Journal of the Neurological Sciences 434 (2022) 120093

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Journal of the Neurological Sciences

journal homepage: www.elsevier.com/locate/jns

Advanced training in interventional psychiatry

Sina Nikayin a, Joseph J. Taylor b, c, Robert B. Ostroff d, *
a
Yale University School of Medicine; 184 Liberty St., New Haven, CT, United States of America
b
Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
c
Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
d
Yale University School of Medicine, 184 Liberty St., New Haven, CT, United States of America

A R T I C L E I N F O A B S T R A C T

Keywords: Interventional Psychiatry is an emerging subspecialty that treats patients with disorders resistant to routine
Interventional psychiatry measures by employing advanced treatment modalities and procedures that require expertise beyond the training
Neuromodulation provided in a general psychiatric residency. Interventional psychiatrists thus require advanced technical, psy­
Fellowship
chiatric, and general medical training and expertise to be able to provide these treatments in a safe and effective
Residency training
ECT
manner. In this article, we will discuss our take on the definition of interventional psychiatry, review the mo­
TMS dalities included in this field, and suggest training requirements for an interventional psychiatrist. We will also
Ketamine share our experience in providing advanced interventional psychiatry training as a chief residency or fellowship
at the Yale New Haven Psychiatric Hospital.

1. Introduction otherwise be appropriate for this field.

Interventional Psychiatry is an emerging subspecialty that employs
advanced treatment modalities and procedures to help patients with
disorders that have been resistant to routine treatments. In this paper,
we will discuss our definition of Interventional Psychiatry, make the
case for specialized training in this field, and provide our experience
with Interventional Psychiatry training at Yale New Haven Psychiatric
Hospital.
2. Defining interventional psychiatry
Interventional psychiatry is a relatively new term that has been
increasingly used in the past decade [1–3]. Despite this increase in in­
terest, there is no consensus on the definition of the term and what it
entails. It has been used to refer to neuromodulation modalities [2,4,5],
or to modalities that are complex to administer [3]. These definitions
overlap, but they mostly focus on technical aspects of treatments rather
than the role of the interventional psychiatrist as part of the multidis­
ciplinary team of healthcare providers addressing the needs of patients
suffering from severe, acute, or refractory psychiatric illnesses. Neuro­
modulation itself is a term that has been frequently used to describe this
field. However, its focus on the technological aspect has a limiting effect
on the scope of the field, and excludes other modalities that would
In this paper, we will use a more comprehensive definition of
interventional psychiatry: Interventional Psychiatry is a subspecialty
that uses advanced modalities and procedures to treat patients who have
been resistant to commonly used treatments; the interventional psy­
chiatrist needs advanced technical, psychiatric, and general medical
training and expertise to be able to provide these treatments in a safe
and effective manner to a patient population who may be at higher risk
of medical and psychiatric complications by virtue of the severity of
their illness and the invasiveness of the treatment.
This definition may have limitations, but we believe that it addresses
core elements of this emerging subspecialty. Based on this definition,
modalities currently considered as part of interventional psychiatry may
include clinically available treatments such as transcranial magnetic
stimulation (TMS), electroconvulsive therapy (ECT), deep brain stimu­
lation (DBS), vagus nerve stimulation (VNS), ketamine, esketamine, and
brexanolone, in addition to emerging modalities such as transcranial
direct-current stimulation (tDCS), psychedelic treatments (e.g., psilo­
cybin), transcranial focused ultrasound, and magnetic seizure therapy. A
detailed review of each modality is beyond the scope of this paper, and
many of the most common modalities are covered elsewhere in this
issue. All these interventions require special training to prescribe and
administer. Defining the field is initial step toward building consensus
among the stakeholders in the field.

* Corresponding author.
E-mail addresses: sina.nikayin@yale.edu (S. Nikayin), jtaylor61@bwh.harvard.edu (J.J. Taylor), robert.ostroff@yale.edu (R.B. Ostroff).

https://doi.org/10.1016/j.jns.2021.120093
Received 4 June 2021; Received in revised form 3 November 2021; Accepted 12 December 2021
Available online 16 December 2021
0022-510X/© 2021 Published by Elsevier B.V.
S. Nikayin et al.
3. Requirements for training in Interventional psychiatry
3.1. Technical expertise
In order to deliver a procedural treatment in psychiatry, the practi­
tioner must know the theoretical mechanism of action for the treatment,
proper patient selection, the risk/benefit of the treatment, and the
technical aspect of delivering the treatment safely and effectively.
Knowledge of psychometric scales is also essential given their current
role in monitoring treatment effectiveness in psychiatry [6].
The procedural modalities used in interventional psychiatry require
advanced technical expertise beyond the training typically offered to
general psychiatrists. For example, the Accreditation Council for Grad­
uate Medical Education (ACGME) [7] only requires psychiatry residents
to know indications for and uses of ECT. Although the American Psy­
chiatric Association (APA) task force on ECT recommends a higher level
of training with participation in at least 10 ECT treatments on at least 3
different patients [8], this training is often inaccessible because of the
lack of program capacity [9]. In our opinion, this level of training does
not lead to the development of adequate expertise to delivery ECT in a
safe and effective manner. A sufficient training should minimally cover
patient selection, various lead placements, appropriate titration, and
adjustment of settings, and addressing inadequate seizures, prolonged
seizures, and common acute and longer-term complications. Most cur­
rent ECT providers acquire this knowledge by working with senior ECT
providers and by attending training sessions held by various organiza­
tions or both. Furthermore, most healthcare systems require attestation
by an established ECT provider, and regular continuation of ECT treat­
ment to maintain competency and privileges.
None of the other interventional treatment modalities are part of the
required psychiatry residency training. Exposure to these interventions
varies significantly between programs, but many offer very limited
training opportunities [5]. Dedicated training in Interventional Psychi­
atry can provide interested providers with a more systematic approach
to learn and enhance their technical and procedural expertise in
providing these treatment modalities.
3.2. Psychiatric expertise
All competent psychiatrists have the required training and tools to
treat and monitor patients with psychiatric disorders including patients
with severe disorders. However, interventional psychiatry has its focus
on patients who have severe or acute disorders that are resistant to more
common treatments. A partial list includes patients with treatment
resistant depression [10], depression with active suicidal ideation or
behavior [11], obsessive compulsive disorder [12], schizophrenia not
adequately treated with clozapine [13], and catatonia [14]. An inter­
ventional psychiatrist must therefore be able to assess, diagnose, treat,
and monitor patients with inherently complex presentations and medi­
cation regiments. Interventional psychiatrists must also be prepared to
treat patients at higher risk for psychiatric complications and patients
with significant medical co-morbidity such as encephalitis leading to
catatonia [15,16]. Also, as many interventional psychiatric modalities
employ brain stimulation technologies, an interventional psychiatrist
should have an in-depth understanding of neuroanatomy and neuro­
physiology. Furthermore, the role of an interventional psychiatrist is
usually as an ally and consultant to the primary psychiatric provider
who will continue to provide care to the patient before, during, and after
interventional treatment. Additionally, an interventional psychiatrist
frequently has to work closely and in coordination with other specialties
such as anesthesia, neurology, neurosurgery, and radiology. These fac­
tors create unique challenges that are only addressed by a person with
sufficient knowledge and expertise in tackling them.
A training focused on interventional psychiatry will provide oppor­
tunities for trainees to hone their psychiatric skills and gain sufficient
expertise to be able to handle these challenges.
2
Journal of the Neurological Sciences 434 (2022) 120093
3.3. General medical expertise
By their nature, many interventional psychiatric modalities have a
higher risk of acute medical complications. Examples of medical com­
plications include prolonged seizure and arrhythmia with ECT, hyper­
tensive urgency with ketamine, and iatrogenic seizure with TMS. An
interventional psychiatrist should be comfortable assessing patients for
medical risks factors and comorbidities, referring patients to other
specialties for further workup or treatment, and assessing and man­
aging/treating/triaging acute complications if they arise. The inter­
ventional psychiatrist should be comfortable interpreting vital signs and
EKGs, obtaining IV access, treating hypertensive urgencies, and
responding to seizures in the context of administering interventional
treatments. Other recommended skills include the basic airway man­
agement, performing diagnostic lumbar punctures, interpreting EEGs
among other skills. As a measure of additional training, we require our
attendings on the Interventional Psychiatry Service to be certified in
Advanced Cardiovascular Life Support (ACLS).
4. Our experience with advanced interventional psychiatry
training
As of this writing, the interventional psychiatry service at Yale New
Haven Psychiatric Hospital has been training a chief resident/fellow
each year for 6 years. Here we present our experience with training for
this specialty. Several other programs across the US also provide
specialized training in interventional psychiatry. As each programs'
strengths and capabilities differ, we recognize that our approach may
not be appropriate for all settings. However, we believe that it can
provide a useful insight both for those who already provide similar
services and those who are interested in making interventional psychi­
atry available to their patients and trainees. There are other factors
involved with initiation or expansion of interventional psychiatric ser­
vices, such as resource utilization, financial aspects, availability of ex­
perts and champions. While these factors are critical to the success of an
interventional psychiatry program, they are beyond the scope of the
current manuscript and thus have not been addressed here.
4.1. Chief residency versus fellowship
As a large university program, the Yale Psychiatry Residency Pro­
gram has been able to structure the residency training in such a way that
the fourth and final year of training can be mostly dedicated to elective
endeavors based on each resident's interests. As such, we designed the
Interventional Psychiatry Resident role to be filled by a 4th year resident
interested in this field. However, over the years we have also offered the
position as a fellowship to recent graduates who are interested. The
goals of our training program have include advanced technical, medical
and psychiatric training and providing the resources and mentorship to
help them achieve excellence in the field of interventional psychiatry.
Depending on the structure of each residency program, dedication of the
entire 4th year to Interventional Psychiatry could be difficult. As such it
is likely that most positions offered for Interventional Psychiatry
training will be in the form of a fellowship. As of this writing, an
Interventional Psychiatry fellowship is not a recognized fellowship by
ABPN,ACGME or UCNS, though given the advanced training required,
this may change in the coming years as the field further develops and
coalesces.
4.2. Roles and responsibilities of the Yale interventional psychiatry chief
resident/fellow
Throughout the year of training, each Interventional Psychiatry
trainee has multiple roles and responsibilities that are designed to help
them develop competency in various aspects required to excel in this
field. A summary of the roles and responsibilities of our trainees is
S. Nikayin et al. Journal of the Neurological Sciences 434 (2022) 120093

available in Table 1. Table 1

Roles and responsibilities of the Yale interventional psychiatry chief resident/
4.2.1. Clinical role fellow.
The Interventional Psychiatry trainee is involved in the clinical care Competencies Required/ Details
of our patients on a regular basis. This role includes initial assessment of optional
patients referred for interventional psychiatric treatment as outpatients, Clinical
and patients admitted to psychiatric or medical units for whom a Consultation Required Assessment, Determination of
consultation is requested by their respective primary teams. After initial need for interventional psychiatric
treatment, determination of
assessment, patients are followed by the trainee and our team
appropriate modality, Patient and
throughout their treatment and are monitored and re-assessed regularly family education, Provider
for improvement and for side effects. By the end of their training, each feedback and education
trainee will become competent in expertly assessing complicated pre­ ECT Required Titration, Administration,
sentations that are common for this subspecialty, providing education Adjustments, Lead Placement,
Monitoring efficacy, Monitoring
and feedback to patients, families, and primary providers, and in side effects, Management of
monitoring of efficacy and side effects of various interventional complications, Patient education
treatments. Ketamine Required Dosage determination, monitoring
The interventional psychiatry trainee is also responsible for admin­ efficacy, monitoring side effects,
management of complications,
istering various interventional psychiatric modalities under the direct
patient education
observation of an attending provider. Each trainee administers over Esketamine Required Dosage determination and
2000 ECT treatments and over 1500 ketamine/esketamine treatments adjustment, monitoring efficacy,
by the end of their training year. They also have the opportunity to get monitoring side effects,
experience in the administration of TMS treatment. management of complications,
patient education
Additionally, trainees are provided with the opportunity to improve
TMS Treatment Optional Motor threshold measurement,
other clinical skills that are frequently required in the field of inter­ Administration, Monitoring
ventional psychiatry, such as cardiac and respiratory monitoring, ECG efficacy, Monitoring side effects,
interpretation, venipuncture, and airway management. We are also in Management of complications,
Patient education
the process of adding diagnostic lumbar puncture as another skill
Psychometric Testing Required Administration of clinician-
available for interested trainees, given the increasing need for this reported outcome measures (e.g.
diagnostic tool in the psychiatric population. MADRS), patient-reported
outcome measures (e.g. QIDS),
4.2.2. Research role cognitive assessment measures (e.
g. MOCA) and dissociative state
Interventional Psychiatry is an emerging subspecialty, and as such
measures (e.g. CADSS)
trainees and practitioners in the field regularly take an active role in the Cardiac/Respiratory Required Placement, Interpretation,
scholarly aspects of this field. Our trainees are strongly encouraged to monitoring Addressing abnormalities
engage in scholarly activities. As a major research site for multiple ECG Required Placement, Interpretation,
Addressing abnormalities
interventional modalities and through a close collaboration with the
Venipuncture Optional IV access placement and
Yale Depression Research Program, we provide trainees with the op­ monitoring
portunity for involvement in various ongoing research projects, to Basic Airway Optional Management of airway in patients
develop and work on their own projects, and write and publish scholarly Management under general anesthesia, Use of
work. Many of our trainees have been actively and enthusiastically non-rebreather masks and bag-
mask ventilation
engaged in research projects before, during, and after their interven­
Lumbar Puncture Optional* Diagnostic Lumbar Puncture in
tional psychiatry training year [17–20]. psychiatric patients
* Not yet implemented
4.2.3. Teaching and leadership roles Research
Teaching and leadership experiences are a critical aspect of their Facilitation/Coordination Required Coordination of clinical and
training. We have thus incorporated tasks that help them develop these research activities for patients
skills. currently under clinical care whoa
are also enrolled in various
As part of their role as the chief resident or fellow of Interventional
research projects
Psychiatry, trainees are responsible for coordination and education of Participation in research Optional Participation in ongoing research
other trainees rotating through our service. This includes teaching projects projects underway by the
medical students about the basics of interventional modalities such as interventional psychiatry service
ECT, teaching and overseeing the administration of treatment by and the Yale Depression Research
Program
second-year residents, and providing education to other observers and Scholarly Activity Optional (highly Completion of trainee-led
students such as nursing students, PA students etc. encouraged) scholarly projects (e.g.
They are responsible for organizing and hosting our “Tumor Board”. observational studies, QI projects,
This monthly clinical meeting, which is modeled on the multidisci­ case reports, book chapters etc.)
plinary approach used by our oncology colleagues for patients with a Education
complicated presentation [21,22], is designed to provide an opportunity Teaching Medical Required Coordinating and teaching
for the team to discuss complicated cases and formulate appropriate Students, observers medical students rotating through
the service and other observers
interventions. The trainee is responsible for identifying and presenting
Teaching and supervising Required Coordinating, teaching, and
the cases, coordinating the required participants based on the needs of junior residents supervising second-year residents
each case (e.g. anesthesiology, neurology etc.), and hosting and man­ rotating through the service
aging the meetings. Lectures Optional (highly Providing educational lectures to
encouraged) students, residents, etc. regarding
Lastly, trainees are encouraged to develop and execute initiatives
interventional psychiatry
depending on their interests throughout the year. Over the years, our
trainees have introduced a vast and diverse collection of initiatives, (continued on next page)

3
S. Nikayin et al.
Table 1 (continued )
Competencies Required/ Details
optional
Leadership
Hosting the “Tumor Required Hosting, organizing and
Board” facilitating the monthly “tumor
board” for complicated cases in
the service
Coordination of the Optional Organizing the grand rounds,
Interventional identifying and inviting speakers,
Psychiatry Grand inviting the participants
Rounds
Initiatives Optional (highly Design and execution of initiatives
encouraged) to improve clinical care or
education in the field of
interventional psychiatry
including journal club, Yale Interventional Psychiatry Grand Rounds
(which are open to the public) [23], Electronic Medical Record(EMR)
optimization for interventional psychiatry, incorporating the use of
electronic psychometric tests in clinical care, etc.
5. The future
Interventional psychiatry is perhaps one of the fastest growing fields
in psychiatry. The introduction of modalities such as TMS, brexanolone,
ketamine and esketamine, and further improvements in established
modalities such as ECT, in addition to the increasing need for treatment
in patients who are resistant to more common treatment approaches
such as oral medication and psychotherapy, have resulted in a rapid
expansion of interventional modalities. Currently, providers using these
advanced treatment modalities are trained only in a single or a few
modalities, and the quality of training is significantly varied. Recog­
nizing this need, a few programs (including our program at Yale) have
introduced a specialized training for trainees interested in becoming
experts in the field of interventional psychiatry. These training programs
are relatively new, are usually designed and focused on the strengths of
each program, each have their own flaws and weaknesses, and will
undoubtedly undergo changes in the coming years. Additionally, to our
knowledge, no formal evaluation of these programs' strengths and lim­
itations are available, which would provide much needed insight into
the best methods to address the training needs in the field. However, we
believe that the field of interventional psychiatry is a much-needed
subspecialty in psychiatry and provides better access to various mo­
dalities under a single umbrella and enables patients to receive the
treatment most appropriate for them. As sch, interventional psychiatry
will continue to expand rapidly throughout the world, and will require
some systematization in the coming years. Here we have provided our
experience and current model of training at Yale, with the hope of
providing an example for those who are invested in starting or
expanding similar programs, to initiate a larger discussion about the
needs and requirements of training in interventional psychiatry, and
perhaps to be a first step toward codification and recognition of this field
as a formally recognized subspecialty in psychiatry by the regulatory
bodies in the coming years.
Declaration of Competing Interest
The authors declare no conflicts of interest for this manuscript.
Journal of the Neurological Sciences 434 (2022) 120093
Acknowledgements
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors. JJT has no
conflicts of interest. He has received research funding from Harvard
Medical School, the Sidney R. Baer Jr. Foundation, and a philanthropic
gift from Jan Ellison Baszucki and David Baszucki. SN and RBO have
nothing to disclose.
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