Stigma

Stigma toward ECT remains present among both the medical community and general public. In one study from the United Kingdom, both medical students and the general public reported receiving most of their knowledge about ECT from movies and television.^{Reference McFarquhar and Thompson18} This source of bias may be especially relevant in an era of ubiquitously available videos, such as YouTube,^{Reference Genc, Wu and Pinjari19} and the use of nontraditional media for sharing peer-reviewed medical information about ECT may be needed to reach a broader demographic of people.^{Reference Zhu, Phuong and Giacobbe20} There are data showing that education about ECT during training reduces the stigma among psychiatrists and increases the likelihood of patients being referred for this procedure.^{Reference Dauenhauer, Chauhan and Cohen21}

Ethnic minorities may be especially less likely to receive ECT, despite an absence of data to suggest inferiority of clinical outcomes based on racial background.^{Reference Williams, Rummans and Sampson22} In a study conducted in the USA, African Americans were over three times less likely than Caucasian patients to receive ECT for severe depression.^{Reference Case, Bertollo, Laska, Siegel, Wanderling and Olfson23} Parker has argued that to reduce disparities in access to ECT in ethnic minorities, clinicians must validate their unique personal lived experiences to reduce stigma to the procedure, especially geriatric minorities who are more likely to have accumulated negative experiences navigating the medical system during their lifetimes.^{Reference Parker, McCall, Rosenquist, Cortese and Spearman-McCarthy24}

Although the comparison of ECT to other Interventional Psychiatry approaches has not been formally studied, it would be expected that this barrier may be further heightened, as proposed treatment progresses toward the more invasive psychiatric neurosurgeries of DBS and FUS. However, there is evidence that in those who do receive ECT, the experience improves both their knowledge and attitudes toward this procedure. Aoki and colleagues have also noted positive change in family members of patients,^{Reference Aoki, Yamaguchi, Ando, Sasaki, Bernick and Akiyama25} suggesting that increasing accessibility to ECT is an important means of reducing the stigma associated with it.

Funding/Advocacy

Results from the preceding section suggest that eliminating institutional barriers to providing ECT may represent a way forward to increase the public sentiment toward this treatment. Compared to other treatments for psychiatric disorders, such as prescribing antidepressant medication or delivering psychotherapy, ECT is a more costly treatment involving coordination of teams of multidisciplinary healthcare professionals.^{Reference Fitzgibbon, Plett, Chan, Hancock-Howard, Coyte and Blumberger26} It is not surprising, then, that many of the variables contributing to ECT utilization reflect social and economic factors.

In a study comparing published rates of ECT and antidepressant medication utilization across nations, and the impact of health, social, and economic indices, Rakita et al. found that government expenditure on mental health was the only significant contributor to global variation in ECT use worldwide, while the Human Development Index, a composite index of life expectancy, education rates, and per capita income indicators, significantly correlates with global antidepressant utilization.^{Reference Rakita, Bingham, Fung and Giacobbe27} These findings suggest that across the globe, ECT, and as an extension, other Interventional Psychiatric approaches that also require equipment and multiple personnel for delivery, can be a bellwether measure of the degree to which a nation financially invests in mental health care for its citizens. Although there are no population data available on rTMS utilization across Canada, the ability to access this Health Canada approved treatment varies by province as a function of whether it is publicly funded. While some provinces and territories provide funding for rTMS,^{Reference MacMaster, Mitchell and Bichel28} funding models vary with procedural fee codes available to any rTMS practitioners in Saskatchewan and Yukon, while there is restricted funding to specialty rTMS clinics in Nova Scotia, Quebec, and Alberta. Further advocacy is needed to ensure that funding for this treatment does not impede equitable access across the country.

Training

Research has consistently revealed that training and education in Interventional Psychiatry are a rate-limiting step to greater utilization and implementation of these treatments. In a nationwide survey of ECT practitioners in the U SA, the lack of trained ECT practitioners was identified as the top barrier to the implementation of an ECT program.^{Reference Wilkinson, Kitay and Harper29} In Canada, the existing literature has indicated that only a minority of psychiatry residents receive adequate training in ECT. The majority of ECT programs indicated that they did not have a formal teaching program for psychiatry residents and in the programs that did provide teaching, methods varied widely.^{Reference Patry, Graf and Delva30} This lack of uniformity is perhaps not surprising given that, up until recently, there have been no specific recommended structured approaches put forward to teach ECT in Canada and the common methods of pedagogy have been indirect observation without experiential learning and supervision.^{Reference Al-Qadhi, Chawla, Seabrook, Campbell and Burhan10}

In a recent survey of 162 residents preparing for licensure in psychiatry, 91% agreed that familiarity with the theory and administration of ECT should be a requirement to be a psychiatrist in Canada; however, fewer than 1 in 4 (24%) felt competent to provide it at the end of their training.^{Reference Giacobbe, Ng and Blumberger31} Unfortunately, these rates have been stagnant over the past three decades (see Figure 2). In 1991, Goldbloom and Kussin reported that 25.3% of residents endorsed competency in ECT, and this rate dipped to 18% in 2001.^{Reference Goldbloom and Kussin32,Reference Yuzda, Parker and Parker33}

Figure 2: Percentage of Canadian trainees endorsing competency in delivering Interventional Psychiatry procedures over time. (a) Goldbloom and Kussin^{Reference Goldbloom and Kussin32}; (b) Yuzda et al.^{Reference Yuzda, Parker and Parker33}; (c) Giacobbe et al.^{Reference Giacobbe, Mithani and Meng34}

What specifically appears to be lacking are opportunities to receive supervision in the delivery of ECT. Although 86% of respondents felt that they received adequate didactic teaching in ECT rates equivalent to reported adequacy of teaching for the use of psychotherapy and pharmacotherapy in the treatment of MDD, only 69% endorsed having adequate supervision in using ECT, in comparison of rates of 81% and 90% for psychotherapy and pharmacotherapy, respectively.^{Reference Giacobbe, Ng and Blumberger31} However, this study showed that administering ECT more than 10 times in residency was significantly associated with perceived ECT competence, providing evidence that the means to achieve increased competency in ECT is through curriculum change to allow more opportunities to receive supervision in the hands-on delivery of this treatment.

Beyond ECT, gaps also exist in training for other Interventional Psychiatry techniques. In the first benchmark in the literature, 57% of the emerging psychiatric workforce in Canada indicated that rTMS should be required for licensure, but only 3% felt that they had achieved competency and 86% felt their exposure to this treatment during their training was inadequate.^{Reference Giacobbe, Ng and Blumberger31} With the rapid advances in evidence for rTMS in the past decade, including data for equivalent effects to ECT on patient-reported outcomes such as quality of life^{Reference Giacobbe, Mithani and Meng34} and the favorable side-effect profile of rTMS in comparison to ECT, the shortage of psychiatrists who are adequately trained in providing rTMS should be a source of concern in the field.

When it comes to psychiatric neurosurgery, a similar mismatch exists between evidence for the efficacy of the treatments and training. In a survey of 99 psychiatrists and psychiatry residents from Quebec, Cormier et al. reported that 69% participants were interested in improving their knowledge on psychiatric neurosurgery and 83% felt that this subject should be included in the psychiatry residency curriculum.^{Reference Cormier, Iorio-Morin and Mathieu9} The lack of significant uptake of DBS for psychiatric indications, in particular obsessive-compulsive disorder, has been attributed to a paucity of psychiatry referrals^{Reference Wu, Hariz and Visser-Vandewalle35} and a lack of knowledge about psychiatric neurosurgery has been identified as the principal limiting factor. Psychiatry residents have indicated an interest in a more neuroscience-based education in their training^{Reference Hassan, Prasad, Meek and Modirrousta36} and curricular development toward greater inclusion of a broad array of Interventional Psychiatry treatments represents a natural step in this regard.

Potential Role for Simulation-Based Education in Interventional Psychiatry

This paper has outlined existing gaps in training and supervision for Interventional Psychiatry treatments and the importance for trainees to have direct experiences in their delivery to develop competency. However, given that access to the array of noninvasive and surgical procedures currently resides in select academic centers with the requisite equipment and multidisciplinary personnel skilled in their delivery, training the emerging psychiatric workforce through current educational models may be difficult. This is expected to exacerbate the previously described geographical and demographic inequities. Indeed, Wilkinson reported that a small number of residency programs (n = 12 of >200) train approximately a third of the ECT practitioners in the USA.^{Reference Wilkinson, Kitay and Harper29} Innovations in pedagogical approaches for disseminating the learning of these procedures may increase the current low rates of competency in these treatments.

Simulation-based education is an important educational methodology in healthcare, serving as a bridge between medical theory and clinical practice. As an artificial representation of an actual clinical process, medical simulation has been used in various specialties for practice to help achieve educational goals. It does this by placing learners in an immersive setting replicating clinical scenarios, to allow acquisition of skills that can be applied in real-world scenarios.^{Reference Lateef42} Evidence has suggested that simulation facilitates the acquisition of knowledge, skills, and attitudes among learners, as well as reduces the risk of medical error and enhances patient safety. Studies have indicated that simulation-based learning, most often with simulated patients and role-play, can be effective approaches for psychiatry trainees to enhance their general clinical skills and knowledge.^{Reference Piot, Dechartres and Attoe43}

There is preliminary evidence that simulation-based training in ECT can facilitate skills acquisition. Psychiatry trainees performed better on the ECT clinical skills after receiving training on a mannequin patient simulator compared to traditional training methods.^{Reference Rabheru, Wiens, Ramprasad, Bourgon, Antochi and Hamstra44} Similarly, Raysin et al. reported that psychiatry residents who received augmented simulation training showed significant improvements in ECT knowledge, skills, and comfort compared to those who received a traditional didactic ECT curriculum.^{Reference Raysin, Gillett, Carmody, Goel, McAfee and Jacob45}

Simulation through virtual reality (VR) has emerged as a novel, immersive, and effective high-fidelity training approach to procedural skill acquisition. A meta-analysis comparing pedagogical methods in pre- and post-skills outcomes revealed a superiority in learners who took part in VR interventions compared to traditional didactic teaching or other forms of digital learning.^{Reference Kyaw, Saxena and Posadzki46} While the use of VR in mental health education is in its infancy, a preliminary synthesis of results has suggested that it results in significant improvement in users’ knowledge and attitudes related to mental illness.^{Reference Wan and Lam47}

To our knowledge, however, no study has yet reported using a VR simulator as an educational technique for procedural skill training. In light of the shift in medical education toward competency by design and a series of recommendations that have recently been proposed for specific core and advanced skill proficiencies for both rTMS and ECT,^{Reference Al-Qadhi, Chawla, Seabrook, Campbell and Burhan10,Reference Fried, Santarnecchi and Antal12} the adoption of the use of VR simulators can allow wide-spread dissemination of standardized training experiences in the proper and safe administration of these interventional approaches. The ability to provide unlimited on-demand training experiences to trainees in their home environment is especially important in situations where in vivo patient contact is not as readily available, such as during a pandemic.^{Reference Chick, Clifton and Peace48}

Funding and Advocacy

The need for advocacy in this emerging field has never been timelier. Data on the detrimental impacts of addiction and pandemic related mental health must be leveraged to lobby governments for increased funding and expedited clinical care program support. The potential for expanded philanthropic and industry support should also be considered; equipping clinicians with access to enhanced interventional tools earlier in their training, distributing them in more remote locations, or offering travel subsidies to patients qualifying may mitigate the social disparity among those treated. Support from industry for fellowship programs which could incorporate both simulation-based and clinical training could engage a new cohort of specialized clinicians in perhaps a more timely fashion than government can facilitate.

Incorporation of Neuroethics Training in Interventional Psychiatry

Although the importance of training in neuroethics for neuroscientists at all levels has been identified,^{Reference Sahakian and Morein-Zamir49} there is a lack of consensus on when and how this curriculum should be delivered. There are compelling reasons to embed neuroethics curricula in the early phases of exposure to the brain sciences^{Reference Abu-Odeh, Dziobek, Jimenez, Barbey and Dubinsky50} but it has been estimated that only approximately a third of undergraduate neuroscience programs in Canada as well as internationally offer any opportunity for training in neuroethics.^{Reference Lombera, Fine A.Grunau and Illes51,Reference Walther52} The rates of inclusion of neuroethics into clinical training programs for psychiatrists, neurologists, and neurosurgeons are currently unknown. When a curriculum in ethics has been employed for undergraduate neuroscience students and postgraduate medical trainees, a pedagogical approach emphasizing problem-based learning and discussion of real-world scenarios over didactic teaching has proven to be effective.^{Reference Abu-Odeh, Dziobek, Jimenez, Barbey and Dubinsky50,Reference Fins and Nilson53}

As neuroethics is ideally considered as a driver of ethical innovation in clinical neuroscience research rather than simply a reaction to rapidly evolving discoveries,^{Reference Rommelfanger, Jeong and Ema40} the incorporation of neuroethics education is considered essential for responsible research in neurotherapeutics and the development of investigators able to translate these findings to the clinical realm in order to deliver Interventional Psychiatry strategies in the appropriate ethical and medicolegal frameworks. Given the range of neurostimulation methods and various range of invasiveness and the complex issues related to modulating brain function via energy, it would be essential to consider the short- and long-term impact of neurotechnology on patients and all stakeholders impacted by these tools.^{Reference Zuk, Torgerson, Sierra-Mercado and Lázaro-Muñoz54}