Dmitry M. Arbuck, MD President and Medical Director Indiana Polyclinic Carmel, Indiana
Ali A. Farooqui, MD Integrative Psychiatry, PLLC Clinical Faculty Department of Psychiatry University of Louisville School of Medicine Louisville, Kentucky
Rif S. El-Mallakh, MD Professor and Director, Mood Disorders Research Program Department of Psychiatry and Behavioral Sciences University of Louisville School of Medicine Louisville, Kentucky
Disclosures Dr. Farooqui is a speaker for AbbVie and BioXcel. Dr. El-Mallakh is a speaker for Axsome, Idorsia, Intra-Cellular Therapies, Janssen, Lundbeck, Myriad, Noven, Otsuka, and Teva, and has received research support from Sunovion. Dr. El-Mallakh is Current Psychiatry’s Section Editor, Clinical Neuroscience. Dr. Arbuck reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers or competing products.
In addition to the forms of neuromodulation we have already described, there are many other techniques. Several are promising but not yet ready for clinical use. Table 1 and Table 2 summarize the neuromodulation techniques described in this article as well as several that are under development.
Acupuncture
Acupuncture is a Chinese form of medical treatment that began >3,000 years ago; there are written descriptions of it from >2,000 years ago.68 It is based on the belief that there are channels within the body through which the Qi (vital energy or life force) flow, and that inserting fine needles into these channels via the skin can rebalance Qi.68 Modern mechanistic hypotheses invoke involvement of inflammatory or pain pathways.69 Acupuncture frequently uses electric stimulation (electro-acupuncture) to increase the potency of the procedure. Alternatively, in a related procedure (acupressure), pressure can replace the needle. Accreditation in acupuncture generally requires a master’s degree in traditional Chinese medicine but does not require any specific medical training. Acupuncture training courses for physicians are widely available.
All forms of acupuncture are experimental for a wide variety of mental and medical conditions. A meta-analysis found that most research of the utility of acupuncture for depression suffered from various forms of potential bias and was considered low quality.70 Nonetheless, active acupuncture was shown to be minimally superior to placebo acupuncture.70 A meta-analysis of acupuncture for preoperative anxiety71,72 and poststroke insomnia73 reported a similar low study quality. A study of 72 patients with primary insomnia revealed that acupuncture was more effective than sham acupuncture for most sleep measures.74
Challenges and complications
Psychiatry is increasingly integrating medical tools in addition to psychological tools. Pharmacology remains a cornerstone of biological psychiatry and this will not soon change. However, nonpharmacologic psychiatric treatments such as therapeutic neuromodulation are rapidly emerging. These and novel methods of medication administration may present a challenge to psychiatrists who do not have access to medical personnel or may have forgotten general medical skills.
Our 2-part article has highlighted several interventional psychiatry tools—old and new—that may interest clinicians and benefit patients. As a rule, such treatments are reserved for the most treatment-resistant, challenging psychiatric patients, those with hard-to-treat chronic conditions, and patients who are not helped by more commonly used treatments. An additional complication is that such treatments are frequently not appropriately researched, vetted, or FDA-approved, and therefore are higher risk. Appropriate clinical judgment is always necessary, and potential benefits must be thoroughly weighed against possible adverse effects.
Bottom Line
Several forms of neuromodulation, including electroconvulsive therapy, transcranial magnetic stimulation, transcranial direct current stimulation, deep brain stimulation, and vagus nerve stimulation, may be beneficial for patients with certain treatment-resistant psychiatric disorders, including major depressive disorder and obsessive-compulsive disorder.
