Interventional Psychiatry and Neurotechnologies: Education and Ethics Training.

The last two decades have seen dramatic growth in the application of procedurally based interventions for treating refractory psychiatric conditions, leading to interest in developing the foundations for the subspecialty of "Interventional Psychiatry." However, there is cause for concern that the rate of expansion of clinical advances in this field may be outpacing the ability of postgraduate curricula to provide sufficient exposure to and teaching and supervision of these treatments. The paucity of adequately trained practitioners in Interventional Psychiatry further exacerbates inequities in the ability of eligible patients to access and benefit from these approaches. This paper explores the rates of utilization of Interventional Psychiatry treatments, the current state of education in these treatments, and the role that training can play in translating scientific advances in this area to ensure equitable access and maximum impact at a population level. The majority of the discussion is centered on electroconvulsive therapy (ECT), the most established and available of these treatments, highlighting how enhancing education and training in ECT can reduce barriers to its utilization. It is argued that innovations in pedagogical approaches for disseminating the learning of these procedures are needed to increase the current low rates of competency in these treatments and can facilitate the more rapid dissemination of other Interventional Psychiatry approaches and neurotechnologies, such as repetitive transcranial magnetic stimulation, ketamine, deep brain stimulation, and focused ultrasound.

Competencies for Repetitive Transcranial Magnetic Stimulation in Postgraduate Medical Education: Expert Consensus Using a Modified Delphi Process.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is recommended in Canadian guidelines as a first-line treatment for major depressive disorder. With the shift towards competency-based medical education, it remains unclear how to determine when a resident is considered competent in applying knowledge of rTMS to patient care. Given inconsistencies between postgraduate training programmes with regards to training requirements, defining competencies will improve the standard of care in rTMS delivery. OBJECTIVE: The goal of this study was to develop competencies for rTMS that can be implemented into a competency-based training curriculum in postgraduate training programmes. METHODS: A working group drafted competencies for postgraduate psychiatry trainees. Fourteen rTMS experts from across Canada were invited to participate in the modified Delphi process. RESULTS: Ten experts participated in all three rounds of the modified Delphi process. A total of 20 items reached a consensus. There was improvement in the Cronbach's alpha over the rounds of modified Delphi process (Cronbach's alpha increased from 0.554 to 0.824) suggesting improvement in internal consistency. The intraclass correlation coefficient (ICC) increased from 0.543 to 0.805 suggesting improved interrater agreement. CONCLUSIONS: This modified Delphi process resulted in expert consensus on competencies to be acquired during postgraduate medical education programmes where a learner is training to become competent as a consultant and/or practitioner in rTMS treatment. This is a field that still requires development, and it is expected that as more evidence emerges the competencies will be further refined. These results will help the development of other curricula in interventional psychiatry.

Electroconvulsive Therapy for Neuropsychiatric Symptoms due to Major Neurocognitive Disorder: A Prospective, Observational Study.

OBJECTIVES: Neuropsychiatric symptoms (NPSs) in those with major neurocognitive disorder (MNCD) include the responsive behaviors of agitation and aggression. Electroconvulsive therapy (ECT) has shown some effectiveness based on retrospective studies and one open label prospective study. We hypothesized that ECT will reduce NPSs between baseline and after treatment in those with medication-refractory behaviors. METHOD/DESIGN: This Canadian prospective multicenter study included MNCD patients admitted to geriatric psychiatry units for the management of refractory NPSs. All treatment-refractory participants suffered from advanced MNCD. We conducted the Neuropsychiatric Inventory-Clinician version and the Pittsburgh Agitation Scale at baseline, and during and after the ECT course. A bitemporal or bifrontal ECT series based on dose titration to 1.5 to 2.5 times seizure threshold was administered. RESULTS: Data were collected for 33 patients with a mean age of 73 and categorized with severe MNCD using the Functional Assessment Staging of Alzheimer's Disease scale (stages 6 and 7). The data showed a drop in mean Neuropsychiatric Inventory-Clinician version from 58.36 to 24.58 (P < 0.0001). Mean Neuropsychiatric Inventory agitation subscale dropped from 7.12 to 3.09 (P = 0.007). Mean Neuropsychiatric Inventory aggression subscale dropped from 6.94 to 0.97 (P < 0.0001). There was a concomitant significant decline in Pittsburgh Agitation Scale scores. No participants dropped out because of intolerance of ECT. One participant died from pneumonia, which did not appear related to ECT. CONCLUSIONS: In this naturalistic study, ECT was found to be a safe and effective treatment for certain NPSs in people with MNCD. This can translate into improving quality of life.

Impact of brief education on healthy seniors' attitudes and healthcare choices about Alzheimer's disease and associated symptoms.

ABSTRACTObjective:The primary objective of this study was to determine whether a brief education session about Alzheimer's disease (AD) stages and associated behavioral and psychological symptoms of dementia (BPSD) changes healthy seniors' treatment choices. A secondary objective was to determine whether pharmacotherapy to reduce BPSD would be preferred over other potentially more restrictive interventions. METHODS: Participants (n = 32; 8 men; aged > 64years; no self-reported dementia diagnosis) were assigned to one of ten group sessions during which they received information about AD and BPSD. Our a-priori hypotheses were: (1) education about AD stages significantly changes care preferences in moderate and severe stages, i.e. less active treatment options (no CPR/hospitalization) are chosen as the disease progresses; and (2) most participants prefer pharmacotherapy over restraints and seclusion to manage BPSD. The main outcome measure was a change in the interventions chosen including CPR and hospitalization. Participants completed three questionnaires and two decisional grids before and after the information session. Qualitative data were derived from discussions during the session. RESULTS: Participants expressed a wide range of attitudes about AD, BPSD, and their management. Those who are born in Canada, had a proxy, and a university education, each have around half of the odds of receiving treatment compared to those in the complementary group. (OR 0.47, 0.40, 0.43) Finally, not knowing someone with AD increases the odds of wanting a treatment by around six times (OR 6.4). Pharmacological measures were preferred over restraints. CONCLUSIONS: Education about dementia and advance directives should consider the person's educational background and experience with dementia. Discussing BPSD may impact a person's advance directives and preferences.

Efficacy and safety of maintenance electroconvulsive therapy for sustaining resolution of severe aggression in a major neurocognitive disorder.

We report a novel electroconvulsive therapy (ECT) regimen for sustaining the resolution of behavioural and psychological symptoms of dementia (BPSD) using alternating acute and maintenance ECT (M-ECT) trials. A 64-year-old man presenting with major neurocognitive disorder was admitted for acute behavioural disturbances and physical aggression. With few treatment options, the impact on patients' quality of life often supersedes cognitive symptoms and is a predictor of long-term institutionalisation. Recent studies indicate that ECT may be an effective and safe way to address BPSD. Clinicians have little information about when and how to stop a successful course of acute ECT or the long-term advantages of M-ECT with subsequent intermittent acute ECT. This case emphasises the benefit of M-ECT and describes potential challenges associated with abrupt discontinuation. This case is the first to detail tapering ECT for treatment of aggression in dementia by interchanging acute and M-ECT courses in response to symptom burden.