Interventional psychiatry

Interventional Psychiatry is a subspecialty within the field of psychiatry, focusing on the use of procedural and device-based treatments to manage mental health disorders, particularly those resistant to conventional therapies such as pharmacotherapy and psychotherapy. This field integrates neuromodulation methods with targeted pharmacological interventions, providing options for patients who have not responded to traditional treatments. ^{[1] [2]}

Historical background

The origins of interventional psychiatry can be traced to the historical use of procedural treatments for psychiatric disorders, with Electroconvulsive Therapy (ECT) being a notable early example. Introduced in 1938 by Ugo Cerletti and Lucio Bini, ECT involves applying electrical currents to the brain to induce seizures, which can alleviate symptoms of severe depression, catatonia, and other psychiatric conditions. Despite its effectiveness, ECT has been subject to stigma due to concerns over side effects, particularly cognitive impairments. ^[3]

During the latter half of the 20th century, the rise of psychopharmacology led to a decline in procedural treatments, as medications became the primary mode of treating mental health disorders. However, the lack of response in some patients to pharmacotherapy renewed interest in procedural treatments, eventually leading to the development of interventional psychiatry as a distinct subspecialty. ^[4]

Scope and treatments

Interventional psychiatry encompasses various treatments, primarily categorized into neuromodulation techniques and interventional pharmacology. These treatments are typically employed in cases of treatment-resistant mental health disorders.

Neuromodulation techniques

• Electroconvulsive Therapy (ECT): ECT remains a cornerstone of interventional psychiatry, especially for severe, treatment-resistant depression and catatonia. The procedure involves controlled electrical currents to the brain, inducing a seizure that can lead to significant improvements in mood and behavior. ^[5]

• Transcranial Magnetic Stimulation (TMS): TMS is a non-invasive technique using magnetic fields to stimulate specific brain areas. It has been approved for treating major depressive disorder and is particularly useful for patients unresponsive to antidepressants. Unlike ECT, TMS does not require anesthesia and has a lower risk of cognitive side effects. ^[6]

• Vagus Nerve Stimulation (VNS): VNS involves implanting a device that delivers electrical impulses to the vagus nerve, influencing brain activity. Initially developed for epilepsy treatment, VNS has also been approved for treatment-resistant depression. ^[7]

• Deep Brain Stimulation (DBS): DBS is an invasive procedure involving the surgical implantation of electrodes in specific brain areas. These electrodes deliver electrical impulses to modulate brain circuits involved in mood regulation. DBS is currently used for conditions such as Parkinson’s disease and obsessive-compulsive disorder and is being explored as a treatment for severe depression. ^[8]

• Other Emerging Techniques: New modalities such as focused ultrasound (FUS), transcranial direct current stimulation (tDCS), and magnetic seizure therapy (MST) are under investigation for potential psychiatric applications, offering the possibility of more targeted and less invasive interventions. ^[9]

Interventional pharmacology

• Ketamine and Esketamine : Ketamine, an anesthetic, has shown rapid antidepressant effects in patients with treatment-resistant depression. It is administered intravenously in controlled settings. Esketamine, a derivative of ketamine, is available as a nasal spray and has been approved for use with oral antidepressants for treatment-resistant depression. ^[10]

• Other Pharmacological Interventions: This category includes intravenous brexanolone, used for postpartum depression, and emerging therapies involving psychedelics such as psilocybin, which are being studied for their potential to enhance psychotherapy and treat refractory depression. ^[11]

Fellowship programs

The demand for specialized training has led to the creation of fellowship programs dedicated to interventional psychiatry. These fellowships typically last one year and provide comprehensive training in various interventional modalities, including both neuromodulation techniques and interventional pharmacology. Fellows gain experience in patient selection, procedural techniques, and side effect management, along with exposure to emerging treatments and research opportunities. ^[12]

Stigma and public perception

Interventional psychiatry faces challenges related to stigma, both within the medical community and the general public ^[13]

References

1. Williams, Nolan R.; Taylor, Joseph J.; Kerns, Suzanne; Short, E. Baron; Kantor, Edward M.; George, Mark S. (2014-08-26). "Interventional Psychiatry". The Journal of Clinical Psychiatry. 75 (8): 895–897. doi:10.4088/jcp.13l08745. ISSN   0160-6689. PMC   4221242 . PMID   25191910.
2. "Handbook of Interventional Psychiatry - Handbook of Interventional Psychiatry". interventionalpsych.org. 2024-07-27. Retrieved 2024-08-25.
3. Fink MD, Max (2010-02-04), "What Is Electroconvulsive Therapy?" , Electroconvulsive Therapy, Oxford University Press, doi:10.1093/oso/9780195365740.003.0005, ISBN   978-0-19-536574-0 , retrieved 2024-08-25
4. Singh, OmPrakash (2020). ""Need to develop "Interventional Psychiatry" as a subspecialty in India"". Indian Journal of Psychiatry. 62 (1): 1–2. doi: 10.4103/psychiatry.indianjpsychiatry_800_19 . ISSN   0019-5545. PMC   6964463 . PMID   32001923.
5. Fink MD, Max (2010-02-04), "What Is Electroconvulsive Therapy?" , Electroconvulsive Therapy, Oxford University Press, doi:10.1093/oso/9780195365740.003.0005, ISBN   978-0-19-536574-0 , retrieved 2024-08-25
6. Lisanby, Sarah H. (January 2014), "Limitations of Transcranial Magnetic Stimulation and Future Directions for Clinical Research" , A Clinical Guide to Transcranial Magnetic Stimulation, Oxford University Press, pp. 152–170, doi:10.1093/med/9780199926480.003.0011, ISBN   978-0-19-992648-0 , retrieved 2024-08-25
7. Aaronson, Scott; Sears, Peter; Ruvuna, Frances; Bunker, Mark (May 2017). "418. Five Year Open Label Study of Vagus Nerve Stimulation vs. Treatment as Usual in Severe Treatment Resistant Depression" . Biological Psychiatry. 81 (10): S170 –S171. doi:10.1016/j.biopsych.2017.02.902. ISSN   0006-3223.
8. Holtzheimer, Paul E.; Mayberg, Helen (January 2020), "Subcallosal cingulate deep brain stimulation for treatment-resistant depression" , Landmark Papers in Psychiatry, Oxford University Press, pp. 311–326, doi:10.1093/med/9780198836506.003.0019, ISBN   978-0-19-883650-6 , retrieved 2024-08-25
9. Trapp, Nicholas T.; Williams, Nolan R. (2021-08-27). "The Future of Training and Practice in Neuromodulation: An Interventional Psychiatry Perspective". Frontiers in Psychiatry. 12. doi: 10.3389/fpsyt.2021.734487 . ISSN   1664-0640. PMC   8429598 . PMID   34512426.
10. Slomski, Anita (2019-07-23). "Esketamine Nasal Spray Effective in Treatment-Resistant Depression" . JAMA. 322 (4): 296. doi:10.1001/jama.2019.10368. ISSN   0098-7484. PMID   31334789.
11. "Brexanolone (Zulresso) for Postpartum Depression" . JAMA. 322 (1): 73–74. 2019-07-02. doi:10.1001/jama.2019.6622. ISSN   0098-7484. PMID   31265098.
12. Lan, Lucy; Raj, Kristin Sharmila; Bhati, Mahendra Takashi (2024), "Proposed curriculum for an interventional psychiatry fellowship program" , Interventional Psychiatry, Elsevier, pp. 17–28, doi:10.1016/b978-0-443-18496-3.00002-1, ISBN   978-0-443-18496-3 , retrieved 2024-08-25
13. Fink MD, Max (2010-02-04), "What Is Electroconvulsive Therapy?" , Electroconvulsive Therapy, Oxford University Press, doi:10.1093/oso/9780195365740.003.0005, ISBN   978-0-19-536574-0 , retrieved 2024-08-25