Public perceptions of psychiatry took a hit from the ’70s classic movie “One Flew Over the Cuckoo’s Nest” where the main character gets sent up to the “shock shop” for electroconvulsive therapy. Ironically, the new frontier in psychiatry is centering on a vast array of brain stimulation techniques, including electroconvulsive therapy or ECT, that is offering relief to patients who have lost hope in other forms of traditional treatment.
|Dr. Baron Short|| |
Baron Short, M.D., clinical director of MUSC’s Brain Stimulation Services with the Institute of Psychiatry at the Medical University of South Carolina (MUSC), said misconceptions remain about these brain stimulation treatments and how they should be used. For example, today’s ECT is considerably different from the primitive “shock treatments” portrayed in the past. There are no paddles with periods of violent convulsions, but rather a low-voltage, ultra-brief pulse of current delivered to just one side of the brain. Modern ECT has been shown to be an effective procedure for many treatment-resistant patients with mood disorders.
Modern ECT is just a small piece of the puzzle, too, when it comes to the rapidly-evolving field of brain stimulation treatments that are transforming the field. It’s one reason MUSC is offering a new interventional psychiatry fellowship for residents and psychiatrists who want to have an additional year of training in the wide variety of both invasive and non-invasive brain stimulation technologies that now are available, some of which have been pioneered at MUSC. The university also has a curriculum within the residency program called the interventional psychiatry track.
Nolan R. Williams, M.D., is chief resident of Combined Neurology and Psychiatry at MUSC, and said the curriculum centers around the concept that the brain is an electrochemical organ, and behavior and emotion are mediated by circuits within the brain in which psychiatrists can “intervene” to create therapeutic change.
“We think it makes these technologies much safer and much more likely to help people who truly need them by creating a set training pathway. What we would hope is that in a few years, several places across the country will have this, and it can really expand our ability to reach out and help those people who really need them the most and who have failed all other treatments.”
Williams, who presented a poster at the American Psychiatric Association meeting last year, received a warm reception, and he and colleague Edward Kantor, M.D., were asked to write an article for Medscape on “A New Psychiatry Subspecialty,” which in a couple of weeks had attracted more than 22,000 readers from all specialties of medicine and numerous positive comments.
| ||Dr. Nolan Williams|
“What we’ve done here that’s unique is recognized this explosion, and we tried to capture it within a training model. We’re the first to develop and implement a formal training model within our educational system here in the psychiatry department,” he said. “We’ve had people from across the world contacting us, asking us if they can train here for interventional psychiatry. So there’s an interest and a recognition of need.”
Short said the goal is to develop a standard of how to train people in these technologies.
“At this point, ECT is widespread throughout the United States. Transcranial magnetic stimulation has spread throughout the United States, and we’re very interested that people are refining how we train and teach people how to use these technologies and be as updated as possible so that we’re giving people the safest most effective treatment possible.”
MUSC has a critical pool of brain stimulation pioneers, such as Mark George who’s director of MUSC’s Brain Stimulation Lab and began developing brain stimulation technologies in the 1980s. He is known for his research in developing transcranial magnetic stimulation, which is a way to non-invasively apply magnetic stimulation that only reaches the outer layers of the brain’s cortex. “Arguably, it’s still in its infancy, yet we’ve already found evidence for transcranial magnetic stimulation for the treatment of depression and it has been FDA-approved for the treatment of depression since 2008.”
Even treatments that have been around for a while, such as ECT, are being revamped, and psychiatrists have had to reeducate patients about how the field has grown, Short said. “We pioneer the same technology with ECT. We do a form of ECT that, literally, no one else is doing in the world, to reduce cognitive side effects while maintaining good efficacy of treatment of depression. We’re not just interested in ECT, and we’re not just interested in TMS. We are involved in various forms of brain stimulation.”
Epidural-cortical stimulation, which is a technology pioneered at MUSC by Istvan Takacs, M.D., and Ziad Nahas, M.D., involves placing electrodes on the front of the brain where there’s thought to be certain types of dysfunctional activity in the brain in depressed patients. MUSC also is involved in what’s called deep brain stimulation, which involves implanting electrodes into the brain to treat such disorders as Parkinson’s Disease, obsessive compulsive disorder (OCD) and depression.
“But it doesn’t stop there,” Short said. “There are a variety of technologies still developing involving using GAMMA technology to stun parts of the brain for treatment of depression. There are transcranial ultrasound technologies that are being used to modify circuits in the brain, so again we’re trying to get across the idea that the brain is an electro-chemical organ that we can modify invasively or non-invasively in very focal ways to change the behavior of the circuits and get people out of serious, severe disorders they experience, including depression, OCD, etc., and we’re still in the infancy of this.”
The changes are bringing doctors a step closer to personalizing medicine to treat mental and neurological disorders.
For example, in the future a depressed patient who gets therapy would undergo brain imaging first to understand the specific disorders occurring in the brain, Short said. “Based on that, we will be able to directly say, ‘You are more likely to benefit from talk therapy; you are more likely to benefit from specific types of medication or you are not going to benefit from either of these right now. You need this type of technology.’ So we will get to the point where we’re so precise in being able to, not only look at what someone’s experiencing or understand it, kind of precisely determine the type of dysfunction and directly intervene and skip a lot of the steps that people are currently having to undergo.”
|Dr. Mark George explains how Epidural Cortical Stimulation, which involves implanting paddles beneath the skull to stimulate the brain, can help with mood disorders.|| |
Interventional psychiatrists work closely with neurosurgeons in the invasive treatments, such as DBS, which has a “brain pacemaker” that is implanted in the chest that transmits an electrical signal from the impulse generator to the electrodes. Short said the neurosurgeon would play more of a role in implanting the electrodes, and the psychiatrist would play more of a role helping coordinate and program the device. “So once you have the device in, you still have to turn it on and make adjustments.”
The psychiatrists and neurosurgeons agree on a target area in the brain based on a patient's symptoms and work as a team to personalize a patient’s treatment, fine-tuning the device to achieve the best effects with the least side effects.
Mood regulation is thought to be controlled by a series of nodes in a circuit, Williams said. “The cortex is one of those nodes, and then there are deep structures, so you have a point here connected to a point here, connected to a point here, and that loops around and closes the circuit. Some of those nodes are deep and when you want to simulate a deep node, you do deep brain stimulation. You stick an electrode deep into the brain, either into a white matter track or a nucleus. If you want to stimulate the cortex, you can do it non-invasively through TMS, which is effective for moderate depression.”
Williams sees the field moving towards this circuit-based understanding of both neurologic and psychiatric diseases. The next 10 to 20 years will bring a better understanding of the brain, its circuits and the brain-based mechanisms that drive disease. The goal is to be able to implement neuromodulation treatments earlier to help normalize the brain, he said. “That way we can really capture everyone who has a mental illness and be able to effectively treat them and reduce their symptoms and suffering.”
Williams said it’s interesting to note how each one of the brain stimulation treatments is being explored for most all of the psychiatric illnesses at some level of severity. The main obstacle to advancement is funding.
Short agreed. “There are current caps in research funding and dollars available for this type of research, so even though it is cutting-edge, we could go tremendously faster than what we’re doing now. Some of us would argue that we’re moving at a snail’s pace, but if we had additional funding, we could really take this to a whole other level and a lot faster."
Just because there’s an explosion of growth in this field does not mean traditional therapies are not needed, but rather that brain stimulation treatments will augment psychotherapy and medication therapies, Short said.
“Many of the folks who are either in clinical treatment or research trials have often failed to respond to medication or talk therapy, and what we find is that we help people recover so that they can actually reengage in psychotherapy.”
Short compares it to an orthopedic surgeon repairing someone’s hip who has not walked in quite a while to the point the muscles have atrophied and thinned out. “If that surgeon replaces the hip, now the person has the capacity to possibly walk, but has to retrain the muscles. So we look at interventional psychiatry as a subspecialty to help the circuits behave in a healthier framework so that people can re-engage in their lives. They often still need talk therapy and medications.”