meeting in 2022 aimed to review the current state of the field and to identify critical barriers and milestones for progress. DESIGN: The ASSFN convened a meeting on June 3, 2022 in Atlanta, Georgia and included leaders from the fields of neurology, neurosurgery, and psychiatry along with colleagues from industry, government, ethics, and law. The goal was to review the current state of the field, assess for advances or setbacks in the interim six years, and suggest a future path forward. The participants focused on five areas of interest: interdisciplinary engagement, regulatory pathways and trial design, disease biomarkers, ethics of psychiatric surgery, and resource allocation/prioritization. The proceedings are summarized here. CONCLUSION: The field of surgical psychiatry has made significant progress since our last expert meeting. Although weakness and threats to the development of novel surgical therapies exist, the identified strengths and opportunities promise to move the field through methodically rigorous and biologically-based approaches. The experts agree that ethics, law, patient engagement, and multidisciplinary teams will be critical to any potential growth in this area.

Neurosurgery for psychiatric disorders: reviewing the past and charting the future.

Surgical techniques targeting behavioral disorders date back thousands of years. In this review, the authors discuss the history of neurosurgery for psychiatric disorders, starting with trephination in the Stone Age, progressing through the fraught practice of prefrontal lobotomy, and ending with modern neurosurgical techniques for treating psychiatric conditions, including ablative procedures, conventional deep brain stimulation, and closed-loop neurostimulation. Despite a tumultuous past, psychiatric neurosurgery is on the cusp of becoming a transformative therapy for patients with psychiatric dysfunction, with an ever-increasing evidence base suggesting reproducible and ethical therapeutic benefit.

Psychiatric outcomes after temporal lobe surgery in patients with temporal lobe epilepsy and comorbid psychiatric illness: A systematic review and meta-analysis.

BACKGROUND: The currently available evidence is unclear in regard to psychiatric outcomes of temporal lobe epilepsy (TLE) in patients with comorbid psychiatric disorders (PD). AIM: To identify and synthesize psychiatric outcomes in patients with TLE and comorbid psychiatric illnesses before and after TLE surgery. METHODS: Studies were included if participants were adults and/or children with temporal epilepsy and comorbid psychiatric illness. Surgical interventions included focal resection (e.g., lobectomy, selective amygdalohippocampectomy) or stereotactic laser ablation. Included studies reported on pre- and post- surgery data of comorbid psychiatric illness (e.g., mood and anxiety disorders, depression, psychosis, adjustment disorders, non-epileptic seizures, and personality disorders). RESULTS: Ten studies were included in the review. The proportion of patients achieving PD resolution or improvements after surgery varied widely between studies, ranging from 15 % to 57 % at the reported follow-up time. Three studies reported on PD symptom worsening after surgery, with considerable variations of patient proportions across studies. Meta-analysis suggests that 43 % of patients demonstrated improvement and 33 % of patients showed a worsening in psychiatric scores across all studies. Preliminary data from three studies suggest that seizure control may be associated with favourable psychiatric outcomes. CONCLUSION: A considerable proportion of reported TLE patients with comorbid psychiatric illnesses have improvement in their psychiatric symptoms after temporal lobe epilepsy surgery. There is scarcity of detailed outcome reporting including symptom scores, and to date, predictive factors for favourable vs unfavourable outcomes in this patient population are not clear. Further research on the topic is warranted.

Patients selection for psychiatric neurosurgery: pitfalls and considerations.

Neurosurgical interventions (destructive or neuromodulation) are considered as a therapeutic option for patients with treatment resistant mental disorders. However, the issues of indications and contraindications for psychiatric surgery, method and patient selection remain unresolved. This article discusses possible problems and contradictions in the selection of patients, the need for an interdisciplinary team to work to solve the question of the feasibility of using neurosurgical methods. The authors have identified the main problems that increase the risks of selection and lead to a lack of results or low efficiency of neurosurgical intervention, namely: (1) diagnostic errors or inaccuracies; (2) inconclusive data on therapeutic resistance; (3) lack of a common understanding of the goals and desired results among participants in the selection of patients for neurosurgery. Possible predictors of surgical outcome and ethical issues are also discussed. Neurosurgical interventions as a treatment option for psychiatric disorders are not officially approved in most countries. So an appropriate algorithm for patient selection and clear criteria for outcome measures are needed.

A comparative history of psychosurgery.

The term "psychosurgery" reflecting neurosurgical treatment of mental disorders, was coined by a Portuguese neurologist Egas Moniz (1874-1955), who, in 1935, suggested a procedure named prefrontal leucotomy (or lobotomy) aimed to divide white matter tracts connecting prefrontal cortex and thalamus. Starting from 1936, this technique and its subsequent modification (transorbital lobotomy) was zealously promoted by a neurologist Walter Freeman (1895-1972) and a neurosurgeon James Watts (1904-1994) at George Washington University, who in 1942 summarized their experience in a monograph, which publication resulted in a tremendous worldwide interest in psychosurgical interventions. The present review describes comparative development of prefrontal leucotomy followed by stereotactic ablation and neurostimulation in three different geographical regions: USA, USSR/Russia, and Far East (China and Japan), where psychosurgery followed nearly similar courses, progressing from the initial enthusiasm and high clinical caseloads to nearly complete disregard. The opposition to neurosurgical interventions for mental disorders around the world was led by different groups and for varying reasons, but, unfortunately, always with political considerations mixed in. Today, with vast advancements in neuroimaging, stereotactic neurosurgical techniques, and physiological knowledge, psychiatric neurosurgery can be performed with much greater precision and safety.

LINAC-based radiosurgery for functional and psychiatric disorders: Problems and their solutions.

Stereotactic radiosurgery (SRS) is practically non-invasive treatment option, and its application for ablative procedures in functional and psychiatric brain disorders seems rather promising. In such cases, gamma knife surgery (GKS) is considered a standard option due to its proved accuracy in targeting and dosimetry. However, modern linear accelerators (LINAC), which are the most commonly used radiosurgical device, provide comparable treatment preciseness. Although at present experience with LINAC-based SRS of functional brain disorders is rather limited, from the technological viewpoint it definitely seems possible and theoretically may be of the similar efficacy as established with GKS for the same indications. However, widespread introduction of such practice requires resolution of several important methodological issues, particularly related to establishment of specific treatment standards, development of dedicated training for involved medical professionals, and creation of the data accumulation and outcome analysis systems.

Modern neurosurgical techniques for psychiatric disorders.

Psychosurgery refers to an ensemble of more or less invasive techniques designed to reduce the burden caused by psychiatric diseases in patients who have failed to respond to conventional therapy. While most surgeries are designed to correct apparent anatomical abnormalities, no discrete cerebral anatomical lesion is evident in most psychiatric diseases amenable to invasive interventions. Finding the optimal surgical targets in mental illness is troublesome. In general, contemporary psychosurgical procedures can be classified into one of two primary modalities: lesioning and stimulation procedures. The first group is divided into (a) thermocoagulation and (b) stereotactic radiosurgery or recently introduced transcranial magnetic resonance-guided focused ultrasound, whereas stimulation techniques mainly include deep brain stimulation (DBS), cortical stimulation, and the vagus nerve stimulation. The most studied psychiatric diseases amenable to psychosurgical interventions are severe treatment-resistant major depressive disorder, obsessive-compulsive disorder, Tourette syndrome, anorexia nervosa, schizophrenia, and substance use disorder. Furthermore, modern neuroimaging techniques spurred the interest of clinicians to identify cerebral regions amenable to be manipulated to control psychiatric symptoms. On this way, the concept of a multi-nodal network need to be embraced, enticing the collaboration of psychiatrists, psychologists, neurologists and neurosurgeons participating in multidisciplinary groups, conducting well-designed clinical trials.

Temporal Lobectomy: Does It Worsen or Improve Presurgical Psychiatric Disorders?

Temporal lobe epilepsy (TLE) is the type of epilepsy most frequently associated with psychiatric morbidity. Respective surgery for focal epilepsy remains the preferred treatment for medically resistant epilepsy. The aim of this chapter is to review what happens with psychiatric disorders once patients have undergone surgery.Early studies demonstrated a post-surgical increase in the incidence rates of anxiety and depressive disorders, while recent studies found that the prevalence of depression and anxiety decreased 12 months after surgery. In spite of this improvement, de novo anxiety and depressive or psychotic cases can be seen. In particular, de novo psychosis ranges from 1% to 14%, with risk factors including bilateral temporal damage, tumors rather than mesial temporal sclerosis, and seizures emerging after surgery again.Personality changes after temporal lobectomy are yet to be established, but decline in schizotypal behavior and neuroticism is the most replicated so far.In children's studies surgery resolved 16% of the participants' psychiatric problems, while 12% presented a de novo psychiatric diagnosis, but further, more conclusive results are needed.The main limitations of these studies are the inconsistent systematic post-surgical psychiatric evaluations, the small sample sizes of case series, the short follow-up post-surgical periods, and the small number of controlled studies.A psychiatric assessment should be conducted before surgery, and most of all, patients with a psychiatric history should be followed after surgery.

The Proud History of Psychosurgery in the USA.

To understand the development and growth of psychosurgery, the context of psychiatric care in the mid-twentieth-century USA must be considered-for example, overpopulation and understaffing of public institutions, and typical use of psychotherapy, which was generally useless in treating the symptomatology of severe mental illness. Therefore, the introduction of prefrontal lobotomy (and, later, transorbital lobotomy) by Drs. Walter Freeman and James Watts, who modified the technique of leukotomy developed by Nobel Prize laureate Dr. Egas Moniz, was considered revolutionary and quickly gained widespread acceptance by medical community. No other alternative treatment at the time demonstrated comparable efficacy. At its peak, psychosurgery was sometimes applied inappropriately, but records from multiple institutions across the USA demonstrate that these were exceptional cases, whereas, as a rule, selection of surgical candidates was based on very strict criteria, indicating the high professionalism and humanity of medical staff. Although psychosurgery has declined heavily since the 1950s, it is not obsolete and is currently considered a valuable treatment option, realized through various open, stereotactic, or radiosurgical procedures.

Predicting epilepsy surgery outcome in adult patients: May psychiatric diagnosis improve predictive models?

OBJECTIVE: With this study, we aimed to assess the importance of including psychiatric disorders in a comprehensive prediction model for epilepsy surgery. METHODS: Ambispective observational study with a sample of adults who underwent resective surgery. Participants were evaluated, before and one year after surgery, to collect data regarding their neurological and psychiatric history. The one-year post-surgical outcome was classified according to the Engel Outcome Scale. Previously identified predictors of post-surgical Engel Class were included in a logistic regression model. Then, the accuracy of alternative predictive models, including or excluding, past and current psychiatric diagnoses, were tried. RESULTS: One hundred and forty-six people participated in this study. The inclusion of psychiatric diagnosis resulted in a model with a higher AUC curve, however, the Delong method showed no significant statistical differences between the models. SIGNIFICANCE: Despite the fact that presurgical psychiatric diagnoses have shown to contribute to the prediction of epilepsy surgery outcome they do not contribute to a significant improvement of predictive models.

Psychiatric symptoms are frequent in idiopathic intracranial hypertension patients.

Idiopathic intracranial hypertension (IIH) is a rare disease with an incidence rate of 0.5-2.0/100,000/year. Characteristic symptoms are headache and several degrees of visual impairment. Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In this study, we evaluated IIH subjects to determine the association with psychiatric symptoms. We evaluated thirty consecutive patients with IIH submitted to neurosurgery from January 2017 to January 2020 in two Brazilian tertiary hospitals. They underwent clinical evaluation, obtaining medical history, comorbidities, body mass index (BMI-kg/m2), and applying Neuropsychiatric Inventory Questionnaire (NPI-Q). There were 28 females and 2 males. Ages ranged from 18 to 66 years old, with mean age of 37.97 ± 12.78. Twenty-five (83%) presented comorbidities, being obese and having arterial hypertension the most frequent. Body mass index ranged from 25 to 35 kg/m2 and mean value was 31 ± 3.42. After application of Neuropsychiatric Interview, 26 of 30 presented psychiatric symptoms (86%). Depression-anxiety syndromes were reported in 25 patients (83%). Nighttime disturbances were reported by 14 subjects (46%). Appetite and eating disorders were described by 23 (76%). Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In our sample, twenty-six out of 30 (86%) reported psychiatric symptoms. We highlight the high prevalence of psychiatric symptoms among IIH patients and the need of managing these patients with a multidisciplinary team, including psychiatrists.

Longitudinal Changes After Amygdala Surgery for Intractable Aggressive Behavior: Clinical, Imaging Genetics, and Deformation-Based Morphometry Study-A Case Series.

BACKGROUND: Intractable aggressive behavior (iAB) is a devastating behavioral disorder that may affect psychiatric patients. These patients have reduced quality of life, are more challenging to treat as they impose a high caregiver burden and require specialized care. Neuromodulatory interventions targeting the amygdala, a key hub in the circuitry of aggressive behavior (AB), may provide symptom alleviation. OBJECTIVE: To Report clinical and imaging findings from a case series of iAB patients treated with bilateral amygdala ablation. METHODS: This series included 4 cases (3 males, 19-32 years old) who underwent bilateral amygdala radiofrequency ablation for iAB hallmarked by life-threatening self-injury and social aggression. Pre- and postassessments involved full clinical, psychiatric, and neurosurgical evaluations, including scales quantifying AB, general agitation, quality of life, and magnetic resonance imaging (MRI). RESULTS: Postsurgery assessments revealed decreased aggression and agitation and improved quality of life. AB was correlated with testosterone levels and testosterone/cortisol ratio in males. No clinically significant side effects were observed. Imaging analyses showed preoperative amygdala volumes within normal populational range and confirmed lesion locations. The reductions in aggressive symptoms were accompanied by significant postsurgical volumetric reductions in brain areas classically associated with AB and increases in regions related to somatosensation. The local volumetric reductions are found in areas that in a normal brain show high expression levels of genes related to AB (eg, aminergic transmission) using gene expression data provided by the Allen brain atlas. CONCLUSION: These findings provide new insight into the whole brain neurocircuitry of aggression and suggest a role of altered somatosensation and possible novel neuromodulation targets.

Gottlieb Burckhardt (1836-1907): 19th-Century Pioneer of Psychosurgery.

Gottlieb Burckhardt was a 19th-century Swiss psychiatrist who introduced the psychosurgical method known as topectomy as a means to relieve the symptoms of aggression and agitation in individuals diagnosed with mental disease. Specifically, he performed topical excision of part of the cerebral cortex on 6 patients with chronic schizophrenia. Most of these patients became more approachable and easier to manage, but they also showed signs of aphasia or seizures, and 2 died soon after the surgery. Burckhardt's presentation of the results of his surgical procedures to the Berlin Medical Congress in 1890 caused an enormous controversy within the European medical community and resulted in his ostracism from it. He continued practicing, however and dispensing advice in his role as a mental hospital director, though he soon gave up his surgical endeavours. His innovative theory of higher cerebral functions anticipated the lobotomy procedure that was developed nearly half a century later by the neurologist Egas Moniz (1874-1955).

An Atypical Presentation of Primary Hyperparathyroidism in an Adolescent: A Case Report of Hypercalcaemia and Neuropsychiatric Symptoms Due to a Mediastinal Parathyroid Adenoma.

Psychiatric disorders are rare clinical manifestations of hypercalcaemia in the pediatric population, are relatively more frequent during adolescence and are often overlooked in cases of severe hypercalcaemia. We described the case of a 17-year-old girl affected by anorexia nervosa, depression and self-harm with incidental detection of moderate hypercalcaemia. Clinical, laboratory and instrumental tests demonstrated that hypercalcaemia was secondary to primary hyperparathyroidism (PHPT) due to a mediastinal parathyroid adenoma in the thymic parenchyma. After parathyroidectomy with robot-assisted surgery, we observed the restoration of calcium and PTH levels in addition to an improvement in psychiatric symptoms. This case demonstrates that serum calcium concentration should be evaluated in adolescents with neurobehavioural symptoms and in cases of hypercalcaemia PHPT should be excluded. Surgery represents the cornerstone of the management of PHPT and may contribute to improving quality of life and psychological function in these patients. However, the complexity of neurological involvement in cases of hypercalcaemia due to PHPT requires further investigations to establish the real impact of this condition on the neurocognitive sphere.

Incisionless MR-guided focused ultrasound: technical considerations and current therapeutic approaches in psychiatric disorders.

INTRODUCTION: MR-guided focused ultrasound operating at higher intensities have been reported to effectively and precisely ablate deeper brain structures like the basal ganglia or the thalamic nuclei for the treatment of refractory movement disorders, neuropathic pain and most recently neuropsychiatric disorders, while low-intensity focused ultrasound represents an approach promoting mechanical blood-brain-barrier opening and neuromodulation. This narrative review summarizes the technical development and the therapeutic potential of incisionless MRgFUS in order to treat neuropsychiatric disorders. AREAS COVERED: A narrative review of clinical trials assessing the safety and efficacy of MRgFUS. A literature review was performed using the following search terms: MR-guided focused ultrasound, psychiatric disorders, noninvasive and invasive brain modulation/stimulation techniques. EXPERT OPINION: MRgFUS ablation is under clinical investigation (unblinded study design) for obsessive-compulsive disorders (OCDs) [capsulotomy; ALIC] and depression/anxiety disorders [capsulotomy] and has demonstrated an improvement in OCD and depression, although of preliminary character. Low-intensity ultrasound applications have been explored in Alzheimer´s disease (phase 1 study) and healthy subjects. Currently, limited evidence hinders comparison and selection between MRgFUS and noninvasive/invasive brain modulation therapies. However, comparative, sham-controlled trials are needed to reexamine the preliminary findings for the treatment of psychiatric disorders.

Psychosurgery in the History of Stereotactic Functional Neurosurgery.

The paper invites to reappraise the role of psychosurgery for and within the development of functional stereotactic neurosurgery. It highlights the significant and long-lived role of stereotactic neurosurgery in the treatment of severe and chronic mental disorders. Stereotactic neurosurgery developed out of psychosurgery. It was leucotomy for psychiatric disorders and chronic pain that paved the way for stereotactic dorsomedial thalamotomy in these indications and subsequently for stereotactic surgery in epilepsy and movement disorders. Through the 1960s stereotactic psychosurgery continued to progress in silence. Due to the increased applications of stereotactic surgery in psychiatric indications, psychosurgery's renaissance was proclaimed in the early 1970s. At the same time, however, a public fearing mind control started to discredit all functional neurosurgery for mental disorders, including stereotactic procedures. In writing its own history, stereotactic neurosurgery's identity as a neuropsychiatric discipline became subsequently increasingly redefined as principally a sort of "surgical neurology," cut off from its psychiatric origin.

Predicting response to psychiatric surgery: a systematic review of neuroimaging findings.

Background: Psychiatric surgery, including deep brain stimulation and stereotactic ablation, is an important treatment option in severe refractory psychiatric illness. Several large trials have demonstrated response rates of approximately 50%, underscoring the need to identify and select responders preoperatively. Recent advances in neuroimaging have brought this possibility into focus. We systematically reviewed the psychiatric surgery neuroimaging literature to assess the current state of evidence for preoperative imaging predictors of response. Methods: We performed this study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) frameworks, and preregistered it using PROSPERO. We systematically searched the Medline, Embase and Cochrane databases for studies reporting preoperative neuroimaging analyses correlated with clinical outcomes in patients who underwent psychiatric surgery. We recorded and synthesized the methodological details, imaging results and clinical correlations from these studies. Results: After removing duplicates, the search yielded 8388 unique articles, of which 7 met the inclusion criteria. The included articles were published between 2001 and 2018 and reported on the outcomes of 101 unique patients. Of the 6 studies that reported significant findings, all identified clusters of hypermetabolism, hyperconnectivity or increased size in the frontostriatal limbic circuitry. Limitations: The included studies were few and highly varied, spanning 2 decades. Conclusion: Although few studies have analyzed preoperative imaging for predictors of response to psychiatric surgery, we found consistency among the reported results: most studies implicated overactivity in the frontostriatal limbic network as being correlated with clinical response. Larger prospective studies are needed. Registration: www.crd.york.ac.uk/prospero/display_record.php?RecordID=131151.

The anterior limb of the internal capsule: Anatomy, function, and dysfunction.

The last two decades have seen a re-emergence of neurosurgery for severe, refractory psychiatric diseases, largely due to the advent of more precise and safe operative techniques. Nevertheless, the optimal targets for these surgeries remain a matter of debate, and are often grandfathered from experiences in the late 20th century. To better explore the rationale for one target in particular - the anterior limb of the internal capsule (ALIC) - we comprehensively reviewed all available literature on its role in the pathophysiology and treatment of mental illness. We first provide an overview of its functional anatomy, followed by a discussion on its role in several prevalent psychiatric diseases. Given its structural integration into the limbic system and involvement in a number of cognitive and emotional processes, the ALIC is a robust target for surgical treatment of refractory psychiatric diseases. The advent of novel neuroimaging techniques, coupled with image-guided therapeutics and neuromodulatory treatments, will continue to enable study on the ALIC in mental illness.