Damian Sendler: The use of brain stimulation technology in the treatment of mental illness is on the rise. A therapist who uses these techniques has been referred to as an ECT practitioner, TMS provider, or somatic therapist by procedure-specific terminology. There are many ways to describe brain stimulation, yet these names fall short. It is our hope that the term “interventional psychiatrist” will serve as a means of facilitating the training and certification of people who conduct these highly specialized treatments [1] and alongside the upcoming training milestone project [2].
Damian Jacob Sendler: Using the word “interventional” does not mean that standard psychiatric therapies have no impact. For our purposes, the word interventional will be used in the same way that it is used in domains like cardiology, radiology, and neuroscience to describe procedures that need intervention. Physicians who are trained and qualified to undertake procedures that are more intrusive than those provided by regular medical care are referred to be interventional in these domains of practice.
Dr. Sendler: A minimal level of knowledge, competence, and experience is essential for an interventional psychiatrist but we believe that this level is best accomplished by working with current clinical training paradigms and the milestones project [2]. We may make use of the existing clinical training paradigms and centers of competence. The present clinical and research infrastructure can best facilitate the mobility of growing knowledge by including interventional psychiatry into resident education. This work attempts to incorporate these notions into specific milestone components [2] by briefly outlining the scope and reasoning for such training paradigms.
An electrochemical organ, the brain may be affected by chemical and electrical interventions. Interventional psychiatrists must have a solid foundation in both neuroscience and physics in order to perform electrical treatments safely and successfully. Interventional psychiatrists must also understand the circuits and native electrical characteristics of the procedures used to alter the brain, in addition to comprehending the circuits and native electrical qualities of the human brain.
Damian Sendler
Interventional psychiatry is a new area that is gaining traction. Newer approaches to classical neuromodulation have emerged in the recent half-century, as have refinements to older methods. EEG research has continued to refine treatment settings in an effort to improve outcomes and minimize adverse effects. Vagus nerve stimulation (VNS) was authorized by the Food and Drug Administration in 2005 as the first invasive neuromodulation device for the treatment of a neuropsychiatric condition (FDA). Transcranial magnetic stimulation (TMS) was licensed by the FDA in 2008 for the treatment of treatment-resistant depression. Deep brain stimulation (DBS) for obsessive-compulsive disorder was given a disputed humanitarian device exemption by the FDA as recently as 2009. (OCD). DBS is presently being explored for the treatment of numerous neuropsychiatric diseases, including as Gilles de la Tourette syndrome and depression, like many other experimental and FDA-approved stimulation treatments [5]. As with other specialities, the area of interventional psychiatry is developing and expanding in a similar way as new techniques and technology are developed [6].
As a result of the interaction between functional neuroimaging, neurophysiology and targeted brain stimulation, interventional psychiatry was established. The goal of such a discipline is to begin to understand the underlying causes of behavior [7]. [7,8] As an interventional psychiatrist, you must be able to distinguish the behavioral changes that emerge from manipulating the neural circuitry linked with mental diseases [6]. Delivering existing therapies and creating new ones both need these abilities. The interventional psychiatry field, for example, is now able to locate and control neuronal activity within malfunctioning brain circuits, and then monitor both patient response and neurophysiologic response. As a result, interventional psychiatry has the potential to uncover novel biomarkers for mental illness and develop new targets for brain stimulation.
Damian Jacob Markiewicz Sendler: Interventional subspecialties have emerged as a result of advances in diagnostics and treatments [12]. A natural progression occurs when normal medical therapies fail and individuals grow resistant to therapy. Using fluoroscopy to visualize arterial occlusions, cardiologists were the first to develop an interventional subspecialty by adapting radiology procedures. Meanwhile, cardiologists created new electrical therapies to restore healthy heart rhythms.
For patients with treatment-resistant neurologic illness, cardiology’s electrical therapies were quickly adopted. [3] The development of the interventional neurology arose, using a modified version of the toolset of cardiology and a sophisticated grasp of their patient’s functional neurologic condition. Neurology, like cardiology, discovered and exploited the brain’s electrochemical nature. TMS has evolved as a noninvasive method to explore the brain’s cortical excitability and neurophysiological activity in a targeted and noninvasive manner [13]. Medically resistant aberrant cortical synchronization may be reversed using electroconvulsive treatment (ECT), according to certain neurologists.
As a first step, implanted vagus nerve stimulation (VNS) was developed, and then responsive neurostimulation (RNS) was introduced. By using functional stereotactic neurosurgery, invasive neuromodulatory therapies such as deep brain stimulation (DBS) electrodes have been proven to alter regional brain circuitry and thereby cure neurological illness.
There were psychological side effects and advantages connected with the use of these technologies when they were first employed for neurologic purposes. Depression may be alleviated with the use of transcranial magnetic stimulation (TMS) on the prefrontal brain. It has been shown that when VNS is implanted to treat medically resistant epilepsy, it also improves depression. It has been shown that DBS may considerably diminish obsessions and compulsions if it is implanted in the limbic region [19]. Interventional psychiatry was born as a result of these neuropsychiatric therapies and the use of electroconvulsive therapy (ECT).
Damien Sendler: Interventional psychiatry is a rethinking of the work that has been done for more than a century in the field. As much as interventional psychiatric treatments have been studied in the past, it took approximately 50 years for the stigma associated with early interventions such as frontal lobotomies to be lifted [20]. There must be a formal recognition and development of the specialization known as interventional psychiatry, with significant training and awareness of the ethics of brain stimulation, in order to prevent previous errors. As an example, approximately a dozen kinds of brain stimulation for neuropsychiatric disorder are either under research or have been licensed for clinical use. Journals dedicated to the field are also available [21].
Damian Jacob Sendler
For the time being, interventional psychiatry has no established definition or training program. In spite of the recommendations of the APA Task Force on ECT, psychiatric residency training has not regularly included ECT as an option. In accordance with current ACGME psychiatric training requirements, trainees are expected to have a basic understanding of ECT but no specific degree of clinical competence is established or assessed [22]. The most recent version of the suggested milestones for psychiatry includes sub-milestone ratings for each of the five stages of professional growth and is more detailed in terms of knowledge and risks [2]. Our proposals do not contradict, but rather support a defined educational program that begins with exposure, progresses to competence, and culminates in advanced practice for residents. TMS, despite its growing popularity and substantial amount of literature, has not been required in resident education in any regular way. When it comes to invasive operations like DBS and VNS, the training disparities in psychiatry are much more severe.
There is now a basic educational framework for somatic treatments and clinical neuroscience in the form of these new milestones. There are many ways in which these notions might be included into psychiatric teaching, and this page aims to provide further details. We recommend elective track and fellowship training programs as a means to go beyond the minimum criteria and construct a route to mastery. Students in interventional psychiatry would benefit from the proposed track and one-year fellowship by having the chance to gain the skills, information, and attitudes necessary to treat their patients with therapies that are safe, ethical, and appropriate. Fellowship training approaches in recognized neurology interventional subspecialties are modified and adapted to match the emphasis of interventional psychiatry, as we suggest here [23].
However, although this appears to be changing [24], neuroimaging is still only used for limited diagnostic and prognostic purposes by psychiatrists, various structural imaging methods are used by interventional psychiatrists for stimulation localization and troubleshooting, while functional imaging methods are improving our understanding of the circuitry underlying mental disorders and may help us choose an effective treatment. Structural brain imaging helps the interventional psychiatrist detect whether a device is failing, while more advanced structural imaging, such as MRI, may assist the interventional psychiatrist find the most optimal stimulation area. With the development of functional MRI (fMRI), it is now possible to study the effects of both online and offline TMS [9]. The training of an interventional psychiatrist should include a full-time equivalent (FTE) credit in a neuroimaging rotation that includes exposure to modalities such as head radiography, CT, MRI, fMRI, diffusion imaging, PET, and SPECT.
Nearly 100 years after it was first used, ECT has improved tremendously in terms of adverse effects. It has been shown that shorter pulse widths and unilateral electrode topologies have minimized cognitive side effects of ECT, and the technique of delivering the electrical pulse has been examined. An multitude of neuropsychiatric disorders may be treated extremely well with ECT [28]. Additionally, the duration and timing of treatment, whether or not to put the patient on maintenance ECT, and what medical and neurological problems are relative contraindications are all significant aspects of training.
Electromagnetic devices are used to provide transcranial-pulsed magnetic fields of sufficient amplitude to trigger neuronal action potentials in rTMS. The symptoms of severe depressive illness may be alleviated in many individuals with daily inductions of neuronal action potentials in the prefrontal cortex (PFC) for many weeks [8]. For acute therapy of depressed patients who have failed at least one antidepressant drug, the FDA approved one rTMS device in 2008. According to research, repetitive TMS-induced neuronal action potentials over a long period of time may be sufficient to restore a functional impairment in the left prefrontal cortex, which controls deeper limbic areas, and so enhance mood [18, 33]. Interventional psychiatrists who use rTMS to treat depression must be aware of the medical and neurological conditions that would rule out a patient as a candidate for the therapy, notably the danger of producing seizures. Training in rTMS for depression is also necessary for interventional psychiatrists. Furthermore, an interventional psychiatrist must determine an exact motor threshold and a specific treatment site in order to consistently apply therapy on a variety of different patients.
The treatment of medically resistant depression with vagus nerve stimulation (VNS) has been authorized by the FDA. Patients with treatment-resistant depression (TRD) were included in the first VNS depression trial, which examined the effectiveness of the therapy in 40 percent of the patients [34]. It takes many months for VNS to attain its maximal therapeutic effects, unlike ECT and TMS. As a result, insurance companies have been hesitant to pay for VNS implants since the FDA authorized it before there was any class 1 proof of effectiveness. While this setback may have been disappointing, it does not seem to diminish the benefits of VNS.
The interventional psychiatrist must be educated on the indications for the device and be aware of the possible adverse effects induced by the device. [36] The interventional psychiatrist must know how to program the device in order to minimize these adverse effects and enhance its effectiveness. Increased exposure to VNS for interventional psychiatry residents in the epilepsy clinic may help them gain experience with the therapy, especially if the facility has few depression patients receiving VNS implantation. At least three VNS patients for depression, as well as a rotation at an epilepsy clinic where VNS patients are implanted, would be sufficient exposure.
The field of interventional psychiatry is only getting started, but it’s an area of psychiatry that’s only going to expand in importance. However, the FDA has authorized at least three types of brain stimulation therapy (ECT, VNS, and TMS) for use in the treatment of conventional psychiatric disorders. The current focus of these experimental therapies is on psychiatric patients who are resistant to therapy, but this is expected to alter in the future. The area of brain stimulation is fast becoming more clinically relevant, more widely accessible, and more sophisticated, thus it is critical to identify and support the training of interventional psychiatrists. Therapeutic-resistant individuals with mental illnesses face a critical shortage of doctors equipped to use brain stimulation as a treatment option. The fact that intrusive treatment of mental diseases is one of the most contentious topics in medicine, raising important moral, ethical, and economical difficulties, is worsened by these training inadequacies. Individual-centered care and mental health recovery paradigms need that these strategies be applied carefully and responsibly by the profession. We can avoid the mistakes and abuses of therapy from earlier generations if we work together in an ethical and procedural manner.
A noninvasive neuromodulation track as an elective in residency programs, as well as a formal interventional psychiatry fellowship, are all ideas we’d like to see implemented in order to make the most of recent advancements in invasive and noninvasive brain stimulation. We think these three approaches would be the best way to ensure that interventional psychiatry is properly trained (ABMS).
