TECHNOLOGY IN PSYCHIATRIC PRACTICE
From The Use of New Technologies in Psychiatric Practice, presented by the University of Iowa Roy J. and Lucille A.
Carver College of Medicine and the American Academy of Clinical Psychiatry
Educational Objectives
| The goal of this program is to explore the use of computers and neurosurgery in the treatment of psychiatric disorders. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Describe some of the computer programs available for treating obsessive-compulsive disorder, depression, and anxiety.
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| 2. Discuss the use of computer programs for treating psychiatric disorders without the involvement of a clinician.
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| 3. Explain why interdisciplinary cooperation is essential for successful use of neurosurgical procedures in treating psychiatric
disorders.
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| 4. Describe some of the neurosurgical procedures currently under investigation or already approved for use in treating
psychiatric disorders.
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| 5. Identify the indications for recommending neurosurgery for psychiatric disorders.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Wright
receives royalties from Mindstreet. Dr. Slavin receives research support/honoraria from St. Jude Medical and Medtronic.
The planning committee reported nothing to disclose.
Acknowledgements
Drs. Wright and Slavin were recorded at The Use of New Technologies in Psychiatric Practice, held March 14-16, 2008,
in San Francisco, CA, and sponsored by the University of Iowa Roy J. and Lucille A. Carver College of Medicine and
the American Academy of Clinical Psychiatrists. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
| THE USE OF COMPUTERS IN PSYCHOTHERAPY —Jesse H. Wright, MD, PhD, Professor and Associate Chairman
for Academic Affairs, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine,
Louisville, KY
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| Introduction: speaker defines computer-assisted psychotherapy as form of psychotherapy directed or supervised by clinician
and that uses a computer to deliver part of therapy; however, this definition not universal, and others broaden it to
include other applications of computer technology
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| Why do computer-assisted psychotherapy? to save money and therapist time; to increase access to different
therapies, particularly those that are empirically driven but not widely available; some patients prefer computer-assisted
psychotherapy (in studies, patient acceptance has been high, but obviously, some patients do not like it); no side
effects observed
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| Appealing features of computer-assisted psychotherapy: programs, especially those that took decade or more
to develop, are refined, so therapy well organized, systematic, and evidence based; interactive exercises promote patient’s
learning; programs can provide extensive feedback to patients, which also promotes learning; programs encourage use of
homework and help build coping skills; computer assistance reduces burden on clinician to perform repetitive tasks; programs
can store, analyze, and import data
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| Psychotherapy programs: “vast majority” based on cognitive behavioral therapy (CBT), which is learning based; psychoeducation
is big component of CBT, and computer can be used to teach concepts to patients; exposure therapies for
anxiety disorders have proven amenable to computer-assisted therapy
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| Computer technologies used in psychotherapy: virtual reality; multimedia presentations; hand-held computers
for behavior therapy; interactive voice response; psychoeducation via Internet; early psychotherapy programs often used
only text to convey information, but patients, especially those with depression, often had trouble concentrating on text for
long periods, so programs expanded to exploit other computer capabilities as well
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| Virtual reality: virtual-reality exposure therapy currently used for therapy for anxiety disorders, but being explored for
use in other disorders (such as posttraumatic stress disorder and substance abuse); although studies show positive results,
they typically have small number of subjects; as yet, no comparisons with other forms of therapy
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| Multimedia applications: speaker’s program, “Good Days Ahead,” uses digital video disk–read-only memory (DVD-
ROM) to deliver video and audio; characters in program illustrate ways of using CBT to solve problems, such as interpersonal
disputes or difficulties at work; user (patient) placed first in role of student learning basic concepts, principles,
and skills of CBT; then placed in role of patient who visits clinician, who explains “what the program is all about and
walks [him or her] through it”; and finally, placed in role of helper to assist main character in making way through life
and recovering from depression; program provides feedback that encourages learning; covers core principles of CBT
for depression thoroughly, but not recommended for anxiety other than anxiety that accompanies depression; professional
edition allows storage of patients’ responses, and patient can use self-help edition as electronic workbook
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| Outcome data: completion rate 78%; satisfaction scores not worse in those who dropped out, so reasons for dropout unknown;
no adverse effects seen; on scale of 1 to 5 (5 highest), acceptance high; scores on various depression scales
same as those for standard CBT; scores for both types of therapy better than those for controls (on waiting list); patients
who used computer-assisted therapy did better on Dysfunctional Attitude Scale (DAS) and on Cognitive Therapy Scale
(CTS) than those on standard therapy; results need to be replicated
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| Other multimedia programs: group in United Kingdom (UK) developed multimedia program for anxiety disorders; trial
showed improvement in patients’ anxiety, but not randomized; “Beating the Blues” and “Fear Fighter” also developed
in UK, approved by UK National Institute of Clinical Excellence for use in primary care settings
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| Internet-delivered CBT (I-CBT): defined for meta-analysis as “CBT where the participant works through [the program]
more or less independently on the Internet”; degree of working independently varies widely, depending on study;
MoodGYM developed in Australia and accessed by greatest number of people worldwide; various characters introduced,
including one named Moody; patient learns how to use basic CBT principles in his or her life; program is psychoeducational
and does not have any clinician guidance or involvement; however, studies have found that if therapist not involved,
rates of completion low (0.4% in one study; speaker posits that people visit site out of curiosity, but soon lose interest
when there is no human interaction); other studies find effect sizes also small when no clinician involved
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| Bottom line: many programs used in research not available for clinical practice, mostly because few studies done on efficacy
of computer-assisted psychotherapy, and even fewer studies have compared computer-assisted psychotherapy to
standard treatments
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| Future directions: computer-assisted psychotherapy currently not widely used, but interest growing; speaker speculates
that, in future, clinicians will have “toolbox” of computer programs to use for treatment of many mental disorders, including
eating disorders, obsessive-compulsive disorder (OCD), and substance abuse
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| NEUROSURGERY FOR THE TREATMENT OF PSYCHIATRIC DISORDERS —Konstantin Slavin, MD, Associate
Professor, Chief of Stereotactic and Functional Neurosurgery, and Director of Clinical Fellowship Program in Stereotactic
and Functional Neurosurgery, Department of Neurosurgery, University of Illinois College of Medicine, Chicago
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| Introduction: neurosurgery for psychiatric disorders is subspecialty of functional neurosurgery (which is subspecialty of
neurosurgery); deals with all aspects of patient selection, choice of surgical procedures, and targets of surgical treatment
for variety of conditions; requires interdisciplinary cooperation between psychiatry, neurology, neuroimaging, neurosurgery,
and other disciplines
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| Theory of neurosurgery for psychiatric disorders: neurosurgeon operates on “circuit of emotions,” which includes
cingulate gyrus, thalamus, amygdala, hippocampus, mamillary bodies, and limbic system; goal of surgery is to
disrupt this circuit which, when abnormal, is believed to be responsible for emotional and behavioral symptoms
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| Stereotactic approach: procedures done for past few decades involve stereotactic approach instead of free-hand techniques;
in stereotactic approach, patient’s head placed in aluminum-based frame that stabilizes head, provides frame of
reference for imaging, and serves as steady base for surgical instruments; procedures currently used include cingulotomy,
capsulotomy, subcaudate tractotomy, and limbic leukotomy
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| Cingulotomy: procedure of choice in United States; historically, used for treatment of pain, particularly cancer pain, and
for treatment of intractable OCD and depression; seems to have most efficacy in affective disorders, medium efficacy in
OCD, and no efficacy for schizophrenia or personality disorders; seizures observed in 1% to 9%; neurologic deficits rare,
because procedure performed posteriorly; target is cingulate cortex at level of coronal suture; radiofrequency (RF) lesions
created bilaterally
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| Capsulotomy: procedure of choice in Continental Europe; performed on connections between limbic system and frontal
cortex; target is anterior limbal internal capsule where frontal orbital cortex connects to rest of brain and where caudate
nucleus connects to putamen; as opposed to cingulotomy, capsulotomy seems to work best for OCD and medium for depression;
does not work for schizophrenia; approach through frontal lobes causes confusion in patient, but usually transient;
seizures occur in ≤3%
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| Subcaudate tractotomy: developed in England; involves undercutting or destruction of frontal orbital cortex or next to
nucleus accumbens under caudate nucleus; target is innominate substance on both sides of brain; initially, surgeons implanted
radioactive seeds, but eventually started to do radiofrequency lesions, too; greatest improvement observed in depression,
less improvement in OCD; personality changes occur in 7%, and “some incidence” of seizures
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| Limbic leukotomy: used in England, Australia, and New Zealand; combination of cingulotomy and subcaudate tractotomy
that disrupts same tracts in 2 different places; 5 lesions created on each side over frontal orbital cortex and cingulate
cortex; seems to work best for OCD and depression, less so for anxiety; personality changes more frequent; confusion,
lethargy, and incontinence also frequent
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| Literature summary: cingulotomy and subcaudate tractotomy probably works best for affective disorders, OCD, and
anxiety; limbic leukotomy works for OCD and affective disorders; capsulotomy works best for OCD
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| Patient selection: indications—patient must have established diagnosis by specialist, and usually confirmed by several
specialists; must be shown that disorder intractable, that patient has not responded to medications or psychotherapy; disorder
must be chronic and disabling; prognosis must be poor; informed consent mandatory; somebody must be available
to follow up on patient and report to interdisciplinary team; contraindications—age is relative contraindication, but most
desirable patient between 20 and 65 yr of age; patient must not be institutionalized or to have court order for treatment;
complicating Axis I, II, and III diagnoses are contraindications
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| Benefits and pitfalls: benefits—no implanted hardware (electrodes removed after lesions made); no need for general
anesthesia or sedation (since brain cannot feel pain, only local anesthesia needed for skin and bone); effects permanent
(so patient does not need repeat procedures); risk for infection minimal; no additional equipment-related expense (procedures
use equipment already in operating room for other reasons); pitfalls—nature of procedure destructive, so effects irreversible;
no way of testing efficacy in operating room; lesion size varies from person to person; risk for hemorrhage;
changes can be abrupt and severe, “so the patient may have good and bad things happening right on the table”; despite
thousands of procedures done worldwide, few good prospective controlled studies
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| Stereotactic radiosurgery: performed by neurosurgeon in operating room, but no actual cutting occurs; radiation device
(gamma knife) focuses cobalt radiation on precise spot in brain; historically, used for treatment of tumors and vascular
malformations, now under study for depression and OCD; most experience so far at Brown University, but nothing
published yet; target is anterior lingual internal capsule; verbal reports say results good; benefits—extremely precise;
instruments attached to frame, so no possibility of fluctuations of surgeon’s hands; no need for incision; painless;
changes not immediate (takes 3-6 mo for improvement to occur), which is attractive for some patients; no procedure-
related confusion; no need for general anesthesia; risk for infection negligible; both sides can be operated on at same
session; no hardware implanted; effects permanent; no additional equipment-related expense; no need to reoperate;
ideal for double-blind studies; pitfalls—procedure destructive and effects irreversible; no physiologic feedback; risk
for radiation injury (individuals vary in sensitivity to radiation); up-front costs “tremendous” because gamma knife
very expensive; treatment latency may be prolonged; clinical experience limited
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| Deep brain stimulation: tissue not destroyed; rather, stimulation changes milieu of electrical signals around electrodes;
exact mechanism unknown; with patient’s head in frame, thin (1.2 mm) wires inserted with guide and special cannulas;
wires do not irritate brain; multiple studies of treatment of OCD, depression, and Gilles de la Tourette’s syndrome;
capsular stimulation for OCD has initial approval from Food and Drug Administration (FDA), and approval
expected soon for humanitarian device-exemption status; results of early trials for treatment of depression encouraging,
but number of subjects small, and FDA requires more study; no big studies planned for treatment of Gilles de la
Tourette’s syndrome because, in trials, some patients disabled by procedure, although most improved; benefits—
nondestructive; parameters adjustable, depending on patient’s response; temporary electrodes can be inserted for testing
patient’s response before battery pack inserted; effect reversible; pitfalls—device must be kept on at all times to
maintain effect; every change of batteries requires another surgery; devices expensive and cost of treatment may be
≥$150,000; implanted hardware may not function or may get disconnected; risk for infection; follow-up time consuming
for clinician; long-term effects unknown
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| Vagal nerve stimulation: use for treatment of depression began in 1998, although it has been used longer for treatment of
epilepsy; although still approved by FDA for treatment of depression, no longer covered by Medicare; outpatient procedure
that requires 2 incisions, 1 in neck for insertion of electrode around vagal nerve, 1 in chest for battery pack; wire
tunnels under skin from battery to electrode; when device on, patient’s voice altered, but otherwise well tolerated
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| Conclusions: best neurosurgical approach for psychiatric disorders unknown; no trials comparing different modalities;
important not to get overzealous in applying new technologies, because, in past, procedures such as lobotomy were used
indiscriminately, and many patients suffered; interdisciplinary cooperation essential for best outcomes
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Suggested Reading
Anderson SW, Booker MB Jr: Cognitive behavioral therapy versus psychosurgery for refractory obsessive-compulsive
disorder. J Neuropsychiatry Clin Neurosci 2006, 18:129; Cosgrove GR: Deep brain stimulation and psychosurgery.
J Neurosurg 2004, 101:574; Difede J et al: Virtual-reality exposure therapy for the treatment of posttraumatic stress disorder
following September 11, 2001. J Clin Psychiatry 2007, 68:1639; Elgamal S et al: Successful computer-assisted
cognitive remediation therapy in patients with unipolar depression: a proof of principle study. Psychol Med 2007, 37:1229;
Jung HH et al: Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: Long-term follow-up results.
Stereotact Funct Neurosurg 2006, 84:184; Mashour GA, Walker EE, Martuza RL: Psychosurgery: past,
present, and future. Brain Res Brain Res Rev 2005, 48:409; Nuttin B et al: Electrical stimulation of the brain for psychiatric
disorders. CNS Spectr 2000, 5:35; Proudfoot J et al: Computerized, interactive, multimedia cognitive-behavioural
program for anxiety and depression in general practice. Psychol Med 2003, 33:217; Rothbaum BO et al: Effectiveness
of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. Am J Psychiatry 1995, 152:626;
Sakas DE et al: Neurosurgery for psychiatric disorders: from the excision of brain tissue to the chronic electrical stimulation
of neural networks. Acta Neurochir Suppl 2007, 97:365; Selmi PM et al: Computer-administered cognitive-behavioral
therapy for depression. Am J Psychiatry 1990, 147:51; Selmi PM et al: Computer-administered therapy for
depression. MD Comput 1991, 8:98; Slavin KV: Neuronavigation in neurosurgery: current state of affairs. Expert Rev
Med Devices 2008, 5:1; Steele JD et al: Anterior cingulotomy for major depression: clinical outcome and relationship to
lesion characteristics. Biol Psychiatry 2008, 63:670; van Straten A, Cuijpers P, Smits N: Effectiveness of a web-
based self-help intervention for symptoms of depression, anxiety, and stress: randomized controlled trial. J Med Internet
Res 2008, 10:e7; Wichmann T, Delong MR: Deep brain stimulation for neurologic and neuropsychiatric disorders.
Neuron 2006, 52:197; Woerdeman PA et al: Frameless stereotactic subcaudate tractotomy for intractable obsessive-
compulsive disorder. Acta Neurochir (Wien) 2006, 148:633; Wright JH et al: Computer-assisted cognitive therapy for
depression: maintaining efficacy while reducing therapist time. Am J Psychiatry 2005, 162:1158; Wright JH et al: Development
and initial testing of a multimedia program for computer-assisted cognitive therapy. Am J Psychother 2002,
56:76.
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