In this video I consider the questions that are raised when evaluating pharmaceutical interventions and what they mean for our understanding of mental illness. Next I describe other biomedical interventions for psychological disorders which are not as commonly used and include electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), phototherapy, psychosurgery, and deep brain stimulation. Disclaimer: This channel is for educational purposes only and is not intended as medical advice for the diagnosis or treatment of psychological disorders.

Video Transcript

Hi, I’m Michael Corayer and this is Psych Exam Review. In the previous video, I introduced a number of pharmaceutical interventions for treating mental disorders and in this video I want to start by thinking about how we can evaluate the effectiveness of these drug treatments. And then we’ll take a look at a few other biomedical interventions that are not so common.

So when we think about evaluating drug therapies, the first thing we have to ask is how exactly we know that a drug therapy is working and what this means for an individual patient. So even if we see that a drug is effective for some people this process of using the drug still needs to be adjusted on an individual basis. The dosage may need to be adjusted, which symptoms improve for some patients using the same drug might differ from one patient to another. And even when we see improvement in symptoms, we don’t necessarily know the precise mechanism. We don’t know why it is that the drug is helping with certain symptoms in some patients and maybe helping with other symptoms in other patients or maybe why it’s not effective for some patients. So we want to avoid being misled and thinking we better understand an illness just because we have an effective treatment for it. To say, OK, we know this drug helps to lift depression in a large number of people, but we still don’t fully understand why that is. What exactly is it doing and why is it not working for other people? So that’s one thing we need to consider when we think about the effectiveness of drug therapies.

Another thing we have to ask, I mentioned when I talked about anxiety drugs and this is the idea of are we correcting problems or are we simply relieving the symptoms, right? And this is an important distinction because if we’re just relieving the symptoms, then the root cause may still be there. And perhaps we could become overly confident that we know how to deal with the particular disorder just because we can make the symptoms go away. But we’re not fully addressing the root of the problem. And so maybe we should think about other interventions that might be better able to correct the underlying cause rather than just making the symptoms go away.

And part of the reason for this leads us to the next point that we need to consider, which is that there are often side effects for all of the drugs that I talked about in the previous video, I mentioned, there are side effects for these drugs and these side effects can vary from patient to patient and the severity can also vary widely from patient to patient. And for patients who are suffering from side effects, we might wonder whether they’re just trading one set of symptoms for another and whether it’s actually worth that risk. So in the case of an anti-anxiety drug, we may be able to reduce anxiety. But if that comes along with a higher risk of addiction and symptoms of withdrawal when the patient stops taking something like benzodiazepines, then we might wonder whether this is really worth it for the patient. And we could also wonder whether we’re increasing the risk of other problems in the future. And this all needs to be taken into consideration when we think about whether or not a drug therapy is effective. And that’s something we’ll come back to in a future video.

Another thing to keep in mind that addresses this point is that these drugs are often not standalone treatments. So even when a drug is effective, we offer use other treatments alongside it. So this brings us to considering the use of psychotherapy along with pharmaceutical interventions. And this is quite common. And the idea is that even if we don’t know fully why a drug is working, we might be able to address some of those underlying causes through psychotherapy. And this also gives patients a greater sense of control because if patients believe that just this pill is going to make them better, they don’t really feel that they’re responsible for their improvement and they don’t have control over their illness in the way that they might feel if they were getting psychotherapy and learning how to cope with certain symptoms or learning strategies for dealing with some of the difficulties that they’re facing.

So one example of this combination is what we see in the treatment of depression. So there’s studies suggesting that cognitive behavioral therapy can be just as effective as medications like SSSRIs for some patients suffering from depression. But these same types of studies also show that the most effective treatment is often a combination of cognitive behavioral therapy plus taking SSRIs. And so this is a case where we aren’t thinking of the drugs as curing the problems. They’re an aide to the treatment, but we also need some psychotherapeutic interventions as well. OK, now that raises some other questions, one of which is how do we coordinate these treatments?

So you may have somebody who’s seeing a therapist to get cognitive behavioral therapy, but they’re also receiving a prescription from their psychiatrist for an SSRI. And it can be hard to know how exactly they should balance these. As I said before, that drugs often involve a sort of trial and error process of adjusting the dosage. And that can be hard to do when there’s also therapeutic interventions going on at the same time. And it’s also hard to know which part is more effective for that patient, which part is reducing which symptoms? How do we assess the results even if the person gets better? How much of that is due to the CBT? How much of that is due to the SSRI that they’re taking? And that’s something that we’ll look at in another video in the future.

Okay, so those are some of the challenges of thinking about effectiveness of drug therapies. And we also have some other biomedical treatments that are used, although these are much more rare. These are less common and they’re often used after some other pharmaceutical interventions have been attempted but have not worked well for a particular patient. So after they’ve tried taking SSSRIs for their depression and nothing seems to work, maybe they’ve tried some other classes of antidepressants. Maybe they’ve also tried some types of therapy if nothing’s working in these cases, then it’s possible they might try one of these other biomedical interventions.

And the first of these is electroconvulsive therapy or ECT and this was first used in 1938, and it involves delivering very brief electric shocks to the brain. Now there’s a misconception or misperception of this process that people might have particular if they’ve seen movies like One Flew Over the Cuckoo’s Nest, where they see this sort of torturous, painful procedure being delivered. And that’s actually not what ECT is like at all. Patients today are given muscle relaxants, and then they’re put under general anesthesia. So this reduces the spasms that they might experience. It also means that they don’t experience any pain during this procedure. They’re under anesthesia. Basically, they’re put under, they experience some very brief shocks, and later they wake up, usually feeling much better in the case of treatment of depression.

And about 80% of patients getting ECT show some improvement. And this is really important to note because these are patients who haven’t responded to other treatments in most cases. So they’ve tried antidepressants, they’ve tried CBT, they’ve tried maybe some other types of interventions without any success. And then ECT can be effective for a large number of these patients.

That said, the mechanism for why this works is still unclear, similar to with the case for antidepressants. So one theory is that these mini seizures that are caused in the brain by this wave, this electrical pulse that this might be calming certain brain regions or reducing their activity. Another possibility is that it’s modifying certain pathways by stimulating certain neurons in the brain. Those pathways are being modified or release of neurotransmitter levels are being adjusted in some way as a result of this mini seizure that occurs. Or it’s also possible that this stimulation aids in the process of neurogenesis, which is the growth of new neurons that I also mentioned when talking about antidepressant medications.

Now, of course, there are side effects with ECT and the main one of these is memory loss. So often patients won’t have much memory of the events just around the time that they receive the stimulation. But this is usually minor and a few other side effects that can occur are headaches and also muscle aches from some of the spasming that can occur during the treatment.

Okay, there is a less intense form of stimulation that’s become used in the past few years. And this is TMS or transcranial magnetic stimulation. So this is less invasive, it involves simply placing a magnetic coil along the skull and stimulating certain brain regions. And because this is a less intense form of stimulation, we see fewer side effects. We don’t see the memory loss that you might see with ECT and while there still might be headaches, they’re usually fairly slight. And there is a slight increase in the risk of seizure through the use of TMS. But we can see that this can be effective for treating certain types of disorders like depression. And again, even when it is effective, we don’t fully understand why. One idea is this is changing the potentiation of certain neurons, making it easier or more difficult for them to fire. And this may be helping to regulate certain aspects of mood. Or it could be the case that the stimulation is helping to form new circuits in the brain. Or this might be related to long–term potentiation and that’s the idea of neurons that fire together, wire together. This is the idea of how memories are formed. The idea is maybe by stimulating certain pathways or certain circuits in the brain where strengthening those connections, right? Because they’re firing together more often, those connections become stronger. And then perhaps they can help to improve mood, even when, of course, the person isn’t receiving the stimulation.

Okay, the next biomedical approach is one that at first glance sounds like a bit of quackery. It sounds a bit strange, if I told you about the healing powers of light for some mental illness, you might think I was a little, you know, exaggerating certain aspects of that. It might sound kind of “new agey” or something. But in phototherapy, we actually do use the healing power of light to treat depression. And this is used for the seasonal pattern of major depressive disorder. So this seasonal pattern is where people experience depressive episodes, but only in the fall and the winter. And they don’t experience them in the spring and summer. And the idea is that this is occurring because of reduced levels of sunlight. And if this is influencing hormone levels in the body, and then those changes in hormone levels are affecting the person’s mood and making them more likely to experience a depressive episode. And so the treatment is simply exposure to light. The person will get a special light box that emits bright light onto their face, and then they use it each morning for about 30 minutes or so. And this fairly limited amount of exposure to bright light can help to influence their hormone levels. And this can actually help to prevent these depressive episodes that occur in the fall and winter.

Okay, next we’ll look at the last biomedical intervention. And this is the rarest kind, and this is psychosurgery. So often this brings to mind something I talked about in the unit on emotion and motivation, which was the leucotomy or the frontal lobotomy. First developed by Egas Moniz and then introduced as the frontal lobotomy by Walter Freeman in the US. And this is often what people think of when they think of, you know, psychosurgery. But this is a practice that’s banned in most places around the world today. So we no longer are performing frontal lobotomies on people, but there are some other types of psychosurgery.

As I said, they’re very rare, and they’re often used as a last resort for patients. No other treatments have been effective, the symptoms are very severe, and sort of the last chance to try to improve the quality of life for this patient. And the reason this is so rare is because these procedures are irreversible. So we really have to hope that they’re effective and there’s no going back if they aren’t. So one type of psychosurgery still in use today is what’s called the cingulotomy. And this is involves destroying some of the connections between the cingulate gyrus and the corpus callosum. And this can be used in severe sort of last resort cases of depression and obsessive compulsive disorder. And another procedure that’s used is the anterior capsulotomy. And this is cutting connections between the caudate nucleus and the putamen. And this can be used for again, severe intractable cases of obsessive compulsive disorder.

OK, lastly, we have a type of psychosurgery called deep brain stimulation. This is also a fairly new procedure. And this involves inserting an electrode into the brain. And this electrode can then influence brain activity in particular regions. And there’s a pacemaker that it’s connected to that’s implanted into the chest. And the reason for this is this allows the person to turn this brain stimulation on or off. So you wouldn’t want the stimulation there all the time because of neuroadaptation. The brain will quickly adjust to this, you know, electrode stimulating or inhibiting the action of certain neurons. And so in order to prevent that, you can turn it off for certain periods when it’s not relevant or it’s not needed. And then when the situations where the symptoms need to be reduced arise, you can turn this device back on. And this has been used successfully for treatment of things like Parkinson’s disease, for chronic pain, for tics related to Tourette’s syndrome, for tremors, and even for obsessive compulsive disorder and depression. Okay, so those are some of the other biomedical interventions.

And in the next video, we’ll start thinking in more detail about how we can evaluate the effectiveness of treatments and what sort of things we need to take into consideration. When we think about patients getting better, how much of that credit can we give to the interventions that we’ve seen, whether it’s psychotherapy or a biomedical intervention, like the ones I’ve just described. Okay, so I hope you found this helpful. If so, please like the video and subscribe to the channel for more. Thanks for watching!