“Modulating Positive Energy”: Approaches, Applications, and Complications in Neuromodulation for CL Psychiatrists

Abstract:

Neuromodulation, or the delivery of energy into the brain for therapeutic benefits, is one of ‎the most rapidly expanding and intensively studied areas of the clinical neurosciences. ‎Neuromodulation encompasses a broad spectrum of different techniques, from use of ‎implanted deep brain electrodes to hospital- and office-based ambulatory procedures to ‎wearable technologies that patients use at home. These techniques can offer significant ‎advantages over pharmacologic and behavioral therapies, including focal targeting of brain ‎circuits, avoidance of systemic side effects, and rapidity of improvement. However, there ‎are also associated liabilities such as complications of stimulation in non-therapeutic or ‎anti-therapeutic areas, wearing off of benefit over time, and ongoing debate around ‎optimal targets for given indications.

Consultation-liaison psychiatrists are increasingly a part of multidisciplinary teams ‎prescribing and managing neuromodulation therapies, and require specific knowledge and ‎skill sets to contribute in these areas. These therapies include invasive means such as ‎deep brain stimulation (DBS) and vagal nerve stimulation (VNS), and noninvasive methods ‎such as transcranial electrical stimulation (TES), transcranial magnetic stimulation (TMS), ‎and electroconvulsive therapy (ECT). More recently, implanted responsive ‎neurostimulation (RNS) has been introduced in the treatment of epilepsy and represents ‎the first use of a “closed loop” paradigm that detects and treats pathophysiologic events in ‎real time.

In this session, the audience will gain an understanding and appreciation for the ways CL ‎psychiatrists are involved in clinical neuromodulation, including pre-procedure ‎assessment for suitability, longitudinal treatment for procedure-related complications, ‎and prescription and delivery of neuromodulation. They will also learn about research in ‎innovative uses of neuromodulation to address neuropsychiatric disorders for which there ‎are few effective treatments. Participants will learn associated functional neuroanatomy, ‎differential diagnoses, therapeutic outcomes, and neuroimaging findings.

In the first half of the session focused on evaluation of suitability and management of ‎psychiatric complications in neuromodulation, Dr. Amit Chopra will review assessment ‎approaches for patients undergoing deep brain stimulation for Parkinson disease, with a ‎focus on the diagnosis and management of cognitive and behavioral sequelae related to ‎target selection, electrode effects, current spread, and disease progression of non-motor ‎symptoms (15 min). Next, Dr. Gregory Nikogosyan will present on the evaluation and ‎assessment of epilepsy patients undergoing responsive cortical stimulation, how this ‎closed-loop system functions to abort seizure activity, and potential complications ‎including current spread, forced normalization, and somatization.

In the second half of the session focused on psychiatric applications of neuromodulation, ‎Dr. James Rustad will present his research on the effectiveness of cranial electrical ‎stimulation using the FDA-approved Alpha-Stim® device for posttraumatic stress disorder ‎symptoms in U.S. Veterans. Next, Dr. Davin Quinn will present preliminary data on the use ‎of accelerated intermittent theta burst stimulation for cognitive sequelae from mild ‎traumatic brain injury (mTBI), including how diffusion magnetic resonance spectroscopy ‎has identified a possible mechanism of action related to thalamic microglial activation.‎