Interventional Psychiatry Comes of Age: How Do We Define the Practice?
Abstract
Over the last few years, I’ve engaged in several discussions regarding the state and direction of interventional psychiatry. It is exciting to see this area of psychiatry develop, and the interest in “interventions,” both within psychiatry and from other medical professionals, is exploding.
A quick search on the internet for services in metropolitan areas indicates that various providers from different medical and nonmedical specialties offer transcranial magnetic stimulation (TMS), ketamine infusions, and, now in specific urban areas, “legal psychedelics.”
Do all of these treatments belong under one tent? Why is one treatment considered a psychiatric “intervention” when all treatments constitute an intervention in one form or another? What should this emerging area of specialization be labeled? (For further reading, see “Interventional Treatments Expand Psychiatrists’ Treatment Options”). Should we call it “interventional brain medicine or perhaps “procedural psychiatry”? Although a name for this subspecialty is critical, defining what an interventional psychiatrist does and what qualifications are required to perform these treatments are essential.
What does an interventional psychiatrist do? Some would argue an interventional psychiatrist is someone who likes to do procedures. However, interventional psychiatrists integrate procedures with medications, psychotherapy, and psychosocial therapies to treat the whole patient.
During a recent private-practice internal quality review (unpublished), we found that physicians whose patients had the highest remission rates exhibited four critical qualities in their clinical work:
They had extramural training and experience in psychotherapy and regularly combined TMS with psychotherapeutic interventions.
They provided longitudinal psychiatric care with their TMS patients (many referrals were from their long-term patient caseload).
They typically had experience and training in administering ECT, esketamine, or IV ketamine in addition to TMS.
They participated in journal clubs and bimonthly conferences reviewing patients who did not achieve remission.
The top-performing physicians had two or more years of experience and achieved remission rates in the 40% to 60% range (the average published rate is 30%).
Thus, interventional psychiatrists perform procedures, actively monitor the therapeutic relationship, and incorporate medications and psychotherapy into treatment. In addition, because they completed a psychiatry residency, they contribute and often lead treatment teams responsible for the patients’ overall biopsychosocial treatment plan.
Who should perform interventional procedures for psychiatric conditions, and what training is required? As someone who completed a combined residency in family medicine and psychiatry, I am open-minded and sensitive to patient access problems. I have contemplated this question for a while and thought that anyone with a license to prescribe and proper training should be able to do interventional psychiatry procedures. However, I am concerned about the number of TMS centers, ketamine infusion centers, and psychedelic clinics that do not have a psychiatrist involved in any meaningful way. For example, during a recent discussion with an anesthesiologist setting up a ketamine infusion center, they asked, “Why do I need a psychiatrist? My malpractice is not requiring it, and we know how to dose IV ketamine for depression.”
Suppose a psychiatrist is not involved in evaluating and managing the psychiatric condition during the interventional treatment. How do we know if the patient receives the proper treatment at the right time?
I believe it is time for professional organizations such as the Clinical TMS Society and the American Society of Ketamine Physicians, Psychotherapists, and Practitioners to engage and inform the public about the risks of receiving psychiatric treatment for complex or treatment-resistant psychiatric conditions without a psychiatrist involved. Furthermore, as an evolving area of specialization, we must have well-thought-out guidelines for training, certification, and credentialing. We owe it to our patients. ■
Richard A. Bermudes, M.D., is the founder and board member at Mindful Health Solutions in San Francisco and a volunteer assistant clinical professor of psychiatry at the University of California, San Francisco. He is also the co-editor of Transcranial Magnetic Stimulation: Clinical Applications for Psychiatric Practice from APA Publishing.
