Methods

Electroconvulsive Therapy (ECT) is a medical treatment for severe mental disorders. The effectiveness of ECT depends on the properties of the electrical field applied and on the activity of the nerve cells during the generalized seizure triggered by the stimulation. It is applied under brief full anaesthesia. During the treatment, the brain is stimulated for a few seconds, with very short electrical impulses via electrodes on the scalp. The acute phase of the procedure is administered two to three times a week and then maintenance ECT can be offered on a case by case basis.

In general, ECT is used when several attempts at treatment with medications and accompanying psychotherapeutic approaches have not yielded sufficient improvement. ECT is effective in severe depressive, manic, psychotic and catatonic disorders. In the majority of patients, it may lead to a complete remission or to a significant improvement of the symptoms. Although it is mainly for patients with previous unfavourable courses of illness who are treated with ECT, a remission of the symptoms can be achieved in 50 to 90 % of cases, depending on the previous treatment. Patients and their relatives are informed if the treatment is expressly desired. As a rule, the onset of action is rapid.

Transcranial magnetic stimulation (TMS), is a recent targeted, relatively painless and well-tolerated treatment for various psychiatric disorders. Its effectiveness has been demonstrated in treatment-resistant depression and obsessive compulsive disorder (both FDA approved) and recommended by the Swiss Society of Psychiatry (evidence A level). TMS can also be used to treat auditory hallucinations and negative symptoms in schizophrenia. Increasingly, it is also used to treat drug addiction such as cocaine addiction as well as post-traumatic disorder based on a good efficacy and side effect profile.

Treatment with TMS can supplement the usual psychotherapeutic and pharmacotherapy or be used instead of these methods if psychotherapy and medications are not sufficient. TMS can regulate specific areas of the brain that are under or overactive and that are responsible for certain psychopathologies. An electric current flows through a coil that is held over specific brain areas that have been proven to be affected by the disorders to be treated. The electro-magnetic field caused by the current can modulate brain towards normalisation of its activity. The acute treatment is offered on a daily basis with different protocols to treat different disorders. TMS is very well tolerated with very minimal side effects. A critical issue in Switzerland at the moment is that rTMS treatment is still not reimbursed by health insurance companies, despite years of proven efficacy.

There are situations in which rTMS may not be used, for example, implanted intracranial electrodes, cochlear implants, acute heart disease or injury, pacemakers or defibrillators.

With transcranial direct current stimulation (tDCS), the activity of specific brain regions is stimulated or inhibited. For this purpose, a very weak current is generally applied between two electrodes that are placed on the surface of the head over the brain regions that are to be modulated. The current strength is comparable to the current of a battery, and the voltage is also low. In order to improve a psychiatric clinical picture with a certain sustainability, a tDCS treatment must be repeated several times, e.g. daily for two to four weeks. Moderate depression in particular can be improved with tDCS. This method can also be used for addictions, cognitive impairments or schizophrenia. The side effects are mostly minor (tingling and itching, local redness, headaches and non-specific discomfort) and not persistent, so that besides a favorable effect/side effect profile, it should be mentioned that the method is highly mobile, and easy to use. However, tDCS is also not yet reimbursed by health insurances in Switzerland. The method may not be used in some situations or used only after very careful consideration.

Besides electrical neurostimulation and modulation in psychiatry, which includes ECT as well as TMS, tDCS and other treatments, certain pharmacological interventions can also be categorized as interventional psychiatry. Well-known are short infusions with e.g. antidepressants, but also new pharmacological interventions such as the i.v. administration of the NMDA antagonist ketamine, primarily known as an anaesthetic, for the treatment of depression or, more recently, the application of esketamine as a nasal spray. Although the use of ketamine as a nasal spray has considerably simplified its application, the prescription and use of nasal ketamine still requires a special setting with the necessary expertise among the psychiatrists using it due to the special indication and possible acute side effects after administration. Thus, it is also subject to controlled dispensing and is only intended for use under the direct supervision of a physician.

Mechanisms of action are not yet fully understood. Presumably, ketamine blocks GABA neurons via NMDA receptors, which subsequently leads to increased glutamate release, which in turn contributes to increased AMPA receptor simulation of the downstream neuron. This may lead to increased BDNF release with subsequent increases in the number, function and strength of synapses. It is also possible that ketamine has an effect on the dopaminergic reward centre. In addition, esketamine also interacts with opioid receptors as a weak agonist and thus has an analgesic effect.

Besides current publications recommending the use of ketamine from a clinical-scientific point of view, there are also recommendations to the contrary.

Most of the methods listed here are currently university research and offered in a very limited number of highly specialized medical practices. The list is not exhaustive since it is a growing field in novel psychiatric treatments.

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