Category: depression

Neuromodulation Co-management in the Primary Care Setting

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Introduction

Depression is a prevalent and debilitating condition that affects millions of individuals across the United States. Primary care settings serve as the frontline for managing a broad spectrum of health problems, including mental disorders. Consequently, most patients receive treatment for depression directly from their primary care provider (PCP). Thus, PCPs play a crucial role in the initial identification, management, and follow-up of depressive disorders.

Most patients with depression can be effectively managed in these settings using evidence-based, first-line interventions like antidepressant medication and psychotherapy. However, some patients may not respond adequately to first-line treatments, necessitating consideration of alternative options. It is essential to recognize when to make this decision and to understand the array of possible interventions. This article describes neuromodulation co-management in primary care, in a manner similar to collaborative care, and specifically focuses on Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT). Guidance on referring patients to specialized care facilities is provided.

Neuromodulation

First-line treatments for depression typically include talk therapy like cognitive behavioral therapy (CBT) and antidepressant medications, such as serotonin reuptake inhibitors (SRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). While these treatments are generally well-tolerated and effective for many, approximately one-third of patients may not achieve sufficient symptom relief or may experience intolerable side effects limiting their usefulness. For these individuals, alternative approaches like neuromodulation may offer important benefits.

Neuromodulation is an emerging treatment area comprising various interventions that modulate neural activity in the brain to improve mood and other neuropsychiatric symptoms. These interventions are broadly categorized into invasive and non-invasive treatments, with most being low risk when used in the appropriately evaluated and medically optimized patient.

Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation (TMS) involves delivering magnetic pulses to specific brain regions to modulate neural activity. This non-invasive procedure is brief (lasting about 20 minutes per session), performed on an outpatient basis, and is generally well-tolerated by patients. TMS is used adjunctively, meaning that patients often continue medications or talk therapy or both. Common side effects, such as headaches or scalp soreness, are relatively minor. The major risk is for seizure, which is mitigated through careful patient screening and strict adherence to treatment protocols.

TMS is FDA-approved for several indications, including Major Depressive Disorder (MDD), Treatment-Resistant Depression (TRD), Anxious Depression, Late-life Depression (up to age 86), Obsessive-Compulsive Disorder (OCD), and smoking cessation. TMS is covered by most insurance plans, although prior authorization is required, and not all indications may be covered. Importantly, TMS usually does not involve additional medical work-up for most patients. More information about TMS can be found here: https://www.uwmedicine.org/practitioner-resources/center-behavioral-health-learning/neuromodulation

TMS and Primary Care

PCPs can effectively co-manage patients undergoing TMS in collaboration with a CfN psychiatrist or other mental health specialist, if needed and similar to collaborative care. Established protocols for behavioral emergencies ensure outpatient safety, while adjunctive treatments, such as medications, may be recommended to optimize outcomes. Familiarity with combination antidepressant approaches is helpful for PCPs involved in co-managing these cases, especially when the acute series of TMS treatments is completed and the focus of care turns to relapse prevention.

Electroconvulsive Therapy

Electroconvulsive Therapy (ECT) involves administering electrical energy to the brain to stimulate neuroplastic processes resulting in modulation of neural activity. The procedure is done while the patient is under brief general anesthesia. ECT is a highly effective treatment for major depression, whether associated with unipolar or bipolar disorder or complicated by psychosis or catatonia, or when a rapid response is needed due to the severity of the psychiatric or medical condition. Most patients can receive ECT on an outpatient basis, though those with more severe depression may require inpatient management.

Although there are no absolute contraindications to ECT, there may be relative contraindications necessitating thorough evaluation and discussion to appropriately risk-stratify and medically optimize the patient. Insurance, including Medicare and Medicaid, generally covers ECT, though managed care plans will often require prior approval.

ECT and Primary Care

Patients undergoing ECT usually require co-management with a psychiatrist or other behavioral health specialist due to the severity of their illness, not because of ECT. The main role of the PCP in the patient undergoing ECT involves conducting a pre-operative evaluation for the procedure since brief general anesthesia will be used. After the initial phase of ECT, the focus shifts to relapse prevention over the following 6-12 months. Strategies for relapse prevention may include combination pharmacotherapy, continued ECT but at reduced frequency, psychotherapy, or other neuromodulation techniques. PCPs should be comfortable collaborating with behavioral health specialists during this phase to identify early relapse.

Conclusion

Managing depression in primary care settings is both a challenging and rewarding endeavor. While many patients respond well to first-line treatments like CBT and antidepressant medications, a significant proportion may require other interventions. Neuromodulation therapies, such as TMS and ECT, offer alternatives for patients who do not respond adequately to initial treatments. By leveraging collaborative care models and co-managing with specialists, primary care providers can continue to help patients and improve outcomes. Referring patients for neuromodulation consultation ensures their patients receive the most appropriate and effective intervention, thereby improving their overall quality of life.

Referring to the UW Medicine Garvey Institute Center for Neuromodulation

The Garvey Institute Center for Neuromodulation at UWMC-Northwest provides a comprehensive suite of neuromodulation treatments within a collaborative care framework, ensuring patients receive holistic and coordinated care. When considering a referral for neuromodulation consultation, primary care providers can access information on the CfN website. The referral process entails providing a reason for referral (e.g., diagnosis), a clinical synopsis of the case, details of current treatments tried, and, if known, the requested intervention.

What to Expect from the Initial Consultation

Comprehensive Review: The initial consultation at CfN provides a thorough review of the patient’s current and relevant medical and psychiatric history and documents a comprehensive mental status and behavioral exam.

Identifying the Best Intervention: The CfN consultant will determine whether neuromodulation is indicated, and if so, the most appropriate neuromodulation intervention to address the patient’s diagnosis.

Explaining the Procedure: The specialist explains the chosen procedure in detail, ensuring the patient understands and consents to the proposed treatment.

Preparation Steps: The consultation includes outlining the necessary steps to prepare for the procedure.

Feedback to the Referring Clinician: Finally, the specialist provides detailed feedback to the referring clinician, including findings, preparation or treatment plans, and follow-up recommendations.

Author

Randall Espinoza, MD, MPH

Dr. Espinoza is the medical director of the Garvey Institute Center for Neuromodulation located at the Center for Behavioral Health and Learning. He specializes in behavioral health, psychiatry, and geriatric psychiatry. He holds certifications in electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).

Related Resource

Dr. Espinoza put together this presentation about the Center for Neuromodulation where his team provides state of the art neuromodulation and interventional psychiatry treatments including: Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (rTMS and dTMS).


Addressing sleep-related difficulties

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“I’m having trouble sleeping” is a common concern of patients who report co-morbid mental health concerns like anxiety or depression and/or have a history of trauma, but sleep issues can be reported independently of other conditions as well. Though it can be tempting to suggest using melatonin or another medication to aid with sleep,  there are simple behavioral interventions that may be just as – if not more – effective in the long-term for addressing sleep-related concerns. 

One of the simplest ways to gain a better understanding of what sleep-related concerns our patients are facing is to ask. Is it that they aren’t sleeping as much as they would like to? Are they sleeping too much? Is their sleep interrupted? Asking about environmental factors is important, too. Do they have a new baby at home? Did they recently change jobs? Do the other people in their home sleep on different schedules than they do? Even clarifying what their sleep schedule looks like can help you to decide what to recommend.

Someone can have sleep-related problems that don’t rise to the diagnostic criteria for insomnia, or they may be experiencing primary or secondary insomnia. Once you’ve gathered information about what problems they are encountering, you’ll have a better sense of whether the difficulties are related to sleep onset, sleep maintenance, or early awakening (or some combination). It’s also a good idea to assess for other sleep disorders, not just insomnia. According to the Center for Disease Control, the most common sleep disorders, in addition to insomnia, are narcolepsy, Restless Leg Syndrome, and Sleep Apnea. An important note about sleep apnea – be sure to assess for it even in your patients who are not classified as obese, as apnea may occur in individual with normal or low BMI.

After clarifying what sleep-related difficulties your patient is reporting – and attending to any potential sleep disorders aside from insomnia – it’s a great time to begin talking about sleep hygiene. Consistency is key when it comes to sleep hygiene. Going to bed at the same time every night (when possible, of course) and getting up at the same time each morning can go a long way. Yes – even on non-workdays!

Another important sleep hygiene tip: the bed is for three things – sleep, sex, and sick. It can be tempting to read or watch TV in bed. And who among us hasn’t played on our phones instead of going to sleep? However, maintaining the sanctity of the bed for sleep, sex, and/or sick – and only these three things – encourages strong sleep-bed associations. Something else that encourages strong sleep-bed associations? Getting out of bed within 10-15 minutes of waking or if unable to fall asleep for approximately 15-20 minutes. The longer you are in bed and awake, the weaker your sleep-bed association will be.

Other sleep hygiene tips:

  • Avoid napping (unless it’s a safety concern). It can be tempting, especially when someone is very tired, but it ultimately decreases one’s “sleep appetite” and makes it harder to sleep at night.
  • Implement a wind-down routine, preferably without screens (TV, phones, computers, etc.). Try to avoid screens for an hour or more before bed.
  • Keep your bedroom cool and dark.
  • Avoid exercise, eating, or drinking close to bedtime. If someone wakes due to hunger, trying a small snack before bed could help – but it’s best to avoid a large meal.
  • Avoid alcohol, cigarettes, and other substances close to bedtime. For those individuals who smoke cigarettes – a gentle reminder that nicotine is a stimulant and therefore counterproductive to sleep can be helpful.
  • If waking in the middle of the night, avoid eating, drinking, or smoking. Our bodies become habituated to patterns and if you eat a snack every night at 2:00am, 2:00am may officially become snack time!
  • Don’t go to bed unless you’re tired. This might run counter to “consistent bedtime” however, getting into bed just because the clock (but not your body) says it is time can make it harder to sleep.

Individuals who are not able to correct their sleep difficulties with sleep hygiene alone may benefit from completing a course of Cognitive Behavioral Therapy for Insomnia. This treatment typically occurs across 4-8 sessions, though individuals may begin to see positive results in as few as 3 weeks. This treatment can be completed with a trained therapist or via a self-paced online course. CBT-I can be tried before sleep medications and, in many cases, may end up making medication unnecessary.

CBT-I provides education about sleep, sleep hygiene, and helps to identify specific strategies to improve an individual’s sleep. It may involve sleep restriction – the practice of restricting when a person gets into bed and gets up – which helps consolidate sleep into a more solid block. As sleep becomes consolidated (and sleep efficiency improves), more time in bed is added based on individual need and bedtimes/wakeups are adjusted.

One last caveat – if you are seeing a patient who has been diagnosed with ADHD and is reporting sleep-related concerns, you may want to explore the possibility of Delayed Sleep Phase Syndrome (DSPS), in which the sleep/wake phase occurs later than “normal.”

Sleep is extremely important to health – and when we’re not getting enough of it, it shows. Hopefully this information will prove helpful in working with patients with that ever-present concern of, “I’m having trouble sleeping!” You can always call the Psychiatry Consultation Line (877-927-7924) for clinical advice when sleep issues co-present with mental health concerns like anxiety, depression or ADHD as well as assessment, treatment decisions and monitoring of mental health conditions in general. Call us anytime – we are a part of your team!

Author
Koriann Cox, PhD
Acting Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences

Learn More:
UW Psychiatry and Addictions Case Conference series (UW PACC)*

When should I use sleep aids in my patients with sleep disorders… (and when should I not?)
Presenter: Catherine McCall, MD
The objectives of this presentation are to 1) learn about different ways in which insomnia can manifest; 2) understand the pathophysiology of insomnia; and 3) explore different ways to address and treat
insomnia effectively.

Psychological and behavioral treatments for insomnia
Presenter: Katherine Palm-Cruz, MD
The objectives of this presentation are to 1) develop an understanding of psychological and behavioral treatments for insomnia disorder; 2) understand recommendations for first line treatments for chronic insomnia; and 3) appreciate the evidence of how CBT-I compares to pharmacologic treatments for insomnia.

My patient has good sleep hygiene. What should I counsel them to do next to improve their poor sleep?
Presenter: Barbara McCann, MD
The objectives of this presentation are to 1) conduct a 24-hour interview to identify problem areas in need of remediation to address insomnia; 2) identify two broad areas of sleep-interfering cognitions and suggest strategies for dealing with each type; and 3) make use of stimulus control principles to address sleep-interfering behaviors.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Learn More: other resources

Mirtazapine in major depressive disorder in adults

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Mirtazapine garnered FDA approval as an antidepressant in 1997. It has been generic for so long that it no longer has an advertising budget and thus you won’t see commercials for it on late-night television. Mirtazapine impacts serotonin and norepinephrine systems in the brain but is not a reuptake inhibitor. While SSRIs are generally considered first-line in major depressive disorder, mirtazapine is a medication worth remembering in certain situations. 

Mirtazapine does not inhibit P450 enzymes and thus can be useful in depressed patients who have complex medical histories and are on complicated (and ever changing) medication regimens. 

Mirtazapine does not cause sexual dysfunction greater than placebo, making it a potentially useful alternative for patients with depression and intractable, SSRI-associated, sexual dysfunction. Sexual side effects are seen in as many as 50% of patients on SSRIs and are frequently cited by patients as a reason for medication discontinuation.

Per the original package insert, 17% percent of patients taking mirtazapine experienced appetite stimulation. “Weight gain” is often all that prescribers remember about mirtazapine. It is true that this medication has a higher risk of weight gain than SSRIs, that this issue needs to be discussed with patients, and that weight needs to be closely monitored. However, it is also notable that only a minority of patients have this side effect. On the other hand, for patients who experience a profound loss of appetite as a feature of their depression, the potential for appetite stimulation with mirtazapine might be seen as an advantage. 

Mirtazapine is a strong antihistamine and, indeed, the original package insert notes that 54% of patients on mirtazapine reported sedation, compared to only 18% for placebo. This side effect can represent a hindrance or a benefit, depending on the specific features of the patient’s depression and on the degree of sedation. For example, psychiatrists sometimes use mirtazapine as an augmentation strategy for patients who have had a partial response to SSRIs and whose depressive symptoms include prominent initial insomnia. It should be noted that oversedation can impair performance and thus this side effect needs to be monitored by the patient and the prescriber.

Unlike the SSRIs and SNRIs, mirtazapine’s only FDA indication is for major depression. In the intervening 25 years since its FDA approval, the bulk of mirtazapine’s positive data remains for its use in major depression. There is some mixed data (variable strength of study and variable results) in generalized anxiety disorder and social anxiety disorder. However, we do not usually consider mirtazapine as a first- or second-line agent for monotherapy in anxiety disorders.

If you are considering using mirtazapine, please refer to your own reference material for full prescribing information regarding medication dosing, risks, benefits, side effects, monitoring requirements, and drug interactions.  We most often use Micromedex, UpToDate, or Epocrates.  Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/. You can also call the Psychiatry Consultation Line (877-927-7924) for clinical advice on using mirtazapine in the treatment of major depressive disorder in adults as well as assessment, treatment decisions and monitoring of mental health conditions in general. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line

Learn More
Treatment Resistant Depression
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) discuss pros and cons of treatment guidelines, 2) walk through cases to determine best options, and 3) Improve confidence in decision making around treatment resistant depression.

Using Stimulants to Augment Depression Treatment
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Ramanpreet Toor, MD
The objectives of this presentation are to review evidence of psychostimulant use in the treatment of depression.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.