The debate on the future of neurosurgery for psychiatric disorders (Reference Persaud, Crossley and FreemanR. Persaud/D. Crossley & C. Freeman, 2003) is curious in many ways. Much of the criticism of neurosurgery still relies upon its historical excesses (Reference PressmanPressman, 1998) rather than the contemporary caution. The ‘lack of evidence’ argument sets up an unrealistic standard that most surgical treatments are unable to meet. The ‘progress in psychiatric treatments’ argument fails to recognise that recent drug treatments are but incremental advances over drugs that have been around for some decades, and there are many patients who continue to suffer chronically from depression, obsessive–compulsive disorder and other illnesses. For those of us who practise in tertiary referral centres, encounters with their suffering are frequent and heart-wrenching. Do we wish to take away all their hope?

I am not arguing for a return to the past. Modern neuroscience is fast removing, in a practical sense, the distinction between brain and mind. It is now quite acceptable to consider neural transplants, gene therapy and neural prosthetics as neuropsychiatric treatments. Is this not the right era to revisit surgical interventions on the brain? We are already excited about developments such as vagus nerve stimulation and deep brain stimulation for psychiatric disorders (Reference Malhi and SachdevMalhi & Sachdev, 2002). We are quite comfortable with ablative surgery for epilepsy when there is functional disturbance, even in the absence of structural abnormality. The neuroanatomical models of psychiatric disorders are becoming increasingly sophisticated (Reference Mayberg, Lichter and CummingsMayberg, 2001). Should we not be working towards a new era of direct brain intervention, with surgery being an important aspect of this strategy? This surgery may or may not be ablative, or follow an initial period of brain stimulation, or be guided by sophisticated functional imaging. If deep brain stimulation, for example, is demonstrated to produce a therapeutic response without adverse effects, but only temporarily, would there not be an argument to proceed with focal ablation? The brain is, after all, not inviolable, and the evidence is convincing that focal and targeted brain lesions can spare both intellect and personality.

The answer to the question, ‘should neurosurgery for mental disorder be allowed to die out?’ is surely, ‘Definitely not’. Let us, however, move towards a new neurosurgery that is bold but not misinformed, and that keeps abreast of the developments in our understanding of brain function.