Interventional Treatments Expand Psychiatrists’ Treatment Options

This is the first article in a new column on interventional psychiatry.

Perhaps you have heard of “interventional psychiatry” or maybe you have heard someone say, “I am an interventional psychiatrist.” It reminds me of the labels used in the 1990s during my residency training years. “Are you a biological psychiatrist or a psychodynamic psychiatrist?” Categorizations of this nature are not new to psychiatry, though some are more well understood than others.

So, what does it mean to practice interventional psychiatry? Is this truly another emerging subspecialty? How has it evolved? Psychiatric treatments are expanding, and the modern-day psychiatrist must seek to create, develop, and implement new therapies and services with the aim of improving safety, tolerability, and effectiveness as many of our psychiatric conditions are treatment resistant. In short, there are limitations to conventional pharmacotherapy and psychotherapy, albeit these treatments have provided tremendous benefits to our patients. It is exciting to see the “psychiatric toolbox” expand.

This column will focus on the new and emerging clinical applications that fall outside of psychiatry’s conventional treatments of psychotherapy and pharmacotherapy. Some of these therapies are readily utilized outside of the United States, and some have just come to be more common in the United States and are approved by the Food and Drug Administration (FDA).

The “interventionism” of medicine started in 1929 when Werner Forssmann conducted a series of cardiac catheter experiments on himself (see box at top right). Interventionalism in psychiatry started soon after when Ugo Carletti first used electroconsulve therapy (ECT) in 1938. Interventional psychiatry expanded when transcranial magnetic stimulation (TMS) was FDA cleared, and pioneering studies were conducted by Mark George, M.D., and Alvaro Pascual-Leone, M.D., Ph.D., in patients with severe refractory depression.

There is no consensus on the definition of interventional psychiatry, and there are no fellowships approved by the Accreditation Council for Graduate Medical Education for this emerging subspecialty. There are some generalizations about the subspecialty that might build a more coherent understanding:

• Psychiatric interventionists utilize neurotechnologies to modulate and apply brain stimulation techniques to modulate dysfunctional brain circuitry that underlies psychiatric disorders.

• Interventionists utilize a number of therapeutics that are administered according to a structured protocol and require monitoring in a clinical setting (see box bottom right). In the last 10 years, the number of treatments that interventionists use has vastly expanded, and more and more general psychiatrists are adopting these therapies into their regular practice.

The training required to be an interventional psychiatrist is still evolving, but there are a number of opportunities to receive extramural training for these innovative treatments. There are academic-based programs that provide training in ECT and TMS. There are also organizations such as the Clinical TMS Society; the International Society for ECT and Neurostimulation; and the American Society of Ketamine Physicians, Psychotherapists, and Practitioners. They sponsor annual meetings and entry-level trainings for general psychiatrists and other practitioners.

Interventional psychiatry is an emerging subspecialty focused on procedural approaches to treating refractory neuropsychiatric disorders. This column will cover several modalities, including TMS, ketamine/esketamine, and ECT as well as other emerging nonconventional treatments for neuropsychiatric conditions. ■

The Interventionalism of Medicine

• Werner Forssmann, who developed cardiac catherization, is considered to be one of the first interventional physicians.

• The main interventional specialties are interventional (or vascular) radiology, interventional cardiology, and endovascular surgical (interventional) neuroradiology.

• Interventional medical practitioners are specialists who do minimally invasive procedures instead of surgery or other standard medical treatments. Interventional psychiatrists use treatments that target or modulate dysfunctional brain networks without surgery (or “noninvasively”) or perform office-based procedures.

_{Source: Shaheen E. Lakhan, et al. “The Interventionalism of Medicine: Interventional Radiology, Cardiology, and Neuroradiology.” International Archives of Medicine, September 9, 2009.}

What Has Fueled the Growth of Interventional Psychiatry?

• Measurement-based care and the incorporation of using valid measures such as the PHQ-9 and GAD-7 in everyday clinical practice.

• Treatment resistance; 30% to 40% of patients diagnosed with neuropsychiatric conditions are treatment resistant and do not respond to pharmacotherapy and psychotherapy.

• Patient preference for alternative treatments to pharmacological and psychological interventions.

• Need for treatments that provide rapid relief of symptoms that are severe and life threatening.

• Recognition that many neuropsychiatric conditions are a product of brain circuit dysfunction.

• Need for office/facility-based monitoring or supervision for many new treatments.

Noninvasive Procedures in Interventional Psychiatry

Interventional psychiatrists perform a spectrum of minimally invasive specialized procedures along the continuum between the conventional (medication/psychotherapy) and surgery. Interventions require specialized monitoring (office or facility based).

Therapeutic Neuromodulation: Therapies Involving Devices

Seizure

• Electroconvulsive therapy (ECT)*

• Magnetic seizure therapy (MST)

• Focal electrically administered stimulation (FEAST)

No Seizure

• Transcranial magnetic stimulation (TMS)*

• External trigeminal nerve stimulation (eTNS)*

• Transcranial direct nerve stimulation (tDCS)

• Transcutaneous auricular vagus nerve stimulation (tVNS)

_{*FDA Cleared}

Medication Therapies That Require Monitoring

• Spravato*

• Zulresso (brexanolone)*

• Ketamine

• Psychedelic-assisted psychotherapy

_{*FDA Approved/REMS Strategy}