English | SGIP-SSPI

ECT is a modern medical treatment method for severe mental disorders. The effectiveness of ECT depends on the properties of the electric field and the activity of the nerve cells during the seizure triggered by the stimulation. During a brief anesthetic, the brain is stimulated for a few seconds with very short electrical pulses via electrodes on the scalp. Similar to a generalized seizure, the brain independently returns to its original functional state in less than two minutes. The procedure is used several times at intervals of days.

In general, ECT is used when several attempts at therapy with medication and accompanying psychotherapeutic treatment have not led to sufficient improvement. ECT is effective in depressive, manic, psychotic and catatonic disorders. It leads to a complete regression or at least a significant improvement of the symptoms in the majority of patients. Although it is mainly patients with previously unfavorable courses of illness who are treated with ECT, a regression of the symptoms can be achieved in 50 to 90% of cases, depending on the previous treatment. Patients and their relatives are informed and the treatment is expressly desired As a rule, the onset of action is rapid.

Transcranial magnetic stimulation, abbreviated TMS, is a targeted and well-tolerated therapy for various psychiatric disorders. The most common treatment is depression, but it can also be used in schizophrenia to treat voice hearing or negative symptoms. Increasingly, it is also used in addiction treatment or obsessive-compulsive disorders due to a good efficacy and side effect profile.

Treatment with TMS can supplement the usual psychotherapeutic and drug treatments or be used instead of these methods when psychotherapy and medication are not sufficient. It has the specific effect of balancing brain activity that is out of balance. A current flows in a coil that is held over brain areas that have been proven to be affected by the disorders being treated. Through the magnetic field caused by the current, the brain can positively towards a balancing normalization of the brain activity. It is stimulated daily. There are now various protocols according to which treatment is carried out with high-frequency or low-frequency or pulsed stimulation. In the meantime, one even goes over to stimulate several times a day in order to see a treatment success faster - while maintaining a good tolerance. Critical at present in Switzerland 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 or only after very careful examination. These are e.g. implanted intracranial electrodes, cochlear implants, acute heart disease or injury, pacemaker or defibrillator.

tDCS is the abbreviation for transcranial direct current stimulation. In tDCS, the activity of individual brain regions is stimulated or inhibited. In general, a very weak current is applied between two electrodes placed on the surface of the head over the brain regions that are to be influenced. The current strength is comparable to the current of a battery, and the voltage is also low. Directly noticeable effects occur within a few minutes, but in order to influence a psychiatric clinical picture with a certain sustainability, a tDCS treatment must be repeated several times, e.g. daily during two to four weeks. As with rTMS, depression in particular can be improved. But this method can also be used for addictions, cognitive impairment or schizophrenia. The side effects (tingling and itching, local redness, headache and non-specific discomfort) are minor and not persistent, so that in addition to a favorable effect-side effect profile with the method, it should be mentioned that it is basically highly mobile, easy to use and inexpensive. However, tDCS is even less supported by health insurance than rTMS.

As with rTMS, the method may not be used in make situation or only after very careful consideration.

In addition to electrical neurostimulation and modulation in psychiatry, which includes ECT as well as TMS, DBS and tDCS and other treatments, pharmacological interventions can also be counted as part of interventional psychiatry. Well-known are short infusions with e.g. antidepressants but also new pharmacological interventions like the i.v. administration of the NMDA antagonist ketamine, which is primarily known as an anesthetic, for the treatment of depression or more recently the application of esketamine as a nasal spray. The use of ketamine as a nasal spray has significantly simplified the application as such, but the prescription and application of nasal ketamine still requires a special environment with the necessary expertise among the applying psychiatrists due to the special indication and possible acute side effects after administration. Thus, it is also subject to controlled dispensing and is intended only 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 center. In addition, esketamine also interacts with opioid receptors as a weak agonist and thus has analgesic effects.

In addition to current publication recommending its use and from a clinical-scientific point of view based on their experience, there are also recommendations to the contrary.

Most of the methods listed here are currently only used in the scientific laboratories of universities. The list is not complete, not least because of the immense growth in this field. For many methods, the abbreviations derived from the English names have also become established.

Overview further Methodes

Interventional methods in psychiatry are currently not a substitute for standard therapies such as psychotherapy and psychopharmacolgy. They are considered alternatives or augmentation.

They are used in case of

- therapy resistance to standard methods (medication, PT, ..)

- when the standard methods cannot be applied (strong side effects, pregnancy, ..)

- at the request of the patient

- or as the first choice for certain diseases.

At the beginning, there is a treatment plan that you create together with your psychiatrist.

Your psychiatrist should give you information about effectiveness and risks. He should inform you about the onset of the effect / the duration of the effect. It is possible that the effects are delayed and will disappear after some time, even if the treatment is successful.

It is very important not to change the medication before or directly after the cure by electrical interventional methods. It is likely that you will have to take medications even despite the use of interventional methods. But the goal is of course to improve your disease symptoms with all methods together.

Medication may need to be taken to get the benefit - but, you will be in better condition than before!

If you are promised that you "no longer need medication," your psychiatrist may not be reputable.

The use of interventional methods must be part of an overall treatment plan for your psychiatric condition that you discuss with your psychiatrist.

The period of acute treatment

10 - 20 days (or longer)

Daily sessions (at least one session per day, tendency is towards more sessions per day).

Each session about 15 - 45 min (tends to be short with newer protocols)

The individual session

First, a conversation with the doctor or assistant performing the treatment.

Estimation of resting motor threshold is made and the exact location of stimulation is measured and marked on your head.

Since the device makes noise, you will be given earplugs.

Every now and then, your symptoms will be measured by a test, so that you and your practitioners can see what progress you are making.

Clinics

German-speaking Switzerland:

• Psychiatrische Universitätsklinik Zürich*: ECT and rTMS