Podcast: Interventional Psychiatry and the Challenge of Difficult-to-Treat Depression

Joseph F. Goldberg, MD, spoke with Lisa Harding, MD, of Yale School of Medicine, about interventional psychiatry in this episode of “Brain Trust: Conversations in Psychopharmacology.” The episode was recorded at the regional psychiatry conference, Jersey City Psychiatry Conference.

Harding called the term a misnomer and described the field as the procedural side of psychiatry, which has no separate ACGME accreditation. Residents can graduate without administering electroconvulsive therapy (ECT), mapping a patient for transcranial magnetic stimulation (TMS), or giving intravenous ketamine, she said. She added that the label wrongly implies these treatments belong at the end of the line, when they act through different mechanisms and few studies show where they belong in treatment sequencing.

ECT and Ketamine

Many centers start with up to 6 right unilateral ECT treatments, given 3 times a week for 2 weeks, and switch to bilateral placement if there is no response, Harding said. Patients who are severely ill or catatonic may start with bilateral treatment. Reported response rates range from 50% to 90% and vary with indication and severity. Goldberg encouraged clinicians to request prior ECT records, including lead placement, number of treatments, and seizure duration, just as they would review a prior medication trial.

For a severely ill patient who needs help urgently, the practical choice is ECT or ketamine. Goldberg pointed to a New England Journal of Medicine trial that found intravenous ketamine noninferior to ECT. Harding said patient preference should guide the decision. For herself, however, she would choose ECT, which she believes is more effective in the short term for sicker patients.

Durability

Both returned repeatedly to “landing the plane,” meaning what to do after an acute response. Harding estimated 80% to 90% of these patients continue to have depression, and little evidence guides maintenance or booster treatment. Esketamine is the exception: SUSTAIN-3 open-label data spanning about 6 years showed no new safety signals.

Goldberg cited an early response rate of about 85% for the Stanford accelerated theta burst TMS protocol, which delivers 10 fMRI-guided sessions daily for 5 days. Harding said one patient was quoted $30,000 out of pocket for it, and its durability is unknown. Vagus nerve stimulation (VNS) faces 2 hurdles, she said: invasiveness and a wait of months before benefit appears.

Harding also cautioned against stacking interventions without a clear target. “You can park the ketamine truck up outside your house. It’s not going to fix your job,” she said she tells patients.

Future Directions

Asked whether neuromodulation is the future of mood disorder treatment, as David Dunner, MD, once predicted, Harding said artificial intelligence will matter more. In her view, AI will help clinicians make better diagnoses and match patients to the treatments that already exist.

Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology.

Dr Harding is a psychiatrist and on the faculty at Yale University School of Medicine.