Interventional Psychiatry Clinical Program

Overview / What We Do

The Interventional Psychiatry Program at St. Michael’s Hospital specializes in the treatment of mood disorders. We offer novel interventional and psychopharmacological treatments for major depressive disorder and other psychiatric disorders where previous treatments have been unsuccessful. Some of these treatments include intravenous ketamine, repeated transcranial magnetic stimulation, electroconvulsive therapy, and other emerging anesthetic and neurostimulation modalities.

We are also conducting a number of research studies with a goal of improving the way that mood disorders are diagnosed and treated using novel interventions.

Referral

Physicians may send a referral to our program using the general Ambulatory Program Intake Form (attach here). Please select the “Mood disorders” sub-specialty and indicate “evaluation for ketamine” in the reason for referral. Please fax the completed referral form. Our office will call the patient with information about their first appointment.

Please note that clinic appointments may be virtual visits. The clinic team will let patients know the type of appointment during their intake phone call.

Contact

Location: Unity Health – St. Michael’s Hospital

  • Phone
  • Fax
  • Email

Current and Upcoming Programs

Program Overview

Our program offers treatment in the form of repetitive transcranial magnetic stimulation, or rTMS, for individuals with major depressive disorder who have failed one or more pharmacological therapies in the past. rTMS is a non-invasive form of brain stimulation which has been approved by Health Canada for the treatment of major depressive disorder. It works by directly stimulating specific areas of the brain using focused magnetic field pulses that are applied using a magnetic coil placed against the scalp. These pulses stimulate specific parts of the brain and are applied repeatedly to strengthen or weaken connections within the brain, leading to long-lasting changes in brain activity. This change is known to reverse unhealthy and abnormal patterns of brain activity that are associated with major depression.

rTMS FAQ for Patients

  1. What is repetitive transcranial magnetic stimulation (rTMS)?
  2. How does rTMS work?
  3. How many treatments will I need?
  4. Who is eligible for rTMS treatment?
  5. Will rTMS work for me?
  6. What are the potential side effects of rTMS?
  7. Can I continue taking my antidepressant medication while getting rTMS?
  8. Are there any medications I should not take while getting rTMS?
  9. Do I have to pay for rTMS?
  10. What should I expect before, during, and after treatment?
  11. Where can I get more information?

What is repetitive transcranial magnetic stimulation rTMS?

rTMS is a Health Canada approved treatment for major depression. It is also being studied for use in other mental health conditions, such as bipolar affective disorder, generalized anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, substance use disorders, and eating disorders.

How does rTMS work?

rTMS uses a strong electromagnetic field to directly stimulate specific areas of your brain. These areas are involved in controlling your impulses, thoughts, emotions and behaviours and may be more or less active in people with depression and mental health disorders.

A magnetic coil is placed against your scalp which will target a specific area of your brain. With repeated treatments, the magnetic pulses change the activity of the brain cells (neurons) and the pathways between brain cells, returning the brain to normal functioning.

How many treatments will I need?

A course of rTMS involves approximately 20 to 30 treatment sessions. Sessions will occur daily for 4 to 6 weeks and each session will last 15 to 30 minutes.

The number of treatments you receive will be decided by your psychiatrist.

Who is eligible for rTMS treatment?

People who have major depression as well as other mental health disorders are eligible for treatment. rTMS is considered for people who have not benefited from one or more treatment options (such as medication or therapy). rTMS is also considered in patients that cannot tolerate side effects from medications.

The following patients may not be eligible for rTMS treatment:

  • Patients with a history of seizures or epilepsy
  • Patients with implanted devices or mental foreign objects in the head or eyes (excluding dental implants)
  • Patients with a history of stroke, brain surgery, traumatic brain injury, or other neurological conditions

Will rTMS work for me?

About half of people who receive rTMS for depression show significant improvement in their symptoms. One third of patients have a significant improvement in their symptoms (up to 80% improvement), one third of patients do not show any benefit from treatment and one third of patients are in the middle, receiving some benefit but requiring other treatments to control their symptoms.

rTMS works best in mood disorders, such as depression. Treatments in other conditions, such as impulse control disorders, are still considered experimental and the efficacy is not as well known.

What are the possible side effects?

Most people who receive rTMS experience only mild side effects. The most common side effect is scalp pain during treatment. The sensation is similar to static electricity and can be intense in the beginning. After the first few sessions, the nerves in the scalp adapt to the stimulation and the pain becomes less intense. Other symptoms may include headache or fatigue after treatment. These side effects are transient, and patients can take ibuprofen (Advil) or acetaminophen (Tylenol) 1 to 2 hours before treatment to reduce the pain or headache.

There is also a small chance that rTMS could cause a seizure. Seizure occurs in about 1 out of every 10,000 people who receive rTMS.

People with bipolar disorder may experience a manic switch, where their symptoms of depression turn to mania or hypomania. This is a rare side effect that occurs in less than 1% of patients with bipolar disorder. Our team will monitor patients daily to prevent such a switch.

Side effects will be discussed in more detail at your first appointment. rTMS has been in use since the early 1990s and there have been no known long-term side effects to date.

Our team will monitor for side effects during treatment.

Can I continue taking my antidepressant medication while getting rTMS?

If you are currently taking medication for depression, you do not need to stop taking it before starting rTMS treatment. You should be on a stable dose of the medication for at least 4 weeks prior to starting treatment. However, some medications may block the effects of rTMS and the psychiatrist and physician assistant will discuss these medications at your initial appointment.

It is important that you do not make any changes to your medications during the 4 weeks before treatment and during treatment. Changes to your medication during rTMS treatment would make it difficult to determine if rTMS works for you or not.

Are there any medications I should not take while getting rTMS?

You should talk to your doctor if you are taking any of the following medications which in some people may cause the rTMS to be less effective:

  • Lorazepam (Ativan)
  • Clonazepam (Klonopin)
  • Diazepam (Valium)
  • Alprazolam (Xanax)
  • Bromazepam (Lexotan)
  • Lamotrigine (Lamictal)
  • Pregabalin (Lyrica)
  • Gabapentin (Neurontin)
  • Carbemazepine (Tegretol)
  • Topiramate (Topamax)
  • Phenytoin (Dilantin)
  • Divalproex/ Valproate (Epival)
  • Clobazam (Frisium)
  • Levetiracetam (Keppra)
  • Meds list can be removed from here and put in referral form/ eligibility criteria

Do I have to pay for rTMS?

No, you do not have to pay for rTMS treatment. While rTMS is not currently covered by OHIP, our clinic has funds that will cover the cost of treatment.

Where do I go for treatment?

Your treatment will be at St. Michael’s Hospital, located at 30 Bond Street. The clinic is located on the 17th floor of the Cardinal Carter South Wing.

Please arrive 15 minutes early to your appointment and check in at the reception desk located on the 17th floor of the Cardinal Carter South wing. Once you exit the elevators in the Cardinal Carter South wing, head through the double doors and you will see the reception desk directly in front of you.

We ask that you complete a set of questionnaires that you can pick up from the reception desk. Once completed, you can hand them to the rTMS technician. The daily questionnaires will help you and the doctor track your treatment progress.

Please call the clinic 48 hours in advance if you need to cancel or reschedule the appointment.

You can contact the clinic at: 416-864-5418.

What happens during the treatment?

  1. During the treatment you will be sitting upright in a comfortable chair. You will be awake the entire time. You will not need any sedation medication or anesthesia.
  2.  The rTMS technician will place the rTMS coil against your forehead. You will be asked to hold your head steady during the treatment so that the coil stays in place.
  3. When the treatment begins, you will feel short bursts of stimulation on your scalp followed by short pauses. Many patients describe the feeling as similar to static electricity on their nose, teeth, and forehead. This sensation tends to be the most intense during the first few sessions and decreases as the nerves adapt.
  4. Each treatment will last approximately 15 minutes. The entire appointment will take approximately ___.

Do I have to restrict my activity after rTMS?

No. You can return to your normal daily activities right after the session. There are no driving restrictions after rTMS. If you choose, you may bring a support person to the first few sessions.

What happens when I finish my course of treatment?

Once you finish 20 to 30 sessions of rTMS over 4 to 6 weeks, you will be asked to return to the clinic for 2 to 4 follow-up appointments. The clinic administrative assistant will help you to book these appointments.

Your follow-up appointments will be with the psychiatrist or physician assistant. They will monitor your symptoms and help you arrange referrals for follow-up medication or therapy as needed. Some people benefit from a course of therapy after a successful course of rTMS treatment, which will help prevent symptoms from returning. This option can be discussed during a follow-up appointment.

In case of an emergency

If you are having thoughts of harming yourself at any time, please call the Greater Toronto Distress Centre Helpline 416-408-HELP (4357) or visit your nearest emergency department. In this situation, please do not use the clinic voicemail or email, as it may not be possible to provide an immediate response.

Program Overview

Our program offers intravenous ketamine treatment for individuals with treatment resistant depression. Treatment resistant depression is a form of depression in which there has been no improvement in symptoms after trying at least two pharmacological therapies. Ketamine is an N-methyl-D-aspartate receptor antagonist, which has long been used as an anesthetic medication. Recent evidence shows that subanesthetic doses of ketamine have rapid and robust antidepressant and anti-suicidal effects, which can have potentially life-saving relief for many individuals. Ketamine appears to work by mediating the glutamatergic system, which leads to changes in neural signaling and connectivity in relation to emotion and cognition in the brain. These changes in brain pathways result in improved depressive symptoms.

Ketamine FAQ for patients

  1. What is ketamine?
  2. How does ketamine work to improve depression?
  3. Will ketamine work for me?
  4. Who is eligible for ketamine treatment?
  5. Do I have to pay for this treatment?
  6. How is ketamine administered?
  7. What dose of ketamine will be used?
  8. What are the side effects of ketamine?
  9. How quickly does IV ketamine treatment begin to work?
  10. How many sessions of treatment will I need?
  11. How long do the effects of ketamine last?
  12. Can I continue taking my antidepressant medication while getting ketamine treatment?

What is ketamine?

Ketamine has been used as an anesthetic medication for the last 50 years. It is on the World Health Organization’s list of Essential Medications for its safety and efficacy as an anesthetic. More recently, over the past two decades, sub-anesthetic doses of ketamine have been used to treat psychiatric disorders including major depressive disorder (MDD).

There have been many clinical trials that have demonstrated the efficacy and safety of ketamine in reducing depressive symptoms and reducing suicidal ideation in treatment resistant depression compared to another drug or no drug at all.

How does ketamine work to improve depression?

In depression and other forms of persistent mood disorders, chronic stress results in changes in the signaling pathways within the brain. Ketamine works by blocking the N-methyl-D-aspartate (NMDA) receptor. By binding to the NMDA receptors, ketamine increases the amount of a neurotransmitter called glutamate within the brain, which leads to the activation of other molecules that help neurons communicate through new signaling pathways. This process is called synaptogenesis. This effect on signaling pathways likely results in changes in cognition and mood which are impacted by depression.

Will ketamine work for me?

Ketamine treatment helps

Who is eligible for ketamine treatment?

Individuals who are aged 18 and older with a diagnosis of moderate to severe depression who have not benefited from other forms of treatment are eligible for ketamine treatment.

Individuals who are not eligible for ketamine treatment include those who have active substance use disorders or have psychotic symptoms.

Do I have to pay for this treatment?

No, there is no cost to you to receive ketamine treatment. Ketamine is not currently covered by OHIP, however our clinic has funds available to cover the cost of treatment.

How is ketamine administered?

The most extensively studied route of administration of ketamine is intravenous, thus it is the most commonly used in clinical practice. Oral, sublingual, transmucosal, intranasal, intramuscular, and subcutaneous routes have also demonstrated an antidepressant effect in clinical trials, however more evidence is needed before being recommended over the intravenous route.

Intravenous ketamine is a mixture of two molecules, R- and S-ketamine. There is another type of ketamine, which uses only the S-ketamine molecule. It is called Esketamine or Spravato, which has Health Canada approval for use in treatment resistant depression, and is administered as a nasal spray. However, there is not enough evidence to suggest which form of ketamine is safer or more effective at this time. Given the depth of evidence-based research available, our program utilizes intravenous ketamine.

 What dose of ketamine will be used?

Intravenous ketamine is most commonly administered at a dose of 0.5mg/kg infused over 40 minutes. Your psychiatrist will determine whether a different dose may be needed for you.

 What are the side effects of ketamine?
The doses of ketamine that are used for depression are much lower than the dose used for anesthesia, which makes it relatively safe and tolerable. The potential side effects of ketamine appear to be dose-dependent and peak within 2 hours of infusion and resolve within 4-24 hours of infusion.

The most common short term side effects of subanesthetic doses of ketamine administered intravenously include a sense of dissociation (feeling disconnected from yourself or surroundings), increased blood pressure, and increased heart rate, which appears during treatment and disappears shortly after the infusion. Other potential side effects are anxiety, blurred vision, dizziness, headache, nausea, vomiting. These are known to be self-limited. We will monitor for these symptoms throughout the treatment.

In terms of long term side effects, studies of prolonged use of higher doses of ketamine have identified urinary symptoms, cognitive impairment, and risks for abuse and addiction. However, the duration of ketamine infusion within our program is not prolonged. The treatment dose used for depression is non-addictive.

How quickly does IV ketamine treatment begin to work?

The antidepressant effects of ketamine have been demonstrated to occur within 24 hours of a single administration. Some patients may see relief within a few days and some may need repeated treatments.

How many sessions of treatment will I need?

You will receive your IV ketamine treatment two times per week for three weeks. In total, you will receive 6 treatments over three weeks.

How long do the effects of ketamine last?

The antidepressant effects of ketamine appear to wear off within 3-12 days after treatment, although some patients remain well for a couple of months. The effects can be maintained with repeated doses of ketamine or other treatment modalities, including pharmacology, psychotherapy, or neurostimulation. However, there is not enough evidence to suggest the best route of administration, treatment interval, or dose of ketamine for maintenance treatment.

Can I continue taking my antidepressant medication while getting ketamine treatment?

Ketamine treatment is safe to receive when taking concurrent conventional antidepressants. There has been some evidence which suggests that concurrent use of some medications such as benzodiazepines and NMDA receptor antagonists may affect the effects of ketamine. Your psychiatrist will review your medications prior to determining if you are eligible for treatment with ketamine.

What are the contraindications for ketamine?
Ketamine should not be given to individuals who suffer from psychotic disorders or have psychotic symptoms. Ketamine is contraindicated in those who have uncontrolled or inadequately controlled elevated blood pressure and those who have shown hypersensitivity to the drug.

Do I need a referral for ketamine treatment?
You will require a referral from a physician

Where do I go for my intake assessment?
Your intake appointment may be conducted in-person or virtually. Our administrative team will let you know what type of appointment you will have prior to your visit. For virtual appointments, you will receive information about how to join your session virtually from the comfort and safety of your home. For in-person appointments, please come to St. Michael’s Hospital and go to the 17th floor of the Cardinal Carter South wing. Please check in at our reception desk. Please arrive 15 minutes early for your appointment to complete questionnaires which you will receive from the reception desk.

What can I expect before coming to the intake assessment?
You will be seen by a Psychiatrist and Physician Assistant to complete an initial 60-minute intake assessment to determine eligibility for the ketamine program. Once eligibility has been determined, you will be provided with information for your treatment schedule, which involves two in-person appointments per week for three weeks.

What can I expect before coming to my treatment sessions?
You will meet with the psychiatrist and physician assistant prior to receiving your treatment. You will meet an anesthesiologist who will be administering the intravenous ketamine treatment. The ketamine will be infused for 40 minutes.You will be  monitored for ___ after receiving the treatment. The entire session will take an average of ____.

Since St. Michael’s Hospital is a teaching hospital and is affiliated with research, you may meet other team members who may ask if you are interested in participating in any existing research trials.

What can I expect after completing the ketamine treatment program?

After completing treatment within our program, you will be referred back to the referring physician with further treatment recommendations and for ongoing care. We will continue to monitor you at regular scheduled follow-up appointments for up to ___ weeks.

In case of an emergency

If you are having thoughts of harming yourself at any time, please call the Greater Toronto Distress Centre Helpline 416-408-HELP (4357) or visit your nearest emergency department. In this situation, please do not use the clinic voicemail or email, as it may not be possible to provide an immediate response.


Anesthesia team to add specific details about treatment day eg. where to go, process

Eligibility criteria for referral form

Eligibility criteria:

  • Age 18-65
  • Individuals who have been diagnosed with moderate to severe Major Depressive Disorder or Bipolar Disorder
  • Individuals who are experiencing a Major Depressive Episode as defined and operationalized in the DSM-V
  • Individuals must have received at least 2 guideline concordant pharmacotherapeutic treatment trials

Exclusion criteria:

  • Individuals who meet DSM-V criteria for substance use and/or alcohol use disorder or have met criteria in the last three months
  • Individuals who are experiencing psychotic symptoms
  • Individuals who are experiencing a current manic episode
  • Individuals with symptomatic traumatic brain injury
  • Uncontrolled medical disorders (i.e. uncontrolled or insufficiently treated hypertension)
  • Individuals who are pregnant
  • Medical contraindications, allergies, or previous intolerability to ketamine
  • Individuals who cannot provide consent to treatment
  • Individuals who cannot commit to biweekly in-person treatments for duration of treatment

References

1. Andrade C. Ketamine for Depression, 1: Clinical Summary of Issues Related to Efficacy, Adverse Effects, and Mechanism of Action: (Clinical and Practical Psychopharmacolgy). J Clin Psychiatry. 2017;78(04):e415-e419. doi:10.4088/JCP.17f11567

2. Andrade C. Ketamine for Depression, 2: Diagnostic and Contextual Indications: (Clinical and Practical Psychopharmacology). J Clin Psychiatry. 2017;78(5):e555-e558. doi:10.4088/JCP.17f11629

3. Andrade C. Ketamine for Depression, 3: Does Chirality Matter?: (Clinical and Practical Psychopharmacology). J Clin Psychiatry. 2017;78(06):e674-e677. doi:10.4088/JCP.17f11681

4. Andrade C. Ketamine for Depression, 4: In What Dose, at What Rate, by What Route, for How Long, and at What Frequency?: J Clin Psychiatry. 2017;78(7):e852-e857. doi:10.4088/JCP.17f11738

5. Andrade C. Ketamine for Depression, 5: Potential Pharmacokinetic and Pharmacodynamic Drug Interactions: (Clinical and Practical Psychopharmacology). J Clin Psychiatry. 2017;78(7):e858-e861. doi:10.4088/JCP.17f11802

6. Andrade C. Ketamine for Depression, 6: Effects on Suicidal Ideation and Possible Use as Crisis Intervention in Patients at Suicide Risk: (Clinical and Practical Psychopharmacology). J Clin Psychiatry. 2018;79(2):18f12242. doi:10.4088/JCP.18f12242

UHN ECT v Ketamine protocol

UHN rTMS FAQ for formatting

Program Overview

Our program offers electroconvulsive therapy (ECT) for individuals with treatment resistant depression and other mental disorders. ECT is a safe and effective treatment for individuals who have not benefited from medications, psychotherapy, or other treatments.

ECT treatment involves applying a small, controlled current between two metal discs, called electrodes, which are placed on the scalp and/or temple. The current passes through a specific part of the brain, which stimulates a targeted area of the brain. It is believed that ECT works by affecting the neurotransmitters in the brain that transfer messages between nerve cells, which are altered in mood disorders. These changes in brain pathways result in improved depressive symptoms.

ECT FAQ for Patients

  1. What is electroconvulsive therapy (ECT)?
  2. How does ECT work?
  3. How many treatments are needed?
  4. How soon before I see results?
  5. Who is eligible for ECT treatment?
  6. Will ECT work for me?
  7. What are the potential side effects of ECT?
  8. Can I continue taking my antidepressant medication while getting ECT treatment?
  9. Do I have to pay for ECT?

What is electroconvulsive therapy (ECT)?
Electroconvulsive therapy (ECT) is a safe and effective treatment for mental health conditions, including major depression, bipolar disorder, and schizophrenia, which have not improved from other treatments, such as medications and psychotherapy. Treatment is administered under general anesthesia.

How does ECT work?

ECT involves administering a brief, controlled electrical current between two metal discs (electrodes) which are applied on the surface of the scalp or temple. The current stimulates a specific part of the brain and causes a small, controlled seizure which lasts between 15 and 90 seconds. This is done while you are under general anesthesia, and you will be asleep for about five to 10 minutes. You will be monitored by an anesthesiologist during your treatment. A course of ECT treatment will involve repeated treatment sessions.

By triggering brief, controlled seizures, ECT is associated with a number of neurophysiological changes. It affects many neurotransmitters which are implicated in mental disorders, which results in improvements in depressive symptoms.

How many treatments are needed?

On average, a course of treatment will involve 12 sessions, with approximately 2 to 3 sessions per week, however this will be determined by your doctor based on individual needs.

How soon before I see results?

Some of the therapeutic effects of ECT may be evident within 3 treatment sessions in some individuals, however may take longer in others. It is recommended to complete the full course of treatment to see full effects.

Who is eligible for ECT treatment?
ECT is recommended for people with severe mental illness, such as treatment resistant major depression, bipolar disorder, and schizophrenia. It is used experimentally in other conditions at this time. It is not a first-line treatment, meaning that it should be considered after people have not responded to other treatments, including medications, psychotherapy, and other forms of neurostimulation. However, for some people with very severe disease with life-threatening symptoms, ECT can be considered.

To be eligible for treatment, you must be medically stable and cleared by an anesthesiologist.

Will ECT work for me?

Current research has shown that 70-80% of individuals have an improvement in depressive symptoms, and 60% of people with depression can achieve remission with a course of ECT treatment.

Although ECT can be very effective for many people with severe mental illness, it is not a cure and other types of treatment may need to be continued to maintain positive effects. This maintenance therapy could involve medications, psychotherapy, other brain stimulation treatments, or ongoing ECT treatments.

What are the potential side effects of ECT?

The most common side effects of ECT include headache and muscle pain or stiffness. Some individuals may experience confusion, nausea, or high blood pressure, but these side effects are temporary. Some individuals may experience memory impairments which can last between several weeks to months.

  • Headache
  • Nausea
  • Confusion
  • Muscle stiffness
  • Memory loss
  • Changes in heart rate or blood pressure

Can I continue taking my antidepressant medication while getting ECT treatment?

Most medications can be continued during your ECT treatment. Your psychiatrist will review your medications prior to starting treatment with ECT.

Medications that may affect the seizure threshold will be evaluated and may be changed accordingly. Irreversible monoamine oxidase inhibitors (MAOIs) should be discontinued 14 days prior to ECT.

Do I have to pay for ECT?

No, there is no cost to you to receive ECT treatment?

In case of an emergency

If you are having thoughts of harming yourself at any time, please call the Greater Toronto Distress Centre Helpline 416-408-HELP (4357) or visit your nearest emergency department. In this situation, please do not use the clinic voicemail or email, as it may not be possible to provide an immediate response.

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