Le jeudi 27 octobre
14:30 – 16:30 (2 hrs)
Salle de réunion : Linden (Mezzanine)
Peter Giacobbe*, MD, MSc, FRCPC; Amer Burhan, MD, FRCPC; Robyn Waxman, MD, FRCPC; Joshua Rosenblat, MD, FRCPC

Rôles CanMEDS :

1. Expert médical
2. Érudit
3. Promoteur de la santé

À la conclusion de cette activité, les participants seront en mesure de : 1) Increase knowledge of the evidence for electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and ketamine in the treatment of psychiatric disorders; 2) Increase confidence in the practical aspects of delivering ECT, rTMS, and ketamine treatments; and 3) Understand the requirements for the pre- and post-treatment monitoring procedures for patients receiving ECT, rTMS, and ketamine.

In a similar vein to interventional cardiology or radiology, the term ‘interventional psychiatry’ has been proposed to describe treatments that are more procedural and invasive than general medical care within that specialty. Descriptions of approaches that fall within interventional psychiatry have emphasized anatomically guided direct-to-brain treatments, such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS), but recently its scope has been expanded to include procedural or device-based treatments that are not delivered directly to the brain, such as intravenous ketamine and intranasal esketamine. Although there has been a veritable explosion of interest in interventional psychiatry in the last decade, the rate of expansion of this field is outpacing the ability of postgraduate curricula to provide sufficient teaching, supervision, and exposure to these treatments, resulting in a shortage of psychiatrists who are adequately trained in providing interventional treatments.

This course will be restricted to members in training, to increase their awareness, knowledge base, and skills in this area. Following a lecture outlining the evidence regarding the clinical evidence, side effects, and practical aspects in the delivery and monitoring of ECT, rTMS, and ketamine (45 minutes), members in training will then receive hands-on exposure and have discussions with experts in each of these three modalities (25 minutes each). Feedback will be provided to members in training on technical aspects of each procedure to increase confidence in their delivery.

C04a – Interventional Psychiatry: An Idea Whose Time Has Come?
Peter Giacobbe, MD, MSc, FRCPC

À la conclusion de cette activité, les participants seront en mesure de : 1) Increase knowledge of the rationale and evidence for electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and ketamine in the treatment of psychiatric disorders; 2) Increase knowledge on who may benefit from ECT, rTMS, or ketamine; and 3) Have greater appreciation of the key role of postgraduate medical education in interventional psychiatry.

In a similar vein to interventional cardiology or radiology, the term ‘interventional psychiatry’ has been proposed to describe treatments that are more procedural and invasive than general medical care within that specialty. Descriptions of approaches that fall within interventional psychiatry have emphasized anatomically guided direct-to-brain treatments, such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS), but recently its scope has been expanded to include procedural or device-based treatments that are not delivered directly to the brain, such as intravenous ketamine and intranasal esketamine. Although there has been a veritable explosion of interest in interventional psychiatry in the last decade, the rate of expansion of this field is outpacing the ability of postgraduate curricula to provide sufficient teaching, supervision, and exposure to these treatments, resulting in a shortage of psychiatrists who are adequately trained in providing interventional treatments. The evidence regarding the clinical evidence, side effects, and practical aspects in the delivery and monitoring of ECT, rTMS, and ketamine will be provided, setting the stage for members in training to receive hands-on exposure and have discussions with experts in each of these three modalities during the course.

Références :

1. Giacobbe P, Ng E, Blumberger DM, et al. Interventional psychiatry: an idea whose time has come? Can J Psychiatry 2021;66:316–8.
2. Danilewitz M, Ainsworth NJ, Liu C, et al. Towards competency-based medical education in neurostimulation. Acad Psychiatry 2020;44:775–8.

C04b – Repetitive Transcranial Magnetic Stimulation for Members in Training
Amer Burhan, MD, FRCPC

À la conclusion de cette activité, les participants seront en mesure de : 1) Establish individualized motor thresholds with a repetitive transcranial magnetic stimulation (rTMS) machine; 2) Use standardized methods to establish stimulation site to treat depression with rTMS; and 3) Set up approved standard and theta-burst stimulation paradigms to treat depression with rTMS.

Repetitive transcranial magnetic stimulation (rTMS) represents an evidence-based and approved therapeutic option for several psychiatric conditions, including major depressive disorder and obsessive–compulsive disorder. In this session, participants will have hands-on exposure with an rTMS machine, including the experience of establishing an individualized motor threshold, determining scalp location of stimulations, and programming the machine to provide standard and theta-burst stimulation paradigms to treat depression with rTMS.

Références :

1. Fried PJ, Santarnecchi E, Antal A, et al. Training in the practice of noninvasive brain stimulation: recommendations from an IFCN committee. Clin Neurophysiol 2021;132:819–37.
2. Milev RV, Giacobbe P, Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. Can J Psychiatry 2016;61:561–75.

C04c – Electroconvulsive Therapy: Theory and Practice
Robyn Waxman, MD, FRCPC

À la conclusion de cette activité, les participants seront en mesure de : 1) Enhance knowledge of recent scientific literature on the clinical efficacy and safety profile of electroconvulsive therapy (ECT); 2) Increase ability to assess who may benefit from ECT; and 3) Increase sense of competency to operate an ECT machine and monitor effects of an ECT treatment.

After nearly a century of use, electroconvulsive therapy (ECT) arguably remains the gold standard for acute antidepressant effects; however, the rates of competency in residents to deliver ECT remains low and stagnant. In this session, participants will get hands-on exposure to an ECT device, including guidance on programming the machine and use of EEG to determine seizure adequacy.

Références :

1. Al-Qadhi SA, Chawla T, Seabrook JA, et al. Competency by design for electroconvulsive therapy in psychiatry postgraduate training: face and content validation study. J ECT 2020;36:18–24.
2. Milev RV, Giacobbe P, Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. Can J Psychiatry 2016;61:561–75.

C04d – Practical Guidance for the Appropriate Use of Ketamine and Esketamine in Psychiatry
Joshua Rosenblat, MD, FRCPC

À la conclusion de cette activité, les participants seront en mesure de : 1) Review the evidence for ketamine and esketamine for depression and suicidality; 2) Discuss side effects and safety concerns for ketamine; and 3) Apply knowledge to inform patient selection, informed consent, and required monitoring for ketamine and esketamine.

Ketamine and esketamine represent novel interventions for adults with treatment-resistant depression (TRD). These agents represent the first non-monoaminergic agents with proven rapid-onset efficacy in major depressive disorder. Based on replicated clinical trials and meta-analyses, Level 1 evidence supports the acute antidepressant effects of intravenous racemic ketamine and intranasal esketamine. Other forms of ketamine and routes of administration have not yet been supported by adequately replicated clinical trials (e.g., oral, intramuscular, nasal racemic). Mood-independent reduction of suicidal ideations has also been demonstrated. Nevertheless, concerns remain about the safety and tolerability of ketamine and esketamine in mood disorders. Moreover, there is uncertainty about the appropriate position of these agents in treatment algorithms, their comparative effectiveness to other TRD treatments, and the appropriate setting, infrastructure, and personnel required for its competent and safe implementation. In this session, we provide a synthesis of the literature with respect to the efficacy, safety, and tolerability of ketamine and esketamine in TRD. The presenters also provide guidance for the implementation of these agents in clinical practice, with particular attention to practice parameters at point of care within the Canadian regulatory landscape. Requirements for informed consent will be reviewed and applied to case examples. Areas of consensus and future research vistas are also discussed.

Références :

1. McIntyre RS, Rosenblat JD, Nemeroff CB, et al. Synthesizing the evidence for ketamine and esketamine in treatment-resistant depression: an international expert opinion on the available evidence and implementation. Am J Psychiatry 2021;178:383–99.
2. McIntyre RS, Carvalho IP, Lui LMW, et al. The effect of intravenous, intranasal, and oral ketamine in mood disorders: a meta-analysis. J Affect Disord 2020;276:576–84.