February 25, 2020

New Program Uses Latest In Technology, Treatment To Give Hope Of A Better Life

Eads and Clothier

Drs. Lou Ann Eads, M.D., director of the Interventional Psychiatry program, and Jeff Clothier, M.D., review a patient’s file in PRI’s ECT suite.

Interventional psychiatry is an emerging sub-specialty of psychiatry, with a goal of helping individuals who have not responded to the long established methods of treatment for depression such as medication management and psychotherapy, or talk therapy. For those who have endured endless episodes of emotional turmoil, not to mention the physical constraints associated with poorly treated psychiatric symptoms of depression  and anxiety, interventional psychiatry is starting to make dramatic improvements in their life and giving them hope of a better overall quality of life.

The Psychiatric Research Institute’s Interventional Psychiatry program has integrated the latest technology and treatment options to help individuals who have failed to respond or tolerate medication therapy and/or talk therapy. As part of the program, a highly trained staff has been put together to provide these services for patients who have little hope of anything working for them and leading to an overall improvement in their life and ability to function day to day.

“For some individuals, the lifting of a severe depression can be lifesaving,” says Lou Ann Eads, M.D., director of PRI’s Interventional Psychiatry program. “Interventional modalities allow us to help those who have lost hope of ever getting better.”

The Interventional Psychiatry program has incorporated four methods of treatment designed to help patients dealing with major depressive disorder and have not seen any improvement in their condition after trying antidepressants and behavioral therapy. One of them is electroconvulsive therapy, designed to help patients with severe depression or suicidal thoughts. ECT involves a brief electrical stimulation of the brain while the patient is under anesthesia. The ECT team of medical professionals at PRI includes a psychiatrist, an anesthesiologist and a nurse; all experts in what Eads calls the “gold standard” of treatment for depression.

All antidepressants take weeks to control depressive symptoms, according to Eads. ECT is able to provide relief in approximately two to three weeks, compared to six to eight weeks or more for medications. This is especially helpful when trying to treat treatment resistant depression, psychotic depression, depression with acute suicidality, depression during pregnancy and severe post-partum depression.

“When it comes to patients who are psychotically depressed, ECT can turn things around pretty quickly,” said Eads, who admits there is a certain stigma attached to the treatment despite the technological improvements made since it was first introduced in the 1940s.

Greg Cook

Greg Cook, RN, hooks up an IV pole in preparation for an ECT patient.

“Today, the procedure is done under general anesthesia and the patient is asleep throughout the treatment. I would now characterize ECT as the most effective and compassionate intervention for treatment-resistant depression,” says Greg Cook, RN, who assists Eads.

Modern ECT involves a consult to minimize any potential medical problems prior to treatment and to address medications that may make the treatment less than successful. The therapy series usually involves a series of six to 12 treatments. This is followed by a tapering off of the treatments, spreading them out weekly for an additional four or more treatments. Afterwards, the individual may be able to go years or the rest of their life without future treatments.

“The treatment plan is based on the individual. Some patients go years without needing further treatment, some need a tune-up that helps them function and stay out of the hospital,” says Eads. “When you need an immediate response, ECT should be on the table.”

Another form of treatment employed by the Interventional Psychiatry program is transcranial magnetic stimulation (TMS), a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. The process involves an electromagnetic coil placed against the patient’s scalp near their forehead. The electromagnet delivers a pain-free magnetic pulse that stimulates nerve cells in the region of the brain involved in mood control and depression.

TMS was approved by the Food and Drug Administration for the treatment of depression in 2008 and has proven to be an effective option for managing treatment-resistant depression. “It has some advantages over ECT,” says Eads, including that one can drive and return to work after treatment and that it does not require the use of general anesthesia on a regular basis. There is no risk of memory difficulty associated with this treatment but it involves a longer time to complete the treatment series.

“Most treatments involve 30 sessions, five days a week, for 6 weeks and then a six-treatment taper afterwards for a total of 36 sessions,” says Eads. “There is a rare risk of having a seizure during the procedure, but this has usually been associated with factors known to increase the risk of seizures such as sleep deprivation, medication changes or previous neurological conditions, and these risks can easily be minimized and addressed.”

Eads has also used TMS to treat patients with obsessive-compulsive disorder (OCD). “By definition, the obsessions and compulsions consume an excessive amount of time daily and severely impact the individual’s quality of life and ability to function in a day-to-day manner,” says Eads. TMS has been approved for the treatment of OCD by the Food and Drug Administration since 2018.

The Food and Drug Adminstration’s approval last year of the drug brexanolone, known commercially as Zulresso, has given Interventional Psychiatry a new approach in treating women with postpartum depression. It is administered intravenously during a 60-hour hospital stay at PRI. This drug is the first and only of its kind earmarked for patients suffering from the feelings of sadness, worthlessness or guilt after giving birth.

“Women are typically back to baseline within 60 hours from beginning the infusion. This treatment has a sustained response up to 30 days post infusion,” says Jessica Coker, M.D., the medical director of PRI’s women’s inpatient unit. Coker expects to begin using the treatment, which is covered by most insurance plans, later this year.

A fourth option offered by Interventional Psychiatry is Ketamine, a drug used primarily in anesthesia since the 1960s that has been shown to dramatically improve the symptoms of patients with severe, long-term depression.

Esketamine is a nasal version of ketamine that is FDA-approved for treatment-resistant depression and is marketed under the brand name of Spravato. “Due to the FDA’S concerns for safety, it can only be used under medical supervision with specific restrictions,” says Eads. It is administered under the supervision of a physician and the patient is monitored for a minimal of two hours at the facility before being discharged.

“Ketamine is the new kid on the block, designed to help people obsessed with suicide,” says Eads. “But because it can be abused, it’s not recommended for people with a history of substance abuse.”

The initial or induction phase is two times per week for four weeks and the maintenance phase is weekly for four weeks. “Since it is FDA approved, Spravato is covered by some insurance plans,” says Eads.

“All of these options have been shown to safely manage depression in people who have not responded to medication and therapy,” says Eads. “Which one they use depends on the patient experience and the severity of their depression. One way or another, we will get them to a better place.”