In a groundbreaking development within psychiatric medicine, a recent case report published in BMC Psychiatry explores the unprecedented combination of stereotactic lesioning with long-term Risperidone maintenance to address life-threatening, refractory suicidal command hallucinations in patients experiencing a major depressive episode with psychotic features. This novel therapeutic strategy emerges as a beacon of hope for individuals whose symptoms evade conventional treatment modalities, marking a paradigm shift in managing acute psychiatric emergencies that had previously left clinicians with few viable options.
The subject of the report centers around a 20-year-old female patient grappling with a severe major depressive episode paired with psychotic features, characterized by a relentless barrage of 10 to 12 suicidal command hallucinations daily. Her clinical course was notably precarious, featuring four suicide attempts within a single week. Despite aggressive pharmacological interventions involving three different antipsychotics—Aripiprazole, Olanzapine, and Risperidone—and a full course of 12 electroconvulsive therapy (ECT) sessions, her symptoms demonstrated stubborn resistance, underscoring the urgent need for alternative interventions.
Stereotactic lesioning, an advanced neurosurgical technique, offers a high-precision method to target specific brain regions implicated in psychiatric pathology. In this patient’s case, bilateral lesioning was performed on the anterior limb of the internal capsule and the cingulate gyrus (SALIC-CG). These brain structures are critically involved in emotional regulation, cognitive control, and integration of complex sensory information, making them strategic targets for interrupting the pathological neural circuits responsible for the patient’s distressing hallucinations.
Remarkably, within only one week following the stereotactic intervention, the patient exhibited profound symptom relief. Clinical rating scales provided quantitative evidence of this improvement: the Montgomery-Asberg Depression Rating Scale (MADRS) score plummeted from a severe 30 to a mild 7, and the Hoffman auditory hallucination score dropped sharply from 25 down to zero. Such rapid remission highlights the potential of stereotactic lesioning to disrupt the neural underpinnings of refractory psychosis, offering renewed hope for patients in otherwise dire clinical scenarios.
However, the course of disease and treatment revealed a critical insight regarding the necessity of adjunctive pharmacotherapy post-surgery. One month after the lesioning procedure, the patient abruptly discontinued Risperidone, an antipsychotic previously deemed ineffective when used in isolation. This cessation correlated with a dramatic relapse; MADRS and Hoffman scores surged back to 22 and 20, respectively. The re-emergence of severe symptomatology upon withdrawal of medication signifies that while stereotactic surgery offers a potent initial intervention, sustained symptom control is intricately dependent on continued pharmacologic management.
Reinstatement of Risperidone therapy precipitated rapid symptom remission, ultimately maintaining the patient in stable remission at six months follow-up, with a MADRS score of 6 and a complete absence of hallucinations. This observation fundamentally challenges existing paradigms that consider pharmacotherapy as merely ancillary to surgical interventions in psychiatric disorders. Instead, it advocates for an integrated “surgery plus long-term pharmacotherapy” treatment model, underscoring the synergistic relationship between precise neurosurgical disruption of pathological circuits and ongoing receptor-level modulation offered by antipsychotics.
The implications of this unique case report extend far beyond a single individual. Refractory suicidal command hallucinations embodied within psychotic major depressive episodes pose an acute clinical emergency with high mortality risk and limited therapeutic options hitherto. The demonstrated efficacy of stereotactic lesioning in conjunction with sustained Risperidone maintenance introduces a potentially life-saving approach and calls for deeper exploration into neurobiological mechanisms that permit remission through combined modalities.
From a neuroscientific perspective, the anterior limb of the internal capsule and cingulate gyrus represent nodes of convergence for fronto-subcortical circuits regulating mood, executive function, and perceptual integration. Targeted lesioning in these areas may interrupt the maladaptive feedback loops perpetuating psychotic command hallucinations, which are typically refractory to pharmacotherapeutic blockade of dopamine receptors alone. The synergistic effect of surgical disconnection and antipsychotic receptor antagonism could modulate neural plasticity and synaptic signaling pathways in a manner unachievable by either treatment independently.
Beyond the technical achievements and clinical outcomes, this case also underscores the critical importance of vigilant postoperative management. Abrupt discontinuation of Risperidone reversed the benefits of an otherwise successful surgery, revealing an essential clinical principle: the neurologic and psychiatric sequelae following stereotactic intervention require carefully calibrated pharmacological oversight, tailored to sustain remission and prevent relapse. This insight commands a reevaluation of post-surgical care protocols in psychiatric neurosurgery.
While still preliminary, the findings also raise significant ethical and procedural considerations regarding the utilization of stereotactic lesioning. As a relatively invasive procedure reserved traditionally for treatment-refractory neurological disorders such as Parkinson’s disease or obsessive-compulsive disorder, its application in psychiatric emergencies demands meticulous patient selection, stringent consent processes, and long-term follow-up studies to assess safety profiles and quality of life outcomes.
As psychiatric medicine continuously evolves, this report highlights that innovative combinations of neurosurgical technology and psychopharmacology can redefine treatment horizons for patients with the gravest neuropsychiatric conditions. The narrative of this young woman’s recovery serves as a compelling call to action for clinical trials and expanded research into integrated therapies that bridge brain circuitry modification and receptor-level modulation for complex depressive psychosis.
Ultimately, this case sets a scientific and clinical precedent with profound implications: the fusion of stereotactic lesioning with sustained pharmacologic maintenance may emerge as a transformative therapeutic avenue, providing new hope for individuals ensnared in the catastrophic interplay of psychosis, depression, and suicidality. As researchers and clinicians digest these findings, the psychiatric field stands on the cusp of redefining approaches that might soon save countless lives otherwise destined for tragedy.
Subject of Research: Refractory suicidal command hallucinations in major depressive episode with psychotic features; stereotactic lesioning combined with long-term antipsychotic maintenance therapy.
Article Title: Stereotactic lesioning combined with long-term Risperidone maintenance for life-threatening refractory suicidal command hallucinations in major depressive episode with psychotic features: a case report.
Article References: Chen, C., Li, R., Bai, H. et al. Stereotactic lesioning combined with long-term Risperidone maintenance for life-threatening refractory suicidal command hallucinations in major depressive episode with psychotic features: a case report. BMC Psychiatry (2025). https://doi.org/10.1186/s12888-025-07627-0
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