Interventional psychiatry

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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]

Contents

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

Interventional pharmacology

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]

Related Research Articles

<span class="mw-page-title-main">Major depressive disorder</span> Mood disorder

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since. The disorder causes the second-most years lived with disability, after lower back pain.

<span class="mw-page-title-main">Electroconvulsive therapy</span> Medical procedure in which electrical current is passed through the brain

Electroconvulsive therapy (ECT) or electroshock therapy (EST) is a psychiatric treatment during which a generalized seizure is electrically induced to manage refractory mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds to 6 seconds, either from temple to temple or from front to back of one side of the head. However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance.

<span class="mw-page-title-main">Transcranial magnetic stimulation</span> Brain stimulation using magnetic fields

Transcranial magnetic stimulation (TMS) is a noninvasive form of brain stimulation in which a changing magnetic field is used to induce an electric current at a specific area of the brain through electromagnetic induction. An electric pulse generator, or stimulator, is connected to a magnetic coil connected to the scalp. The stimulator generates a changing electric current within the coil which creates a varying magnetic field, inducing a current within a region in the brain itself.

<span class="mw-page-title-main">Deep brain stimulation</span> Neurosurgical treatment

Deep brain stimulation (DBS) is a surgical procedure that implants a neurostimulator and electrodes which sends electrical impulses to specified targets in the brain responsible for movement control. The treatment is designed for a range of movement disorders such as Parkinson's disease, essential tremor, and dystonia, as well as for certain neuropsychiatric conditions like obsessive-compulsive disorder (OCD) and epilepsy. The exact mechanisms of DBS are complex and not entirely clear, but it is known to modify brain activity in a structured way.

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.

<span class="mw-page-title-main">Vagus nerve stimulation</span> Medical treatment that involves delivering electrical impulses to the vagus nerve.

Vagus nerve stimulation (VNS) is a medical treatment that involves delivering electrical impulses to the vagus nerve. It is used as an add-on treatment for certain types of intractable epilepsy, cluster headaches, treatment-resistant depression and stroke rehabilitation.

<span class="mw-page-title-main">Brodmann area 25</span> Part of the brain

Brodmann area 25 (BA25) is the subgenual area, area subgenualis or subgenual cingulate area in the cerebral cortex of the brain and delineated based on its cytoarchitectonic characteristics.

Treatment-resistant depression (TRD) is major depressive disorder in which an affected person does not respond adequately to at least two different antidepressant medications at an adequate dose and for an adequate duration. Inadequate response has most commonly been defined as less than 25% reduction in depressive symptoms following treatment with an antidepressant. Many clinicians and researchers question the construct validity and clinical utility of treatment-resistant depression as currently conceptualized.

<span class="mw-page-title-main">Transcranial direct-current stimulation</span> Technique of brain electric stimulation therapy

Transcranial direct current stimulation (tDCS) is a form of neuromodulation that uses constant, low direct current delivered via electrodes on the head. It was originally developed to help patients with brain injuries or neuropsychiatric conditions such as major depressive disorder. It can be contrasted with cranial electrotherapy stimulation, which generally uses alternating current the same way, as well as transcranial magnetic stimulation.

<span class="mw-page-title-main">Esketamine</span> Medication

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Endogenous depression(melancholia) is an atypical subclass of major depressive disorder. It could be caused by genetic and biological factors. Endogenous depression occurs due to the presence of an internal stressor instead of an external stressor. Endogenous depression includes patients with treatment-resistant, non-psychotic, major depressive disorder, characterized by abnormal behavior of the endogenous opioid system but not the monoaminergic system. Symptoms vary in severity, type, and frequency and can be attributed to cognitive, social, biological, or environmental factors that result in persistent feelings of sadness and distress. Since symptoms are due to a biological phenomenon, prevalence rates tend to be higher in older adults. Due to this fact, biological-focused treatment plans are often used in therapy to ensure the best prognosis.

Management of depression is the treatment of depression that may involve a number of different therapies: medications, behavior therapy, psychotherapy, and medical devices.

Magnetic seizure therapy (MST) is a proposed form of electrotherapy and electrical brain stimulation. It is currently being investigated for the treatment of major depressive disorder, treatment-resistant depression (TRD), bipolar depression, schizophrenia and obsessive-compulsive disorder. MST is stated to work by inducing seizures via magnetic fields, in contrast to ECT which does so using alternating electric currents. Additionally, MST works in a more concentrated fashion than ECT, thus able to create a seizure with less of a total electric charge. In contrast to (r)TMS, the stimulation rates are higher resulting in more energy transfer. Currently it is thought that MST works in patients with major depressive disorder by activating the connection between the subgenual anterior cingulate cortex and the parietal cortex.

Late-life depression refers to depression occurring in older adults and has diverse presentations, including as a recurrence of early-onset depression, a new diagnosis of late-onset depression, and a mood disorder resulting from a separate medical condition, substance use, or medication regimen. Research regarding late-life depression often focuses on late-onset depression, which is defined as a major depressive episode occurring for the first time in an older person.

<span class="mw-page-title-main">Mark S. George</span>

Mark S. George is a Distinguished University Professor of psychiatry, radiology and neurosciences and is the director of the Medical University of South Carolina (MUSC) Center for Advanced Imaging Research as well as the Brain Stimulation Laboratory. As of June 2020, his research has been cited over 47,000 times, with an h-index of 113 and i-10 index of 404.

<span class="mw-page-title-main">Brainsway</span>

BrainsWay Ltd. is an international company that is engaged in the development of a medical device that uses H-coil for deep transcranial magnetic stimulation as a non-invasive treatment for depression, OCD, and smoking addiction. The company was founded in 2003 and has offices in the US and Jerusalem.

Neuromodulation is "the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body". It is carried out to normalize – or modulate – nervous tissue function. Neuromodulation is an evolving therapy that can involve a range of electromagnetic stimuli such as a magnetic field (rTMS), an electric current, or a drug instilled directly in the subdural space. Emerging applications involve targeted introduction of genes or gene regulators and light (optogenetics), and by 2014, these had been at minimum demonstrated in mammalian models, or first-in-human data had been acquired. The most clinical experience has been with electrical stimulation.

<span class="mw-page-title-main">Arketamine</span> Chemical compound

Arketamine (developmental code names PCN-101, HR-071603), also known as (R)-ketamine or (R)-(−)-ketamine, is the (R)-(−) enantiomer of ketamine. Similarly to racemic ketamine and esketamine, the S(+) enantiomer of ketamine, arketamine is biologically active; however, it is less potent as an NMDA receptor antagonist and anesthetic and thus has never been approved or marketed for clinical use as an enantiopure drug. Arketamine is currently in clinical development as a novel antidepressant.

Electroconvulsive therapy (ECT) is a controversial therapy used to treat certain mental illnesses such as major depressive disorder, schizophrenia, depressed bipolar disorder, manic excitement, and catatonia. These disorders are difficult to live with and often very difficult to treat, leaving individuals suffering for long periods of time. In general, ECT is not looked at as a first line approach to treating a mental disorder, but rather a last resort treatment when medications such as antidepressants are not helpful in reducing the clinical manifestations.

Non-invasive cerebellar stimulation is the application of non-invasive neurostimulation techniques on the cerebellum to modify its electrical activity. Techniques such as transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS) can be used. The cerebellum is a high potential target for neuromodulation of neurological and psychiatric disorders due to the high density of neurons in its superficial layer, its electrical properties, and its participation in numerous closed-loop circuits involved in motor, cognitive, and emotional functions.

References

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