Description
Treatment-resistant depression can occur in 30-50% of patients, and after medication trials and psychotherapy have been exhausted, patients will frequently ask about non-pharmacologic treatments. The three most commonly used non-pharmacologic treatments for depression are repetitive transcranial magnetic stimulation (rTMS), ketamine/esketamine, and electroconvulsive therapy (ECT). This session will review the basics of each of these “interventional psychiatry” treatments, focusing on what residents, fellows, and medical students need to know.
Dr. Kung will review the origins of rTMS and the neurobiological rationale for it use. Disruption of the brain network connections between the dorsolateral prefrontal cortext (DLPFC) and the subgenual cingulate cortex (sCC) is thought to improve depression. Each treatment is 3.5 minutes with the newer intermittent theta burst stimulation (iTBS) protocol, or 20 minutes with the traditional protocol. The course of treatment is 6 weeks, with a response rate of about 60%. Advantages of rTMS include no anesthesia or memory loss, and no restrictions on driving. The only side effect is scalp pain during the simulations. At 6 months after successful rTMS, the relapse rate is about 50%. Medications are still continued after rTMS. rTMS has also been FDA-approved for obsessive compulsive disorder (OCD).
Dr. Singh will review the purported mechanism of action of ketamine/esketamine and NMDA receptor antagonism. While IV ketamine is not FDA-approved for depression but is commonly used for that purpose, intranasal (IN) esketamine is FDA-approved for unipolar treatment-resistant depression. An acute course (3-6 over 2-3 weeks for IV ketamine, 8 over 4 weeks for IN esketamine) results in approximately 60-70% response rate. Side effects include mild dissociation symptoms during the treatment. The relapse rate is high, so maintenance treatments will usually be needed every few weeks. Practical issues such as cost and availability will be reviewed, as well as the unanswered question of how long maintenance treatments should continue, especially with less knowledge about the addictive potential of a long course of ketamine.
Dr. Petrides will review the history of ECT, which is still considered the “gold standard” of severe depression. While there are significant side effects such as memory loss and cognitive impairment, ECT can be life-saving in the appropriate patient. A standard course of ECT varies between 6-12 treatments, and the right unilateral ultrabrief technique offers less cognitive impairment than the traditional bitemporal technique. Medications or maintenance ECT may be needed to prevent relapse. Recent studies comparing ECT and ketamine will be reviewed.
The panel discussion at the end will synthesize the pros and cons of rTMS, ketamine, and ECT. Case examples will be used to facilitate further discussion about when to use each of these treatments.
Format
Recorded webinar.
This content was recorded during the APA 2024 Annual Meeting.
Learning Objectives
- Describe the neurobiological rationale for repetitive transcranial magnetic stimulation (rTMS) and its use in psychiatric conditions.
- Describe the neurobiological rationale of how ketamine or esketamine can help with depression, and the current uses.
- Describe the use of electroconvulsive therapy (ECT) in psychiatric conditions.
- Discuss a comparison of the pros and cons of each of these treatments and when to use each.
Target Audience
Residents/Fellows, Psychiatrists, Psychologists
Estimate Time to Complete
Estimated Duration: 1.5 hours
Program Start Date: May 17, 2025
Program End Date: May 17, 2028
How to Earn Credit
Participants who wish to earn AMA PRA Category 1 Credit™ may do so after completing all sections of the course including the evaluation. After evaluating the program, course participants will be provided with an opportunity to claim hours of participation and print an official CME certificate (physicians) or certificate of participation (non-physicians) showing the completion date and hours earned.
Continuing Education Credit
In support of improving patient care, the American Psychiatric Association is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
The APA designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Faculty and Planner Disclosures
The American Psychiatric Association adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Medical Education. Any individuals in a position to control the content of a CME activity — including faculty, planners, reviewers or others — are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.
Instructors
- Simon Kung, MD
- Balwinder Singh, MD. Reports financial relationships with Mayo Clinic
- Georgios Petrides, MD
Planners
- Vishal Madaan, MD, Chief of Education and Deputy Medical Director at the American Psychiatric Association.
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