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Trapp NT, Barbour T, Kritzer MD, Pottanat R, Carreon D, Chen L, Brown J, Siddiqi S. Defining a Neurostimulation-Focused Subspecialty: Perspectives Inspired by a Debate at the 2023 Clinical TMS Society Annual Meeting. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024:10.1007/s40596-024-02025-2. [PMID: 39148002 DOI: 10.1007/s40596-024-02025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 08/04/2024] [Indexed: 08/17/2024]
Affiliation(s)
| | | | | | | | | | - Leo Chen
- Monash University, Melbourne, Victoria, Australia
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Cortright MK, Bluhm R, Achtyes ED, McCright A, Cabrera LY. Perceived Barriers to Using Neurostimulation: A National Survey of Psychiatrists, Patients, Caregivers, and the General Public. J ECT 2024; 40:111-117. [PMID: 38265758 PMCID: PMC11136602 DOI: 10.1097/yct.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
OBJECTIVES Neurostimulation interventions often face heightened barriers limiting patient access. The objective of this study is to examine different stakeholders' perceived barriers to using different neurostimulation interventions for depression. METHODS We administered national surveys with an embedded experiment to 4 nationwide samples of psychiatrists (n = 505), people diagnosed with depression (n = 1050), caregivers of people with depression (n = 1026), and members of the general public (n = 1022). We randomly assigned respondents to 1 of 8 conditions using a full factorial experimental design: 4 neurostimulation modalities (electroconvulsive therapy [ECT], repetitive transcranial magnetic stimulation [rTMS], deep brain stimulation [DBS], or adaptive brain implants [ABIs]) by 2 depression severity levels (moderate or severe). We asked participants to rank from a list what they perceived as the top 3 barriers to using their assigned intervention. We analyzed the data with analysis of variance and logistic regression. RESULTS Nonclinicians most frequently reported "limited evidence of the treatment's effectiveness" and "lack of understanding of intervention" as their top 2 most important practical barriers to using ECT and TMS, respectively. Compared with nonclinicians, psychiatrists were more likely to identify "stigma about treatment" for ECT and "lack of insurance coverage" for TMS as the most important barriers. CONCLUSIONS Overall, psychiatrists' perceptions of the most important barriers to using neurostimulation interventions were significantly different than those of nonclinicians. Perceived barriers were significantly different for implantable DBS and ABI) versus nonimplantable (rTMS and ECT) neurostimulation interventions. Better understanding of how these barriers vary by neurostimulation and stakeholder group could help us address structural and attitudinal barriers to effective use of these interventions.
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Affiliation(s)
| | - Robyn Bluhm
- Michigan State University, Lyman Briggs and Philosophy
| | | | | | - Laura Y. Cabrera
- Pennsylvania State University; Department of Engineering and Mechanics and Rock Ethics Institute
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Menon SN, Torrico T, Luber B, Gindoff B, Cullins L, Regenold W, Lisanby SH. Educating the next generation of psychiatrists in the use of clinical neuromodulation therapies: what should all psychiatry residents know? Front Psychiatry 2024; 15:1397102. [PMID: 38812486 PMCID: PMC11133724 DOI: 10.3389/fpsyt.2024.1397102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
A variety of neuromodulation treatments are available today and more are on the way, but are tomorrow's psychiatrists prepared to incorporate these tools into their patients' care plans? This article addresses the need for training in clinical neuromodulation for general psychiatry trainees. To ensure patient access to neuromodulation treatments, we believe that general psychiatrists should receive adequate education in a spectrum of neuromodulation modalities to identify potential candidates and integrate neuromodulation into their multidisciplinary care plans. We propose curricular development across the four FDA-cleared modalities currently available in psychiatric practice: electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). With a focus on psychiatry residency training, the article delineates core learning components for each neuromodulation technique. For each modality, we review the clinical training status, the respective FDA-cleared indications, mechanisms of action, clinical indications and contraindications, adverse effects, informed consent process, dosing considerations, and clinical management guidelines. The approach outlined in this article aims to contribute to the development of a well-rounded generation of psychiatry trainees with the capacity to navigate the growing field of neuromodulation. Whether or not a psychiatrist specializes in delivering neuromodulation therapies themselves, it is incumbent on all psychiatrists to be able to identify patients who should be referred to neuromodulation therapies, and to provide comprehensive patient care before, during and after clinical neuromodulation interventions to optimize outcomes and prevent relapse.
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Affiliation(s)
- Sahit N. Menon
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States
| | - Tyler Torrico
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States
| | - Bruce Luber
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States
| | - Brian Gindoff
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States
| | - Lisa Cullins
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, United States
| | - William Regenold
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States
| | - Sarah H. Lisanby
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States
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Cabrera LY, van den Heuvel OA. Ethical Considerations Regarding the Use of Transcranial Magnetic Stimulation in Mental Health Practice. Biol Psychiatry 2024; 95:491-493. [PMID: 37172711 DOI: 10.1016/j.biopsych.2023.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/05/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Laura Y Cabrera
- Center for Neural Engineering, Department of Engineering Science and Mechanics, and the Rock Ethics Institute, The Pennsylvania State University, University Park, Pennsylvania.
| | - Odile A van den Heuvel
- Departments of Psychiatry and Anatomy and Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Neuroscience, Compulsivity Impulsivity Attention Program, Amsterdam, the Netherlands
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Barnes R, Skvarc D, Fitzgerald PB, Berk M, Dean OM, Dodd S, Schriemer T, Singh AB. Equal remission rates and reduced length of hospital stay with twice-daily repetitive transcranial magnetic stimulation (rTMS) for major depression - A large naturalistic retrospective cohort association study. Prog Neuropsychopharmacol Biol Psychiatry 2023; 127:110820. [PMID: 37406796 DOI: 10.1016/j.pnpbp.2023.110820] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/16/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVES Repetitive transcranial magnetic stimulation (rTMS) is a level 1a evidence-based treatment for major depression, but high cost of care and limited effectiveness in naturalistic cohorts have been lingering criticisms. This naturalistic, retrospective cohort analysis compares the effect of once and twice daily treatment protocols of rTMS using quality assurance data collected at an Australian private psychiatric hospital. METHODS A total of 210 inpatients self-selected into two groups receiving up to 30 sessions of either daily (n = 101) or twice daily (n = 109) 10 Hz rTMS to the left dorsolateral prefrontal cortex (DLPFC). The a priori primary outcome measure was remission rate as measured by pre and post treatment HAMD-17 scores. Length of hospital stay was a secondary post hoc outcome adopted due to the importance to cost of acute psychiatric care. RESULTS Remission rates were similar across groups, with 44.9% and 45.4% for twice daily and daily rTMS groups respectively, although these may be confounded by patient expectations, other treatments and medication changes given the naturalistic setting. The length of hospital stay was 10.11 days and 18.44 days for twice daily and daily rTMS respectively - the twice daily rTMS length of hospital stay was 45.1% shorter 95% CI [38.7% - 51.56%]. Dropout rates were high; Twenty-seven (24.77%) twice daily participants dropped out before 20 sessions were completed, and 35 (34.65%) of daily participants. CONCLUSIONS Twice daily 10 Hz left sided rTMS remission outcomes were similar to traditional once daily rTMS but required a shorter length of hospital stay. This finding has substantial cost of care implications. If these findings are independently replicated, twice daily rTMS may become the standard of care for inpatient rTMS.
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Affiliation(s)
- R Barnes
- School of Medicine and Psychology, The Australian National University, Canberra, ACT, Australia
| | - D Skvarc
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, P.O. Box 281, Geelong 3220, Australia; School of Psychology, Deakin University, Geelong, Australia
| | - P B Fitzgerald
- School of Medicine and Psychology, The Australian National University, Canberra, ACT, Australia
| | - M Berk
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, P.O. Box 281, Geelong 3220, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, the Department of Psychiatry, and the Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - O M Dean
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, P.O. Box 281, Geelong 3220, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Kenneth Myer Building, 30 Royal Parade, Parkville 3052, Australia
| | - S Dodd
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, P.O. Box 281, Geelong 3220, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, the Department of Psychiatry, and the Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - T Schriemer
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, P.O. Box 281, Geelong 3220, Australia
| | - A B Singh
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, P.O. Box 281, Geelong 3220, Australia.
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Chen SC, Bluhm R, Achtyes ED, McCright AM, Cabrera LY. Looking through the lens of stigma: Understanding and anticipating concerns about the responsible development and use of psychiatric electroceutical interventions (PEIs). SSM - MENTAL HEALTH 2023; 4:100261. [PMID: 38188866 PMCID: PMC10768967 DOI: 10.1016/j.ssmmh.2023.100261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024] Open
Abstract
Psychiatric electroceutical interventions (PEIs) show promise for treating depression, but few studies have examined stakeholders' views on them. Using interview data and survey data that analyzed the views of psychiatrists, patients, caregivers, and the general public, a conceptual map was created to represent stakeholders' views on four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and adaptive brain implants (ABIs). Stigma emerged as a key theme connecting diverse views, revealing that it is a significant factor in the acceptance and usage of PEIs. Stigma not only discourages seeking mental health services for depression but also inhibits the acceptance of PEIs. Addressing the pervasive and complex effects of stigma highlights the need to change societal attitudes toward mental illnesses and their treatments and to provide support to patients who may benefit from these interventions. The map also demonstrates the value of conceptual mapping for anticipating and mitigating ethical considerations in the development and use of PEIs.
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Affiliation(s)
| | - Robyn Bluhm
- Michigan State University, Lyman Briggs and Philosophy, USA
| | | | | | - Laura Y. Cabrera
- Pennsylvania State University, Department of Engineering and Mechanics and Rock Ethics Institute, USA
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Sandoval-Pistorius SS, Hacker ML, Waters AC, Wang J, Provenza NR, de Hemptinne C, Johnson KA, Morrison MA, Cernera S. Advances in Deep Brain Stimulation: From Mechanisms to Applications. J Neurosci 2023; 43:7575-7586. [PMID: 37940596 PMCID: PMC10634582 DOI: 10.1523/jneurosci.1427-23.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 11/10/2023] Open
Abstract
Deep brain stimulation (DBS) is an effective therapy for various neurologic and neuropsychiatric disorders, involving chronic implantation of electrodes into target brain regions for electrical stimulation delivery. Despite its safety and efficacy, DBS remains an underutilized therapy. Advances in the field of DBS, including in technology, mechanistic understanding, and applications have the potential to expand access and use of DBS, while also improving clinical outcomes. Developments in DBS technology, such as MRI compatibility and bidirectional DBS systems capable of sensing neural activity while providing therapeutic stimulation, have enabled advances in our understanding of DBS mechanisms and its application. In this review, we summarize recent work exploring DBS modulation of target networks. We also cover current work focusing on improved programming and the development of novel stimulation paradigms that go beyond current standards of DBS, many of which are enabled by sensing-enabled DBS systems and have the potential to expand access to DBS.
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Affiliation(s)
| | - Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee 37232
| | - Allison C Waters
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York 10029
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York 10029
| | - Jing Wang
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455
| | - Nicole R Provenza
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030
| | - Coralie de Hemptinne
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida 32608
| | - Kara A Johnson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida 32608
| | - Melanie A Morrison
- Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, California 94143
| | - Stephanie Cernera
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California 94143
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Bluhm R, Sipahi ED, Achtyes ED, McCright AM, Cabrera LY. Stakeholders' Ethical Concerns Regarding Psychiatric Electroceutical Interventions: Results from a US Nationwide Survey. AJOB Empir Bioeth 2023; 15:11-21. [PMID: 37343219 PMCID: PMC10733552 DOI: 10.1080/23294515.2023.2224592] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Psychiatric electroceutical interventions (PEIs) use electrical or magnetic stimulation to treat mental disorders and may raise different ethical concerns than other therapies such as medications or talk therapy. Yet little is known about stakeholders' perceptions of, and ethical concerns related to, these interventions. We aimed to better understand the ethical concerns of a variety of stakeholder groups (patients with depression, caregivers of patients, members of the public, and psychiatrists) regarding four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), and adaptive brain implants (ABI). METHODS We conducted a national survey of these four stakeholder groups, using an embedded video vignette experiment depicting a patient with treatment-resistant depression and her psychiatrist discussing the possibility of treatment with one of the four PEIs. RESULTS Participants' ethical concerns varied by stakeholder group, by PEI, and by the interaction of the two. The three non-clinician groups tended to have similar ethical concerns, but to differ from psychiatrists. Similar concerns were raised with regard to the two implantable technologies, DBS and ABI. Overall, there was relatively little concern about the involuntary use of PEIs, though some expressed concern about the adequacy of information provided during the consent process. There was also significant concern that patients may not receive helpful therapies. CONCLUSIONS To our knowledge, this is the first national survey that includes multiple stakeholder groups and multiple PEI modalities. A better understanding of the ethical concerns of stakeholders can help to shape clinical practice and health care policy regarding PEIs.
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Affiliation(s)
- R Bluhm
- Philosophy and Lyman Briggs College, Michigan State University, East Lansing, MI, USA
| | - E D Sipahi
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - E D Achtyes
- School of Human Medicine, Western Michigan University, Kalamazoo, MI, USA
| | - A M McCright
- Sociology, Michigan State University, East Lansing, MI, USA
| | - L Y Cabrera
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, USA
- Rock Ethics Institute, The Pennsylvania State University, University Park, PA, USA
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Widge AS. Closed-Loop Deep Brain Stimulation for Psychiatric Disorders. Harv Rev Psychiatry 2023; 31:162-171. [PMID: 37171475 PMCID: PMC10188203 DOI: 10.1097/hrp.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
ABSTRACT Deep brain stimulation (DBS) is a well-established approach to treating medication-refractory neurological disorders and holds promise for treating psychiatric disorders. Despite strong open-label results in extremely refractory patients, DBS has struggled to meet endpoints in randomized controlled trials. A major challenge is stimulation "dosing"-DBS systems have many adjustable parameters, and clinicians receive little feedback on whether they have chosen the correct parameters for an individual patient. Multiple groups have proposed closed loop technologies as a solution. These systems sense electrical activity, identify markers of an (un)desired state, then automatically deliver or adjust stimulation to alter that electrical state. Closed loop DBS has been successfully deployed in movement disorders and epilepsy. The availability of that technology, as well as advances in opportunities for invasive research with neurosurgical patients, has yielded multiple pilot demonstrations in psychiatric illness. Those demonstrations split into two schools of thought, one rooted in well-established diagnoses and symptom scales, the other in the more experimental Research Domain Criteria (RDoC) framework. Both are promising, and both are limited by the boundaries of current stimulation technology. They are in turn driving advances in implantable recording hardware, signal processing, and stimulation paradigms. The combination of these advances is likely to change both our understanding of psychiatric neurobiology and our treatment toolbox, though the timeframe may be limited by the realities of implantable device development.
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Affiliation(s)
- Alik S Widge
- From the Department of Psychiatry & Behavioral Sciences and Medical Discovery Team on Addictions, University of Minnesota
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