Interventional psychiatry treatments offer hope

If you or a loved one has faced depression or anxiety - like nearly 40 percent of Americans-- the first steps in treatment are usually counseling and prescription medications. Many people improve with these traditional methods. However, when symptoms don't get better, there are other effective options to try in a specialized field called interventional psychiatry. Techniques like transcranial magnetic stimulation (TMS) and ketamine therapies are bringing hope to people with more stubborn depression. We're taking a look at these interventional tools that work by directly stimulating the brain. Before delving into these treatment options, let's first review the symptoms of depression.

Symptoms of depression

How do you know if you or someone you care about is dealing with depression or if it may be some other health condition? According to the National Institute of Mental Health, these are some of the most common signs of depression:

• Persistent sad, anxious, or "empty" mood
• Feelings of hopelessness or pessimism
• Feelings of irritability, frustration, or restlessness
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities
• Decreased energy, fatigue, or feeling slowed down
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, waking early in the morning, or oversleeping
• Changes in appetite or unplanned weight changes
• Physical aches or pains, headaches, cramps, or digestive problems that do not have a clear physical cause and do not go away with treatment
• Thoughts of death or suicide or suicide attempts

"If you have some of these symptoms almost every day for at least two weeks, it's a good idea to reach out to your doctor for help," said Leopoldo M. Vocalan, Jr., MD, a board certified psychiatrist with LG Health Physicians Behavioral Health and chair of Psychiatry and Behavioral Health at Penn Medicine Lancaster General Health. "They may recommend you meet with a counselor or therapist or prescribe an antidepressant medication. If these treatments are not successful, interventional psychiatry can be a next step."

What is interventional psychiatry?

For people with major depression that is harder to treat, there are interventional psychiatry tools, including transcranial magnetic stimulation (TMS) and ketamine therapies, which are shown to be safe and effective.

"These approaches aim to fix brain circuits that aren't functioning correctly by stimulating nerve cells," explained Dr. Vocalan.

What is transcranial magnetic stimulation (TMS)?

TMS is a non-invasive, drug-free, FDA-approved outpatient procedure performed right in a psychiatrist's office. It uses magnetic fields to stimulate nerve cells in the brain. Treatments usually take place five days a week for seven weeks. A physician referral is required for treatment. Here's how it works.

• You sit comfortably in a chair that looks similar to a dentist's chair, without any anesthesia, for about 20 minutes.
• A cushioned electromagnetic coil, similar to a small round dinner plate, is placed gently against the scalp.
• Magnetic pulses stimulate nerve cells in left prefrontal cortex - the area of the brain associated with depression and mood control and one that can be underactive in people with depression. This often feels like a tapping, tingling, or warming sensation where the coil is positioned.
• You go back to your regular activities right away.

"Some people may have temporary scalp pain or discomfort that usually stops after the first week of treatment," said Dr. Vocalan. "Although the results aren't permanent, most patients feel better for a year or more. At that time, after discussion with their doctors, some patients may opt to have further treatment."

What is ketamine?

Ketamine is drug that has used for anesthesia since the 1970s. It is referred to as a "dissociative anesthetic" because it causes people to feel detached from their pain and their environment. Over the years, studies showed that ketamine could also be an effective treatment for people with severe depression and other mood disorders.

"Ketamine can be given two ways, either as a nasal spray or as an intravenous infusion" explained Dr. Vocalan. "At Penn Medicine Lancaster General Health, we currently offer the intranasal esketamine therapy."

Like TMS, esketamine is only available with a referral from a physician. Because it can distort a person's perception for a few hours, it is given in an outpatient setting under a doctor's care. Here's how it works:

• You sit comfortably in a treatment room on a recliner.
• A nurse provides you with the appropriate dose of esketamine that you self-administer by nasal spray.
• You are monitored at the office for about two hours.
• Because of the sedation, another person drives you home.

Treatment lasts for a specified period of weeks or months. "Most people's treatment course starts at twice a week for four weeks, then once a week for four weeks," said Dr. Vocalan. "Following these first eight weeks, the interventional psychiatrist will assess your responsiveness to the treatment and determine if a maintenance schedule is needed."

Who is eligible for interventional psychiatry treatments?

"TMS and esketamine have different criteria for treatment, but typically include symptoms, age, willingness and ability to commit to treatment, and not having had successful results with a psychiatric medication," said Dr. Vocalan. "This means you might not have tolerated a medication due to its side effects or it did not help to reduce your symptoms."

Some insurances also require that patients' symptoms were not reduced through therapy or counseling. Depending on which service is recommended, you may need to have an additional consultation, medical screening, and authorization from your insurance company before starting treatment.

Depression is a very treatable condition. If standard, first-line therapies like counseling and medications aren't effective for you, know that there are other options. TMS and intranasal esketamine therapy, available through the Interventional Psychiatry Program at Penn Medicine Lancaster General Health, are offering hope to many patients. Please call 717-544-5443 if you have any questions.

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