Bret S. Stetka, MD; Edward M. Kantor, MD; Nolan R. Williams, MD

Disclosures

May 30, 2013

In This Article

Putting Neuromodulation Into Practice

Medscape: Can you expand on how these techniques might be incorporated into care in conjunction with psycho- and pharmacotherapy?

TMS: In the pivotal trials, the patients were not on any medications. In the real world, TMS is typically combined with medications and therapy. There are now studies looking at combining therapy with TMS for a synergistic effect.

ECT: There are medications that, when used alongside ECT (venlafaxine/nortriptyline) or after ECT (lithium), increase the chances of improvement and better cognitive outcomes.

DBS: Typically this intervention can eventually replace medications; many of the studies reduced/removed medications once the device was working. In many instances, DBS (particularly in depression) will allow for patients to better participate in therapies that they would not have been able to participate in before.

TDCS: The most efficacy that has been shown to date is in combination with sertraline. This will potentially be a role for TDCS in enhancing therapeutic efficacy.

Medscape: Tell us about the interventional psychiatry training program at MUSC and how you envision the program evolving and affecting care.

Dr. Williams: Drs. Mark George and Baron Short have developed a 1-year interventional psychiatry fellowship with the first fellow, Dr. Jon Snipes, finishing June 30, 2013. A second fellow, Dr. Suzanne Kerns, will begin in July 2013.

We feel that interventional psychiatry should be present at 3 levels: (1) a core curriculum of introductory knowledge and experience during psychiatry residency training for all psychiatrists; (2) a neuromodulation elective track during residency at some locations; and eventually (3) a formal interventional psychiatry fellowship that leads to an approved subspecialty certification process under the American Board of Medical Specialties (ABMS).

Base resident education: Psychiatry residents should have an introductory-level understanding of the brain circuits underlying behavior and how they can be modulated using invasive and noninvasive brain stimulation. This fundamental knowledge should improve the quality of patient management by ensuring that patients are aware of the full complement of available therapeutic interventions. Ideally, all psychiatric residents would have a core curriculum that includes brain stimulation consultation and observation of ECT and TMS.

Interventional psychiatry track: Psychiatry residents who have a specific interest in brain stimulation should have the option of pursuing a dedicated training track within their residency program. Under this proposal, interested residents would be required to manage ECT and TMS treatment cases, from initial consultation to acute therapy and maintenance treatments. Psychiatrists who are currently performing these duties could be grandfathered into this arrangement.

Interventional psychiatry fellowship: Psychiatrists who wish to pursue the most rigorous training program should have the option of pursuing a 1-year fellowship that includes focused training in all of the aforementioned techniques. This training would occur at institutions with robust neuromodulation programs in collaboration with neurology, neurosurgery, and neuroradiology. Fellowship trainees should receive hands-on exposure in established (ECT, TMS, DBS, VNS) and emerging (eg, TDCS) neuromodulatory technologies. Additionally, fellowship trainees should have experience with the tools used to measure the effects of neuromodulation, such as functional MRI and EEG.

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