CLINICAL RESEARCH CENTRE FOR NEUROMODULATION IN PSYCHIATRY
In a recent editorial of the Indian Journal of Psychiatry, the significance of “Interventional Psychiatry” and the urgent need for systematic training in this subspecialty was aptly emphasized. Interventional psychiatry has two significant components: (i) harness the potential of neurotechnologies to elucidate the circuit level brain dysfunctions that underlie the pathogenesis of psychiatric disorders and (ii) application of disparate brain stimulation techniques to modulate the aberrant brain circuits. The proponents of this subspecialty have clarified that the usage of the term “interventional” does not intend to mean that the existing interventions do not impact change; rather, “interventional psychiatry” is analogous to respective subspecialties other medical specialties such as cardiology, neurology, pulmonology, nephrology, and radiology; i.e. “interventional” describes those physicians that are formally trained and qualified to perform procedures that are considered relatively more invasive than the general medical procedures of the respective specialty. An interventional psychiatrist either applies brain stimulation techniques with concurrent neurotechnology based assessments for understanding pathophysiology (mostly in research studies) or utilizes the brain stimulation techniques (invasive or noninvasive) to treat psychiatric disorders in clinical practice guided by evidence generated from systematic clinical/neurobiological research studies.
Given the exponential increase in our knowledge about the brain bases of cognition and behavior, more than ever, there is a compelling need for a neuroscience-informed approach to understand and treat psychiatric disorders. These discoveries in neuroscience are ably matched with advances in neurotechnologies. Such advances have created novel avenues to assess the brain, as well as, generated a fascinating set of brain stimulation devices and techniques that can modulate neural circuits. Needless to add, the dry pipeline of psychopharmacological agents amidst the persistent challenges of treatment resistance in psychiatry has made us aware of the acute need for alternative treatment avenues.
Contextually, it is interesting to note that the brain may be conceptualized as an “electro-chemical soup.” However, modulating the “electro” component has not been intensively pursued to match the psychopharmacological interventions that have targeted the “chemical” component. Hence, it is high time that the “interventional” potential in psychiatry deserves it due credit on par with other medical specialties.
Indeed, there are promising leads for the application of noninvasive neuromodulation techniques such as electroconvulsive therapy (ECT), transcranial magnetic stimulation, theta burst stimulation, transcranial direct current stimulation for the treatment of psychiatric disorders. Nonetheless, to enhance the standard practice of interventional psychiatry, we need a large and strong evidence base on the optimal use of these neuromodulation techniques. In parallel, we need to generate psychiatrists who are equipped to implement the standardized practice of these techniques. Significantly, for a systematic practice of interventional psychiatry, one needs sound knowledge of relevant neuroscience foundations, familiarity with brain investigation tools, as well as a grasp of the fundamental principles and practice of standard neuromodulatory devices. Moreover, the effective implementation of interventional psychiatry needs a multi-disciplinary team involving other medical specialties (for example, anesthesiologists for ECTs) as well as allied mental health professionals; hence, the training programs should be inclusive. However, as aptly described in the editorial of the Indian Journal of psychiatry, in the contemporary Indian scenario, there is a paucity of research works, standard practice guidelines, and systematic training in Interventional Psychiatry.
To address such critical needs of the biomedical scenario in India, the DBT Wellcome Trust India Alliance has launched a funding mechanism to establish Clinical Research Center (CRC)/Public Health Research Centers. This CRC scheme “aims to improve clinical and public health research ecosystems in India to bridge gaps in human resource, supervision, mentorship, equipment, and administration by establishing CRCs. The CRCs are envisioned as research-oriented centers established with a focus on major biomedical research problems and preferably involving multiple institutions”. Importantly, these CRCs are embedded with a “Clinical Research Training Programme (CRTP) that aims to develop Physician Scientists as a way forward for improving clinical and public health research ecosystems in India” (https://www.indiaalliance.org/clinical-public-health-research-centres).
In the year 2019, DBT Wellcome Trust India Alliance awarded the prestigious CRC/Public Health Research Center grant to establish a “CRC for Neuromodulation in Psychiatry” and implement the “CRTP” to train clinician-scientists in Interventional Psychiatry.” This multi-institutional research program will be led by NIMHANS (Bengaluru) in collaboration with the Central Institute of Psychiatry (Ranchi), and Kasturba Medical College (Manipal). The Center has been launched officially as the grant got activated on October 1, 2020.
This CRC will conduct cutting-edge research to address both the components of interventional psychiatry, i.e. translational disease modelling studies to understand the neural circuit bases of pharmacoresistance in psychiatric disorders as well as apply state-of-the-art brain stimulation techniques to generate clinically translatable prognostic markers of clinical response to facilitate personalized neuromodulatory interventions. Importantly, this CRC is committed to moving these scientific discoveries to society by increasing human resources through comprehensive training programs to generate “clinician-scientists” in interventional psychiatry. Furthermore, virtual/hands-on learning programs will be conducted to enhance practice standards of interventional psychiatry in India. The CRC/CRTP will have a strong emphasis on training to generate the much-needed interventional psychiatry expertise at different levels, namely (a) curriculum for undergraduate and postgraduate training in psychiatry (in consultation with all stakeholders), (b) upskill practising psychiatrists, (c) intensive clinical research training (including fellowships/doctoral theses) to generate state-of-art evidence on practice standards as well as clinical applications.
This CRC will establish a data repository that will facilitate advanced data science analyses toward the development of personalized Interventional Psychiatry through precision medicine principles. We are hopeful that the translational research studies and the training programs envisaged through this center will facilitate the development of cost-effective, advanced interventional psychiatry tailored to resource-limited Indian clinical settings and similar other countries as well. Besides, through this CRC, we will have participatory interaction with all stakeholders (psychiatrists in the community, professional societies/associations, patients and caregivers, policymakers, device regulatory bodies, other psychiatric institutes, and industry) and ascertain measures to facilitate the effective implementation of interventional psychiatry at different levels of health-care delivery through standardized, scalable, pragmatic interventions, and advance this important sub-specialty in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This work is supported by the Clinical/Public Health Centre Research Grant from the DBT Wellcome Trust India Alliance (IA/CRC/19/1/610005).
1. Singh OP. Need to Develop “Interventional Psychiatry” as a subspecialty in India Indian J Psychiatry. 2020;62:1–2
2. Williams NR, Taylor JJ, Kerns S, Short EB, Kantor EM, George MS. Interventional psychiatry: Why now? J Clin Psychiatry. 2014;75:895–7
3. Lakhan SE, Kaplan A, Laird C, Leiter Y. The interventionalism of medicine: Interventional radiology, cardiology, and neuroradiology Int Arch Med. 2009;2:27
4. Vincent KM, Ryan M, Palmer E, Rosales JL, Lippmann S, El-Mallakh RS. Interventional psychiatry Postgrad Med. 2020;132:573–4 [doi: 10.1080/00325481.2020.1727671]
5. Dean B, Moller HJ, Svensson TH, Geyer MA, Rujescu D, Scarr E, et al Problems and solutions to filling the drying drug pipeline for psychiatric disorders: A report from the inaugural 2012 CINP Think Tank Int J Neuropsychopharmacol. 2014;17:137–48
6. Koek RJ, Roach J, Athanasiou N, Korotinsky AKim YK. Novel Neurostimulation therapeutic approaches for treatment-resistant psychiatric disorders Treatment Resistance in Psychiatry. 2019 Singapore Springer:325–47
7. Pereda AE. Electrical synapses and their functional interactions with chemical synapses Nat Rev Neurosci. 2014;15:250–63
8. Mitra S, Thirthalli J. ECT in schizophrenia: Does indication affect the outcome? Asian J Psychiatr. 2018;32:5–7
9. Goyal N, Nizamie SH, Desarkar P. Efficacy of adjuvant high frequency repetitive transcranial magnetic stimulation on negative and positive symptoms of schizophrenia: Preliminary results of a double-blind sham-controlled study J Neuropsychiatry Clin Neurosci. 2007;19:464–7
10. Praharaj SK, Ram D, Arora M. Efficacy of high frequency (rapid) suprathreshold repetitive transcranial magnetic stimulation of right prefrontal cortex in bipolar mania: A randomized sham controlled study J Affect Disord. 2009;117:146–50
11. Mehta UM, Naik SS, Thanki MV, Thirthalli J. Investigational and therapeutic applications of transcranial magnetic stimulation in schizophrenia Curr Psychiatry Rep. 2019;21:89
12. Baliga S, Sreeraj VS, Parlikar R, Rai D, Chhabra H, Kumar V, et al Role of transcranial direct current stimulation in bipolar depression: A case report Asian J Psychiatr. 2020;47:101873
13. Venkatasubramanian G, Narayanaswamy JC. Transcranial direct current stimulation in psychiatry Lancet Psychiatry. 2019;6:8–9
14. Williams NR, Taylor JJ, Snipes JM, Short EB, Kantor EM, George MS. Interventional psychiatry: How should psychiatric educators incorporate neuromodulation
into training? Acad Psychiatry. 2014;38:168–76
15. Brown JC. An interventional psychiatry track Am J Psychiatry Resid J. 2019;15:11–4