What Is Interventional Psychiatry?

If you or someone close to you struggles with a mental health condition that hasn’t responded to traditional treatment methods, there may be another option: interventional psychiatry.

Interventional psychiatry involves using rapid-acting medications and neuromodulatory techniques, which can improve mental illness symptoms.

You may already be familiar with some of the treatment approaches of this psychiatric subspecialty, which include electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), ketamine infusions, esketamine nasal spray, deep brain stimulation (DBS), and vagus nerve stimulation (VNS).

At Yale Psychiatric Hospital’s Interventional Psychiatry Service (IPS), psychiatrists deliver interventional treatments to address major depressive disorder (MDD), obsessive-compulsive disorder (OCD), bipolar disorder, catatonia, and chronic psychotic disorders, such as schizophrenia and schizoaffective disorder, that haven’t been helped by existing treatments, including medication and psychotherapy.

“There is a real need for interventional psychiatry because we know the impact depression and other mental health conditions can have on quality of life and functioning, including the ability to attend school and hold a job,” says Rachel Katz, MD, a Yale Medicine psychiatrist. “Our interventional treatments are highly effective, even in the most difficult cases.”

Below, we talk with Dr. Katz about interventional psychiatry and how some of the treatments work.

Treatments for certain mental health conditions, such as depression, may involve antidepressant medications, psychotherapy (sometimes called “talk” therapy)—or both. Often, medication is from a class of drugs called selective serotonin reuptake inhibitors (SSRIs), which includes fluoxetine, sold under the brand name Prozac®.

“If people don’t respond to two medications of different classes with or without therapy, they may meet the criteria for the diagnosis of treatment-resistant depression, at which time interventional psychiatry treatments may be appropriate,” Dr. Katz says.

There are a few reasons, one of which is called "mechanism of action." Interventional psychiatry treatments have evolved alongside new thinking on the neurobiology of depression and other mental health disorders. SSRIs, for example, primarily target levels of serotonin and norepinephrine—neurotransmitters that play important roles in mood regulation.

But some interventional techniques act on different pathways. Ketamine, an anesthetic that has some psychoactive properties, is thought to affect the glutamatergic pathways.

Interventional techniques are also often fast-acting. Ketamine and ECT can provide relief within hours to days, unlike many antidepressants, which may take four to six weeks to show noticeable changes in depressive symptoms. “This is particularly beneficial for patients who need urgent relief from severe depression or who experience suicidal thinking,” says Dr. Katz.

What’s more, interventional treatments can induce changes in synaptic plasticity, potentially leading to longer-lasting improvements in depressive symptoms. “They essentially help ‘reset’ neural circuits that are dysfunctional in depression,” she adds.

Currently, Yale IPS offers the following treatments:

• ECT: Patients receive general anesthesia, and an electrical current is delivered to the brain via electrodes to induce a brief seizure. It is indicated for the treatment of severe depression, bipolar disorder, catatonia, and chronic psychotic disorders.
• TMS: Patients are awake for this noninvasive neuromodulatory technique, which involves sending pulsatile magnetic fields to the brain via an electrical coil placed on the scalp. It is indicated for the treatment of several conditions, including MDD and OCD.
• Ketamine infusions: This anesthetic drug, which has psychoactive properties, is delivered intravenously and can relieve depressive symptoms within hours. It is not FDA-approved for any mental health condition but is often used off-label to treat depression.
• Esketamine insufflation: This derivative of ketamine is also fast-acting, and is delivered via nasal spray to patients in treatment sessions overseen by a medical provider. It is indicated for the treatment of treatment-resistant depression and MDD with suicidal thoughts or actions. It is sold under the brand name Spravato®.

There are several other types of interventional psychiatry techniques, though they aren’t currently offered through Yale IPS. These include:

• Deep brain stimulation (DBS): Electrodes are implanted in the brain to deliver low-level electrical pulses that help change brain activity and improve communication between the parts of the brain involved in mood. It is indicated for treating Parkinson’s disease, though it is used off-label for depression.
• Vagus nerve stimulation (VNS): A small battery-operated device is implanted under the skin in the chest and connects to the vagus nerve in the neck. The vagus nerve regulates many key functions in the body, including mood and sensation. Sending electrical pulses to the nerve can calm abnormal activity in the brain. This can help improve mood and pain levels, as well as help with conditions such as epilepsy. VNS is indicated for treating depression and epilepsy and for use as a rehabilitation tool after a stroke.

Several different medications, including psychedelic drugs, such as MDMA and psilocybin, are being studied as treatments for PTSD and depression. The FDA last summer rejected MDMA as a treatment for PTSD, but research is ongoing.

Yes. With SSRIs, common side effects include nausea, insomnia, dizziness, weight gain, dry mouth, and sometimes increased anxiety or agitation, especially at the beginning of treatment.

But the side effects from interventional psychiatry techniques can vary by method.

• ECT side effects can include short-term memory loss, confusion, and disorientation immediately after treatment. These cognitive side effects are usually temporary.
• TMS is generally well-tolerated, but side effects can include headache, scalp discomfort at the site of stimulation, and, very rarely, seizures.
• Ketamine infusions and esketamine nasal spray can cause disorientation, dizziness, increased blood pressure or heart rate, nausea, and temporary perceptual disturbances. These effects are typically short-lived.
• DBS can cause cognitive changes, speech difficulties, balance problems, tingling sensations, and, rarely, seizures.
• VNS can cause voice changes and throat pain, as well as breathing difficulties during physical exertion.

“Each treatment has its own risk-benefit profile, and the choice of therapy often depends on individual patient circumstances, including the severity of the mental health condition, previous treatment responses, and the presence of any co-occurring medical conditions,” says Dr. Katz. “We work with each patient to determine which treatment is right for them.”

Technically, any psychiatrist can offer these interventional techniques because there isn’t an accredited training program at the national level or a board certification for the subspecialty, but it’s safer to seek care from someone with extensive experience with this type of treatment.

Some medical schools around the country now offer psychiatric chief resident positions that specialize in the field, as well as one-year interventional psychiatry fellowships. (Yale School of Medicine offers both.)

During interventional psychiatry training, physicians develop expertise in delivering these treatments and assessing the patients they treat.

Dr. Katz says she advises people to seek care from clinics with expertise and experience delivering these treatments. “At IPS, we prioritize safe, effective, and evidence-based care,” she says.

Dr. Katz says she is excited by the promise of using neuroimaging techniques to refine neuromodulatory approaches through improved targeting accuracy, for example. This might entail using different types of magnetic resonance imaging (MRI) scans to locate specific regions of the brain when using TMS.

“We are hoping for improved efficacy and sustainability of the treatments, meaning that patients can have either complete or longer relief from symptoms with fewer treatment sessions,” Dr. Katz says. “We can also possibly achieve this by combining certain forms of psychotherapy, such as cognitive behavioral therapy [CBT], with these IPS techniques.”