There is real danger of implementing new SPI such as DBS without appropriate governance structures in place. Trying this technology in all psychiatric illnesses may lead to similar justifiable reactions and over-reactions from the public, politicians, and lawmakers in this century. There is a real and justifiable fear that SPI can be abused to control dissidents and political opponents or used to subdue those with violent behaviour or rioters. Not long ago (1970), in a book entitled “Violence and the brain,” the authors called for the development of an early warning test to detect those with low thresholds for impulsive violence. The authors had also called for better and more effective methods for treating such people once they were identified [8]. Another psychosurgeon was quoted saying, “A person convicted of a violent crime should have the chance for a corrective operation.” He went on to say, “Each violent young criminal incarcerated from 20 years to life costs the taxpayers about $100,000. For roughly $6,000, society can provide medical treatment which will transform him into a responsible, well-adjusted citizen” [3]. It is these extreme views that led to psychosurgery disrepute in the past. In reality, SPI is a very expensive and difficult technique to be used to subdue violent behaviour, dissidents, or political opponents. There are much easier, cheaper, and effective ways of mass control, including the use of media, television, medicines, and education systems. Historically, psychosurgery was not based on proper scientific studies; it started by Ego Moniz who turned to psychosurgery as a means to be in the limelight and for fame to obtain a Nobel Prize. Ego Moniz used lobotomy on patients after hearing of Fulton’s case report of a single chimpanzee lobotomized by Jacobsen where the agitated chimp became calm [7]. There has been no verification of the exact location of the lesion or report of its potential serious side effects [3]. Almost everyone at the time ignored these important ethical issues because they felt they were morally obliged to help thousands of incarcerated mentally ill patients. They were blinded by the huge unmet need and the greed for wealth and fame. After the introduction of Moniz’s lobotomy in the USA, it spread like wildfire and was practiced in smaller and less-equipped hospitals [17]. It was the actions of Walter Freeman, who was neither a neurosurgeon nor a psychiatrist, which brought psychosurgery to disrepute. Recognizing psychosurgery was a “Catch 22” situation; while psychosurgery relieved symptoms of psychosis, it was very costly in terms of loss of affect and creativity. Despite this fact, Walter Freeman continued the procedure and introduced the transorbital lobotomy (today’s equivalent of minimally invasive procedure) instead of reflecting and auditing his results [17].

It is comforting to know that the way SPI is practiced today is very different from that of psychosurgery of the past; today’s SPI is accurate and precise, and it can allay most of the concerns encountered in the past in this field of neurosurgery. However, a review of the literature on DBS for OCD and MDD uncovers a plethora of articles in recent years; a total of 90 publications during 2009–2011 compared to only 17 articles between 2002 and 2005 [7]. The vast majority of these publications reported unblinded outcomes of small selected study patients with favourable outcome, which was not verified when larger multicentre controlled studies were conducted. My own concern is that many psychiatric patients are being treated in small groups outside multicenter, controlled, prospective trials. In a survey of North American Functional Neurosurgeons published in 2011, 50 % of the responders were engaged in some sort of SPI, mainly DBS for OCD or MDD, and saw SMI as a growing field of business [9]. Although, DBS and VNS are neither destructive nor irreversible and give sufferers the option to discontinue the stimulation if they wished to do so, these procedures should not be used outside properly designed clinical protocols because of the large placebo effect and inherent biases [7]. Although DBS had Food and Drug Administration (FDA) approval for OCD under Humanitarian Device Exemption (HDE) rules and VNS had FDA approval for MDD, some concerns had been raised regarding their use. These concerns are based on lack of strong scientific evidence on their safety and efficacy in the long run, the numerous conflicts of interests held by investigators such as holding patents for certain procedures, and the ambiguity and lack of transparency of research sponsored by commercial partners [8]. However, recent studies on ablative, VNS-, and DBS-SPI were carried out within stringent protocols that stood the heat of scientific rigor and scrutiny of peer reviewers [4, 6, 10–12, 16]. The outcomes reported in these studies were objective and based on objective assessments. Reduction of YBOCS score of 35 % is considered a clinical response in OCD, while a reduction of 50 % on MADRS or HDRS is considered a worthwhile response in MDD. However, careful observation and further studies of SPI procedures are required to establish their long-term efficacy, longevity, and side effects. Nevertheless, there remain ethical and social challenges facing SPI and consensus guidelines, workshops, and public engagement are just a few things that need to be done to overcome these challenges [2]. SPI must be approached with caution and commitment for long-term care. SPI is complicated by issues such as patient categorization, selection criteria, long-term management of these patients, and the different patterns of potential benefits and burdens [15]. There is a need for stringent ethical, governance, and regulatory frameworks to be put in place in each legal jurisdiction in the world to prevent potential misuse of SPI. In Scotland, the service was centralized at Ninewells Hospital and Medical School. It is regulated by six-monthly review visits from the National Services Division of the Scottish Department of Health. Each patient’s diagnosis, suitability for SPI, and his/her ability to give informed consent are determined by independent MHWC. In the state of Victoria, Australia, each request for SPI must be approved at a hearing of an independent Psychosurgery Review Board [14]. The aforementioned are just a few examples of how some jurisdictions around the world ensure the continuation of provision of SPI under stringent regulatory and clinical governance frameworks. Unless similar stringent rules are adopted by other jurisdictions, SPI will face the same fate as its predecessor.