Non pharmacological Treatments in Psychiatry

Non-pharmacological
Management in Psychiatry
Dr Bhakti Murkey
Assistant Professor
Department of Psychiatry
PMCH

Components
• Brain Stimulation methods
• Neurosurgery
• Deep Brain Stimulation
• Psychotherapy

ECT
o Also known as shock treatment
o Electrical induction of seizures in patients
o Highly effective treatment
o Role of informed consent
o Indications:
o Severe/ resistant Schizphrenia
o Severe/ resistant Depression
o Severe/ resistant Bipolar Disorder
o Catatonia
o Actively suicidal patient
o Patient with poor self care/ general health condition
o Traditional vs Modified ECT (under general anaesthesia with muscle relaxant)

ECT
o No absolute contra-indication
o Indicated for treating psychiatric disorders even in pregnancy
o General physical risks similar to those of brief general anesthesia
o Most common adverse effects:
o Confusion and memory loss
o Immediately following treatment
o Transient
o Usual course involves multiple administrations
o Typically 2-3 times/ week until symptom response

ECT
o Different applications:
o Electrode placement
o Frequency of treatments
o Electrical waveform of the stimulus
o Significant differences in both adverse side effects and symptom remission
o Electrode placements:
o Bilateral: electric current passed across the whole brain (greater efficacy
but greater risk of memory loss)
o Unilateral: current is passed across one hemisphere

ECT
o After treatment:
o Drug therapy usually continued
o Some patients receive maintenance ECT
o Mechanism:
o Short term response via anticonvulsant effect (frontal lobes)
o Longer term effects via neurotrophic changes (primarily in the medial
temporal lobe)

Repeated Transcranial Magnetic
Stimulation

rTMS
o Non-invasive stimulation of small regions of the brain
o Magnetic field generator "coil" placed near the patient’s head
o Coil connected to a pulse generator (stimulator) that delivers electric current to
the coil
o Produces small electric currents via electromagnetic induction in adjacent
regions of the brain
o Constant, low current delivered to the brain area of interest via electrodes on
the scalp
o Single-pulse TMS approved by the FDA for use in migraine
o Repetitive TMS (rTMS) approved for use in treatment-resistant major
depressive disorder
Lefaucheur, JP; et al. (2014). "Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic
stimulation (rTMS)". Clinical Neurophysiology 125 (11): 2150–2206

rTMS
o Probable mechanism:
o Alteration of synaptic transmission ability
o Plasticity via long term potentiation (LTP = strengthening between two
neurons) and long term depression (LTD = weakening between two
neurons)
o Evidence suggests usefulness for neuropathic pain and treatment-resistant
depression
o May be useful for negative symptoms of schizophrenia and loss of function
caused by stroke
Nitsche, M. A.; Paulus, W. (2000). "Excitability changes induced in the human motor cortex by weak transcranial direct
current stimulation". The Journal of Physiology 527 (3): 633–639

Transcranial
Direct Current Stimulation

tDCS
o Non-invasive brain stimulation
o Small, pulsed electric current applied across a person's head
o Electrodes placed on the ear lobes, maxilla-occipital junction, mastoid processes
o Recognized by FDA (2014) for reasonable assurance of safety and effectiveness
o Used to treat anxiety, depression, insomnia and chronic pain
Kavirajan HC, Lueck K, Chuang K (2014). "Alternating current cranial electrotherapy stimulation (CES) for depression". Cochrane Database
Syst Rev 7: CD010521

Magnetic Seizure Rx
o Proposed form of electrotherapy and electrical brain stimulation
o Currently being investigated for the treatment of treatment-resistant
depression, schizophrenia and obsessive-compulsive disorder
o Stated to work by inducing seizures via magnetic fields
o In contrast to ECT (direct electric shocks)
o In contrast to rTMS (higher stimulation rates, e.g. 100 Hz at 2 T, resulting in
more energy transfer)
"Magnetic Seizure Therapy (MST) for Treatment Resistant Depression, Schizophrenia, and Obsessive Compulsive
Disorder"U.S. National Institutes of Health. 10 May 2013

VNS
o Medical treatment
o Delivering electrical impulses to the vagus nerve
o Adjunctive treatment for certain intractable epilepsies and treatment-resistant
depression
o Little understood about exact mechanisms for mood modulation and seizure
control
o Proposed mechanisms:
o Alteration of nor-epinephrine release at locus coeruleus
o Elevated GABA levels
o Inhibition of cortical activity at Reticular Activation System
Ghanem, T; Early, S (2006). "Vagal nerve stimulator implantation: An otolaryngologist‘s perspective".Otolaryngology - Head
and Neck Surgery 135 (1): 46–51

Cortical Implants
o Novel neurosurgical approach
o Electrodes are implanted over the surface of the cortex to provide electrical
brain stimulation in a targeted superficial region
o Being studied for treatment of conditions like stroke, tinnitus, and treatment-
resistant depression

Neurosurgery
o First formal report of neurosurgical treatment in psychiatry published in 1891
o Mixed results in bilateral cortical excisions in demented and depressed patients
o John Fulton and Charles Jacobsen (1935):
o Research on primate behavior following frontal cortical ablation
o Lobectomized chimpanzees showed reduction in "experimental neurosis"
o Were less fearful, while retaining an ability to perform complex tasks
o Egaz Moniz (Portuguese neurologist) pioneered prefrontal leukotomy in
collaboration with Almeida Lima
o Use of absolute alcohol injections and/ or leukotome
o Performed "psychosurgery" on 20 severely ill institutionalized patients
o Of them 14 exhibited worthwhile improvement

Neurosurgery
o Psychosurgery targets the limbic system:
o Aamygdala, hippocampus, certain thalamic and hypothalamic nuclei,
prefrontal & orbitofrontal cortex and cingulate gyrus
o Role in the regulation of emotions
o Anterior cingulotomy:
o Most commonly used psychosurgical procedure
o Target site the anterior cingulate cortex
o Surgery disconnects the thalamic and posterior frontal regions

Neurosurgery
o Anterior capsulotomy:
o Developed in Sweden
o Disconnect the orbitofrontal cortex and thalamic nuclei
o Subcaudate tractotomy:
o Targets the lower medial quadrant of the frontal lobes
o Severs connections between the limbic system and supra-orbital part of the
frontal lobe

Neurosurgery
o Limbic leucotomy: combination of subcaudate tractotomy and anterior
cingulotomy
o Amygdalotomy:
o Targets the amygdala
o Developed as a treatment for aggression
o Success rates for anterior capsulotomy, anterior cingulotomy, subcaudate
tractotomy and limbic leucotomy in treating depression and OCD have been
reported as between 25 and 70%
Mashour, G.A.; Walker, E.E.; Martuza, R.L. (2005). "Psychosurgery: past, present and future". Brain Research Review 48 (3):
409–18

DBS
o Neurosurgical procedure introduced in 1987
o Implantation of a medical device called a neuro-stimulator ('brain pacemaker')
o Sends electrical impulses to specific parts of the brain (brain nucleus) through
implanted electrodes
o Used for treatment-resistant movement and affective disorders such as
Parkinson's disease, essential tremor, dystonia, chronic pain, major depression
and obsessive–compulsive disorder (OCD)
Kringelbach ML, Jenkinson N, Owen SLF, Aziz TZ (2007). "Translational principles of deep brain stimulation". Nature Reviews
Neuroscience 8 (8): 623–635

DBS
o Three components: the implanted pulse generator (IPG), the lead and the
extension
o IPG:
o Battery-powered neuro-stimulator encased in a titanium housing
o Sends electrical pulses that interfere with neural activity at the target site
o Lead:
o Coiled wire insulated in polyurethane with four platinum iridium electrodes
o Placed in one or two different nuclei of the brain

DBS
o Lead is connected to IPG by the Extension:
o An insulated wire that runs below the skin from the head, down the side of
the neck, behind the ear to the IPG (placed subcutaneously below the
clavicle or abdomen)
o Proposed target of DBS in depression – superolateral branch of the medial
forebrain bundle (slMFB) – rapid antidepressant effects in very treatment
resistant patients
Schlaepfer, TE; et al. (2013). "Rapid effects of deep brain stimulation for treatment-resistant major depression". Biological
Psychiatry 73 (12): 1204–12

Psychotherapies
To be covered in subsequent sessions…

References
…As mentioned on the slides

Non pharmacological Treatments in Psychiatry

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Non pharmacological Treatments in Psychiatry