Functional psychosurgery in psychiatry: indications and preoperative evaluation. A narrative review

Functional neurosurgery has evolved from a marginal and controversial intervention into a promising, technically feasible option for carefully selected patients with treatment-resistant psychiatric disorders. Among available techniques, deep brain stimulation has gained increasing clinical acceptance for selected patients with severe obsessive-compulsive disorder and Tourette syndrome, while other psychiatric indications, including treatment-resistant depression, substance use disorders, schizophrenia, anorexia nervosa and pathological aggression, remain largely investigational or restricted to clinical trials and highly specialized programs. However, the absence of harmonized preoperative assessment standards across centers highlights the need for a structured, multidisciplinary framework to guide consistent clinical decision-making and ensure procedural safety. The framework proposed in this review is intended to support structured clinical profiling and outcome monitoring, but should not be interpreted as a substitute for professional consensus recommendations, multidisciplinary clinical judgment, ethics committee review, or applicable regulatory requirements. This narrative review examines the current role of functional psychosurgery in psychiatry, with particular focus on structured preoperative assessment models that optimize patient characterization within specialized clinical settings. We propose a pragmatic, circuit-informed framework integrating diagnostic precision, psychopathological assessment, neuropsychological profiling, functional evaluation, and ethical-regulatory oversight. By synthesizing evidence across psychiatric disorders, neurobiological models, and multidimensional assessment strategies, we outline a practical framework for preoperative characterization and outcome monitoring in psychiatric neurosurgery. When applied within specialized centers and under rigorous clinical, ethical, and regulatory oversight, functional psychosurgery may offer clinically meaningful symptom relief and improved quality of life for carefully selected patients who have exhausted conventional treatments.