Interventional Psychiatry: Addressing Resistant Disorders

David Robinson

Interventional Psychiatry Reset Button

When traditional medications for resistant mental disorders fail, doctors may turn to novel therapies that fall under a relatively new realm of medicine known as interventional psychiatry. This includes electroconvulsive therapy (ECT), ketamine infusions, repetitive transcranial magnetic stimulation (rTMS), and deep-brain stimulation.

“Interventional psychiatry is a new way of addressing more severe cases,” said Jeffery Clothier, M.D., a psychiatrist and professor in the UAMS College of Medicine Department of Psychiatry.

Severe and resistant depression is the most-treated disorder using interventional psychiatry methods, and ECT is the most used of these treatments. ECT, also used for catatonia, schizophrenia and mania, is safe, effective and it is covered by insurance.

Interventional psychiatry is a new way of addressing more severe cases.Dr. Jeffery Clothier

Formerly known as electroshock, ECT induces seizures by sending electrical current through two electrodes. The brain is “reset,” making it more responsive to medications, said Lou Ann Eads, M.D., who directs UAMS’ ECT service.

“ECT is the heart and soul of interventional psychiatry,” Clothier said.

Patients who don’t respond to ECT may be offered ketamine, an FDA-approved anesthetic that has shown to be effective at treating depression. Clothier said patients respond to ketamine about 80 percent of the time, but it is often not covered by insurance

“We use it to break the depression and then have patients on a more definitive medication,” Clothier said.

Repetitive transcranial magnetic stimulation (rTMS) is being studied by UAMS’ Erick Messias, M.D., Ph.D., M.P.H. During the procedure, a large magnet sends pulses through the skull, and depending on the frequency of pulses, may excite or inhibit the activity of the brain’s neurons.

Messias hopes rTMS can be used to help people with auditory hallucinations — hearing voices — which usually is associated with schizophrenia.

“Schizophrenia can be a devastating disease and our medications are limited,” said Messias, medical director for the Walker Family Clinic at the UAMS Psychiatric Research Institute. “They suffer tremendously.”

Patients may hear commanding voices that tell them to hurt themselves, that they are no good and they should die, he said.

Messias notes that his pilot study evolved from research in the laboratory of UAMS’ Edgar Garcia-Rill, M.D., and the UAMS Center for Translational Neuroscience.

UAMS’ Erika Petersen, M.D., a neurosurgeon, is studying the potential of deep brain stimulation in helping patients with resistant mental illnesses.

 

Patients Say ECT Saved Their Lives

Bob Scroggin thought of the movie “One Flew Over the Cuckoo’s Nest” when his psychiatrist suggested electroconvulsive therapy (ECT) for his severe depression, but he barely flinched.

“I was ready to try anything,” said Scroggin, 69, of Conway. “I was that bad off.”

Dr. Lou Ann EadsAlthough ECT – formerly known as electroshock – has been significantly improved since that 1975 movie starring Jack Nicholson, the idea initially terrified Leigh Phillips, of Searcy. But medications hadn’t helped her anxiety, panic attacks and depression.

“I was so sick I couldn’t even go to Wal-Mart,” said Phillips, who was a licensed practical nurse for 33 years. “I was terrified of people.”

After its introduction in 1938, ECT was widely adopted by the 1950s, then abandoned by many providers as new medications became available, said Lou Ann Eads, M.D., a psychiatrist who oversees the ECT service at the UAMS Psychiatric Research Institute.

People get better with ECT. They really get better and it improves their quality of life.Dr. Lou Ann Eads

But all patients did not respond to medication, and as ECT delivery was improved, it became a standard treatment, providing relief from psychiatric illnesses, primarily resistant and severe depression.

During ECT, seizures are induced by sending electrical current through two electrodes. During the roughly 30-second seizures, there’s a massive release of neurotransmitters, Eads said, helping “reset” the brain and making it more responsive to medications.

Patients sleep through the procedure while under anesthesia, and a muscle relaxer prevents physical harm from the seizures. Eads also takes a conservative approach to minimize risks, primarily memory loss.

UAMS is one of only two ECT sites in Arkansas and the only site that treats pregnant women. It is also the only site adjacent to a comprehensive medical facility, important for patients with other serious medical conditions.

ECT helps patients 75-80 percent of the time, Eads said. “People get better with ECT. They really get better and it improves their quality of life.”

Scroggin and Phillips say that’s an understatement.

After Phillips initially rejected the idea in September 2012, she talked to her husband and Eads and concluded that she didn’t have anything to lose; and she trusted Eads.

After a series of ECT treatments she said she feels “100 percent better” with a new outlook on life. She’s traveled to California to see four of her six grandchildren. “It’s just wonderful to be well again.”

At his worst, two years ago, Scroggin was suicidal and left his public relations job. His psychiatrist mentioned that UAMS offered ECT. Scroggin quickly scheduled an appointment.

Today Scroggin volunteers and has several hobbies, including wood working and motorcycle riding. “It feels good to live,” he said. “UAMS saved my life.”

David RobinsonInterventional Psychiatry: Addressing Resistant Disorders