Interventional psychiatry

KEYWORDS:

• Interventional psychiatry
• magnetic stimulation (TMS)
• electroconvulsive therapy (ECT)
• Risk Evaluation and Mitigation Strategies (REMS)
• specialty pharmacy

The recent growth in neuromodulation techniques has led to establishing the term ‘interventional psychiatry’; it refers to the administration of electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS) [1,2]. However, there are further interventional techniques to consider, including implants [3,4]; intramuscular, subcutaneous, or intravenous medications [5,6]; and treatments requiring utilization of Risk, Evaluation, and Mitigation Strategy (REMS) protocols [7–9]. In the future, interventions such as acupuncture and botulinum toxin injections may be added to the interventional armamentarium [10,11]. Many of these treatments are underutilized and only administered by few physicians [12–16]; even older therapies, such as by intramuscular injection, REMS-requiring clozapine, or ECT, are prescribed by a limited number of doctors and are generally underutilized [17,18]. Expanding the term ‘interventional psychiatry’ would include these older and newer complex treatment modalities; the term ‘neuromodulatory psychiatry’ still refers to ECT, TMS, VNS, and DBS. The proposed changes in terminology are intended to improve education, training about, and expand availability to these underutilized options.

These advances in psychiatric treatments can improve patient prognoses for people suffering from depression, obsessive-compulsive disorder, psychoses, and/or other conditions. The Food and Drug Administration has approved new pharmacotherapies for patients with illnesses that previously had suboptimal treatments, such as for those with post-partum depression, tardive dyskinesia, pseudobulbar affect, and psychoses with Parkinson’s disease [19–21]. Many of these newer therapeutic options mandate specific instrumentation, specialized training, invasive interventions, and/or are available only through specialty pharmacies [19–21]. Psychiatric clinicians are often unable or unwilling to meet the regulations, registrations, and additional training to administer these treatments, a problem that is magnified by the fact that psychiatric care is often provided by primary care providers [22]. Patient access is also hampered by restrictive insurance requirements and/or medications being available only in specialized pharmacies [23]. This limits access to interventions only offered through academic practices, at mental health centers that employ specialized personnel, or in specialty infusion clinics, where comprehensive psychiatric services are not consistently provided.

Our profession should start a discussion about broadening the definition of interventional psychiatry to include non-neuromodulatory treatments that are complex to administer and not provided by most practicing psychiatrists. Introducing a new subspecialty to encompass these modalities and training to more psychiatric physicians, would deliver these interventions and improve patient access. More residency training and post-graduate education ought to offer knowledge and practical experience about these treatments.

Current psychiatry residency training requirements by the Accreditation Council for Graduate Medical Education (ACGME) include curriculum for the application of ECT, neuromodulation therapies, and principles for the treatment of people with psychiatric disorders [24]. The ACGME recognizes diversity among residency programs and allows them to meet these requirements in ways that reflect the mission of their department and the needs of their community. However, this latitude in application creates problems. For example, the American Psychiatric Association recommends that each resident participate in a minimum of 10 ECT treatments, a standard that is not achieved by some 37% of residency programs [25]. Additionally, some residencies do not have immediate access to patients receiving TMS, DBS, VNS, or to those receiving subdermal buprenorphine implants. Nonetheless, these programs are charged with finding ways to address these requirements and teach the proper method to safely administer such psychiatric treatment options. Expanded curricula have been developed to cover the training needs of residents, including invasive and noninvasive brain stimulation techniques [2,26]. They focus on adding didactics and clinical experiences into the core curriculum of general psychiatry residencies, establishing elective track training during residency, and development of a fellowship that fosters expertise at neuromodulation. Expanding interventional psychiatry beyond neuromodulation encourages training about these modalities during residency and/or to post-graduate physicians and would widen patient access. This should improve knowledge, competence, and clinical outcome. Such proposed additions to residency educational curricula would incorporate learning objectives and measurable outcomes, following the Milestones format, developed to monitor resident competencies [27,28].

Continuing efforts to update practicing psychiatrists about these novel treatments must be stressed; that could be made easily available via meetings with ‘hands-on’ training, courses, videotapes, journal supplements, webinars, podcasts, or online courses. There also must be more general medical education regarding these therapeutic options and about appropriate psychiatric referrals to-and-from primary care providers, since they are often the first professionals to assess and treat patients with psychiatric illnesses.

To summarize, mastery of traditional neuromodulation treatments (ECT, TMS, VNS, DBS), and the newer, complex choices (REMS programs, injections/implants, work with specialty pharmacies, etc.) requires additional training and/or certification. Discussion ought to include input from residency training directors, their organization – the American Association of Directors of Psychiatric Residency Training, leaders in the field, academic faculty, practicing psychiatrists, mental health clinic staff, pharmacists, and selected non-psychiatric specialists. Optimally, there would also be an advisory board with input from insurance companies, businesses, and patients. A national approach to interventional psychiatry would benefit all of society through more comprehensive mental healthcare that utilizes these modern treatment modalities.

Declaration of interest

None of the authors have any relevant conflicts of interest to report. Dr. El-Mallakh has received research funding from Janssen and Sage, and is a speaker for Allergan, Janssen, Lundbeck, Neurocrine, Otsuka, Takeda, and Teva. The other authors have no conflicts of interest.

The contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.

Reviewers disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work was not supported by extramural funding.