Learning Objectives
By the end of this section, you will be able to:
- Describe how alternative treatments are used in psychiatric-mental health settings
- Explain how digital tools can be used to identify and track at-risk clients
- Describe the role of telemental health in the treatment of psychiatric-mental illness
The past 60 years has seen dramatic change in the treatment of mental health disease—from the chronic internment of the serious mentally ill and treatment with insulin-based shock treatments to the home-based, data-driven technologies of today. This section covers the innovations in medicine, technology, and internet-based applications that are advancing the science of mental health care.
Alternative Treatments
Alternative treatments are considered those that are done instead of the standard treatment procedures. For those who are engaged in mental health care, standardized treatment includes individual or group therapy, psychopharmaceutical treatments, and more intensive treatments, such as residential or in-client treatment facilities. This section will review the more commonly used and approved alternative treatments for mental health disorders.
Transcranial Magnetic Stimulation (TMS)
A noninvasive treatment called transcranial magnetic stimulation (TMS) was developed in 1985 and approved for use in those with major depressive disorder in 2008. The treatment consists of an electromagnetic coil that is placed against the client’s head (over the prefrontal cortex) that delivers a magnetic pulse to stimulate nerve cells in the brain. Different combinations and types of stimulations manage different symptoms. The exact mechanism of action is not quite understood, but theories posit that TMS stimulates areas of the brain that have decreased neuronal activity. Indications for TMS include failure of at least one antidepressant and approval by insurance, if applicable. Approximate costs for TMS range between $6,000 and $12,000 with the TMS course entailing approximately 20 to 30 clinic sessions lasting 30 to 40 minutes each, but these costs and number and length of sessions can vary by insurance coverage. Effects of TMS are statistically significant with optimal remission rates. Prior to referral to TMS, clients should be assessed for risk factors related to seizures, traumatic brain injury, intracranial masses, neurological disease, metal in the head or neck, alcohol or benzodiazepine withdrawal, or medications that lower seizure threshold (bupropion, theophylline, and stimulants). Side effects include pain and irritation at the site of the magnet, tingling, facial muscles that twitch, and lightheadedness. Some clients with trauma might become triggered by the experience. After the first course of treatment, clients might engage in maintenance treatments or a tapering regimen. Deep TMS is the stimulation of deeper brain structures by the same TMS devices. It is indicated for major depression and obsessive-compulsive disorder. The treatment algorithms are commensurate with that of regular TMS.
Esketamine
A innovative treatment for treatment-resistant depression and major depressive disorder with suicidality is esketamine, which is derived from a drug called ketamine, an anesthetic. It works very differently from traditional antidepressants; theoretically, it causes an increase in brain-derived growth factor (BDNF), which has been implicated as a factor in unipolar depression. Esketamine has been found to have optimal remission rates when treating depression and has FDA approval for this use. It has also demonstrated a rapid reduction in suicidal thoughts. Side effects include increased blood pressure, nausea, vomiting, anxiety, depersonalization/derealization, hallucinations, vertigo, and sedation. Prior to treatment, assess clients for conditions that are contraindicated, such as hypertension, substance misuse disorders, CNS depressed states, and hepatic impairment; also assess vital signs before and during treatment. Esketamine comes in a nasal spray at a 28 mg dose and is usually administered in a clinic setting. Clients arrive at the clinic, generally self-administer the esketamine, and then wait for 40 minutes to one hour before someone else drives them home. Treatments last up to 10 weeks with one to two treatments per week.
Ketamine may be administered intravenously (IV) or intramuscularly (IM) by a qualified professional. Infusions are administered weekly or more frequently; injections may have different administration schedules. Because FDA approval for ketamine is still as an anesthetic, with “off label” use for mental health treatment, insurance policies may not cover the expense.
Electroconvulsive Therapy
The use of electrical currents under anesthesia to produce a seizure is electroconvulsive therapy (ECT). It is FDA approved for treatment resistant or severe unipolar depression. How ECT works to decrease depressive symptoms is not known. There are theories that the induction of the seizure activity releases the neurotransmitters that are involved in depressive states (serotonin, dopamine, and norepinephrine), and it potentially results in stimulation of brain derived neurotropic factor (BDNF), which is responsible for neuronal growth, learning, and memory. Clients who are referred for ECT are first evaluated to see if they are a candidate for the treatment. They are then screened for medical history to determine if there are any contraindications for the treatment (potentially those with coronary disease, with asthma or COPD, poorly controlled hypertension, those with implanted pacemakers, or those who are pregnant). Seizures can cause increases in blood pressure, heart rate, and intracranial pressure. Assess and manage client status before and after the procedure.
Also prior to ECT treatment, educate clients on the risks versus benefits and side effects of the treatment versus no treatment at all. The risks include the risks of anesthesia, medical complications of the procedure inclusive of heart attack, stroke, respiratory difficulty, or continuous seizure. Other side effects include dental complications, irregular heart rate, memory loss, and confusion upon awakening from anesthesia that usually lasts no more than an hour. The recommended number of ECT treatments is between six and 12, based on the clinical response. Once the client is ready for their treatment, they are usually brought to a surgical suite or pre-anesthesia holding area where the procedure takes place. The client is sedated and provided anesthesia. The client is given either unilateral or bilateral treatment (meaning that electrodes are placed on one side or both sides of the temporal region) based on their symptomology. Once the procedure is done, the client wakes from anesthesia.
Nursing care prior to the treatment includes:
- ensuring that the client has understood and signed informed consent
- making sure the client has had nothing by mouth for at least eight hours prior to the procedure
- removing all dentures, jewelry, eyewear (glasses, contact lenses), hearing aids
- having the client void before the procedure
- giving perioperative medications
Nursing care during the procedure includes:
- monitoring vital signs and symptoms
- placing oral/dental protection device
- giving procedural medications
- assessing client during procedure
Nursing care after the procedure includes:
- monitoring vital signs and symptoms
- assessing cognitive status
- checking for gag reflex, fluids, ambulating, and toileting
- placing client on falls precaution
Virtual Reality
A useful and effective treatment for anxiety and fear disorders, such as phobias and traumatic stress, is virtual reality (VR), a computer generated two- or three-dimensional environment that contains scenes or objects that allow the user to immerse in a seemingly real surrounding. Using VR, mental health professionals can engage in cognitive treatment like exposure therapy to gradually “expose” their clients in vivo to fear-related situations, in a controlled environment, while managing their fear response with use of relaxation techniques taught prior to the VR experience. It is the same principle for those who experience trauma triggers. VR immersion can assist clients with modulating the trauma trigger through safe encounters while managing their negative beliefs with relaxation exercises and cognitive reframes. Side effects of VR include dizziness, headache, nausea, eye strain, and decreased sense of present self or dissociation. Those who experience light-triggered seizures are not candidates for VR experiences. Recommendations for VR treatment include engaging in between eight and 12 sessions for 15 minutes each or for a single session that lasts from 45 minutes to three hours.
Digital Tools to Identify and Track At-Risk Clients
Nearly one in five U.S. adults have or will have a mental health diagnosis in their lifetime. With a paucity of mental health providers and an explosion of technology, clients and providers are turning to digital tools to assist at-risk clients. For those with access to the internet and technology, there are a variety of applications for use in mental health. They range from applications to track sleep, mood, stress, and vital signs, such as heart rate and respirations, to those that track symptoms of mental health disorders. There are apps that can follow along with providers to assist with, monitor, and evaluate cognitive and behavioral interventions. Some apps take the user along guided imagery exercises. Others provide motivational experiences to lift mood and provide feedback for substance use disorders. There are tools that combine cognitive behavioral therapy and nutrition to achieve a healthier diet. Applications assist in goal attainment, recovery from loss, and management of anxiety and panic. Applications track self-harming and suicidal thoughts and can assist with the formation of suicide safety planning. In a world where stigma and lack of providers creates barriers to care for mental health issues, these applications can create bridges to care that reach millions. While they do not replace the clinician, they can provide additional resources and tools for those who have access to the virtual world.
Telemental Health
An extension of the virtual platform for those seeking mental health care is telemental health. It is the provision of mental health services though telephone or videoconferencing. Telemental health is a cost-effective alternative to in-person mental health services, especially in cases where access is limited. It is not useful in areas where broadband or cellular communication is not available. In the aftermath of COVID-19, major regulatory efforts have tried to expand broadband capabilities to extend the reach of telemedicine. Insurance companies and state and federal regulations have become increasingly supportive of internet-based mental health care, especially after the pandemic. There are several considerations before providers can engage in internet-based treatment. The services must be HIPAA-compliant, meaning that the providers’ internet-based platforms and communications are required to have secure communication and privacy features. Moreover, clients must be informed ahead of their first appointment that internet-based services are part of the care algorithm. Altogether, internet-based mental health care is a cost-effective and stigma-free way to engage in evidence-based care for those with the health literacy and technology to engage.
Link to Learning
Review this Evidence-Based Resource Guide from SAMHSA on the use of telehealth for treating mental illness and substance use disorders to learn more.