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 rTMS, is an evidence-based well-tolerated targeted brain stimulation treatment that is offered on a daily manner for up to 6 weeks (depending on the response) for various psychiatric disorders. The most common treatment is for resistant depression, but it can also be used in schizophrenia to treat the auditory hallucinations and negative symptoms. Increasingly, due to a good efficacy and low side effect profile, it is also used in Post Traumatic Stress disorder (PTSD), addiction treatment (like for Cocaine addiction) or obsessive-compulsive disorder depending on the zone of the brain treated and the parameters used.

Treatment with rTMS can supplement the usual psychotherapeutic and pharmacological treatments or be used instead of these methods when psychotherapy and medication are not sufficient or tolerated. It has the specific effect of regulating brain activity. An electric current flow in a coil that is held over the head to stimulate specific areas of the brain that have been proven to be affected by the disorders being treated. Through the magnetic field caused by the current this can positively lead to a normalization of the brain activity.

There are various protocols according to which the treatment can be carried out with high-frequency, low-frequency or pulsed stimulation called Theta-burst stimulation (TBS). There are also accelerated protocols called a-TMS in which more than one treatment is offered in one day with the intention of having treatment response in shorter days while maintaining a good tolerance.

Careful examination should be performed by a psychiatrist specialized in rTMS to see if the treatment is indicated and appropriate for the patient. There are situations in which rTMS may not or should not be used (contra-indications). These are e.g. implanted intracranial electrodes, cochlear implants, acute heart disease or injury, pacemaker or defibrillator (that are not compatible with an MRI devices).

At present in Switzerland rTMS treatment is still not reimbursed by health insurance companies, despite years of proven efficacy.

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.

A psychiatrist specialized in interventional methods evaluates you at the beginning, and together with you elaborates a treatment plan.

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

It is very important to discuss all the medications that you are taking and not to change the medication before or directly after the treatment by electrical interventional methods if advised by the specialist psychiatrist or inform her/him of any changes immediately (since certain medications may have an effect on the treatment or your motor threshold). 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 combined together.

In most cases, medications may need to be taken or continued to get the optimal benefits of all the treatments together- but you will hopefully (or potentially) be in better condition than before!

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

The period of acute treatment

It depends on the interventional method, for rTMS, it may be 20 – 30 days (or longer)

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

Duration of each session depends on the protocol of treatment chosen. Generally, each session is about 45 min.

The individual session

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

During the first session, your doctor will determine your resting motor threshold and the exact location of stimulation will be measured and marked on your head.

Since the rTMS device makes a clicking noise, you will be given the option of wearing earplugs.

Your symptoms will be measured on a regular basis by a questionnaire, so that you and your practitioners can see the progress you are making.

Clinics

German-speaking Switzerland:

• Psychiatrische Universitätsklinik Zürich*: ECT and rTMS

• Psychiatrische Dienste Aargau (PDAG)*: ECT and rTMS

• Psychiatrische Universitätsklinik Bern: ECT and rTMS

• Sanatorium Kilchberg: ECT

• Privatklinik Meiringen: ECT and rTMS

• Monthey - Hôpital psychiatrique: ECT

• Universitätsklinik für Psychiatrie und Psychotherapie Basel: ECT

French-speaking Switzerland:

• CHUV Lausanne, Département de psychiatrie*: ECT and rTMS

Practices:

German-speaking Switzerland

NeuroStim.CH in Zürich*: rTMS und tDCS

NeuroPsychiatrie.CH in Wallisellen*: rTMS und tDCS

French-speaking Switzerland

Dr. med. Fady Rachid in Genf: rTMS

Centre de Psychiatrie interventionelle de Lausanne: ECT and rTMS

Accueil - Le Square: rTMS

* recognized continuing education centers

Overview of centers:

Centers in Switzerland