Demonstration of a TMS device being used
This novel mood disorders fellowship has a focus on education in somatic treatments in psychiatry (ECT, rTMS, VNS, DBS), as well as advanced pharmacological approaches in the realm of mood disorders. The duration of the Fellowship will be a minimal period of one year, with salary at a PGY-5 level.
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Its central goal is to provide advanced and superior training in the application of somatic treatments such as repetitive Transcranial Magnetic Stimulation (rTMS) and Vagus Nerve Stimulation (VNS) in the treatment of resistant mood disorders as well as exploring their potential as a neuropsychiatric instruments in a range of other disorders such as attention deficit hyperactivity disorder, anxiety disorders and schizophrenia.
The Fellow in Mood Disorders will participate in the clinical treatment of cases in the VNS clinic (1/2 day per week) and on the ECT service (1 morning per week). In the newly established VNS Clinic, training will comprise assessment of complex mood disorder cases to assess appropriateness of VNS implantation as the next step in the therapeutic algorithm. The Fellow will adjust dosing of existing, ongoing cases with a VNS device already in-situ. Advanced training in ECT techniques including the opportunity to consult on particularly challenging cases and to develop case reports for publication where appropriate will be provided. In the psychopharmacology realm, training will be provided in the proper conduct of clinical trials as new therapeutic agents in mood disorders are formally tested, as well as in advanced psychopharmacology of complex clinical cases.
A formal outpatient clinical dimension in the Fellowship will one full-day per week (at minimum) seeing psychiatric outpatients with the fellowship supervisor through the outpatient clinic. Such patients will often include treatment resistant mood disordered patients, unipolar, bipolar with co-morbid axis I and II pathologies, include second opinion referrals from other psychiatrists as well as evaluations for possible ECT or evaluation for enrollment in a clinical trial. However, it is also intended that a significant proportion of patients seen in the Fellow’s clinic will be general clinic patients, such that general diagnostic and treatment skills from residency, will be appropriately maintained during Fellowship. The fellowship supervisor, by virtue of his/her training in cognitive behavioral therapy, will be able to provide supervision for a small cohort of therapy patients that the Fellow may elect to bring with him/her from residency.
The Fellowship Director will meet informally on a daily basis in the course of the conduct of activities on the unit but in addition will meet for 1-2 hours weekly for more formal supervision. Each of these supervision sessions will serve a specific goal. One will be devoted to the acquisition of skills in connection with the safe and appropriate administration of the somatic therapies (rTMS, VNS, ECT, DBS) as well as the conduct of the clinical trials in rTMS, VNS, DBS and pharmacological agents. A second supervision session will be devoted to broadening of intellectual knowledge in the area of mood disorders through reviewing recommended readings from journal articles and textbooks, with this then being applied specifically to the writing of manuscripts together for publication arising from studies conducted on the unit and in collaboration with others. The Fellow will be granted authorship in line with his/her intellectual contribution to the projects. Finally, time will be devoted to review of clinical cases including psychotherapy cases seen in the Fellow’s practice. Attendances at appropriate conferences, whenever feasible and not in conflict with the immediate needs for research subject and patient care on the unit, will be encouraged. In particular the Fellow will be encouraged to attend the annual meetings of the International Society for Transcranial Stimulation (ISTS) and the Association for Convulsive Therapy (ACT). The Fellowship Director will make every effort to attain financial support for the Fellow to attend these conferences as well as encouraging the submission of completed academic work in the form of posters and oral presentations. Finally, the fellow will seek out additional opportunities for teaching medical students and residents in regard to his/her areas of emerging expertise.
- The Fellow will become expert in the techniques of rTMS such that fully independent delivery of rTMS has been attained by the end of the Fellowship year. This includes the requisite skills in determining the optimal scalp location and precise energy dose for motor threshold, collection of 3-dimensional measurements to facilitate repeatability of site application, use of a computer assisted algorithm for assessing threshold if required, application of e-shields, monitoring of subjects during stimulus administration for any adverse effects including early manifestations of incipient seizure activity. Safety is an essential component in training such that the Fellow will be fully conversant with the safe management of an inadvertent seizure by means of positioning of the subject, administration of oxygen, suction of the airway, and administration of anti-seizure drugs as required. The Fellow will administer rTMS following training in both the clinical trials underway in TMS in the laboratory as well as the clinical TMS administered off-label on a humanitarian basis to a small number of patients who previously responded to rTMS.
- The Fellow will learn dosing strategies in optimizing treatment results with VNS as well as combination of psychopharmacology and ECT with VNS.
- The Fellow will learn the application of rTMS in disorders other than major depression, such as application of slow rTMS over the tempero-parietal region in schizophrenia with the goal of attenuation of auditory hallucinations, and in addition to potentially improve attention and reduce hyperactivity in ADHD. In such situations rTMS will be provided at other sites on the scalp separate from that overlying the left dorsolateral prefrontal cortex and at slow frequencies of 1 Hz rather than the typically fast frequencies of 10 Hz applied in major depression.
- The fellow will participate as a sub-Investigator in planned future trials of DBS in TRD and acquire the appropriate training in subject selection, assessment, close collaboration with our neurosurgery colleagues, and follow up of subjects post implantation in this pioneering intervention in treatment resistant mood disorders.
- Become skilled in the screening of subjects for possible inclusion in depression trials. This will include becoming trained in formal SCID-I diagnostic assessment, MINI SCID, and uses of the Antidepressant History Form (ATHF) used to assess prior treatment resistance.
- Become trained and credentialed in the application of the formal outcome measures - these include neuropsychology assessments, the Hamilton Depression Rating Scale (HDRS), Montgomery Asberg Depression Rating Scales (MADRS) and Young Mania Rating Scale (YMRS). Credentialing and attestation of achievement of adequate skill level on the HDRS, MADRS, YMAR is provided independently through the psychometrics division of the Department of Psychiatry at Columbia University and other entities.
- In the pharmacology mood disorder trials the Fellow will become skilled with the use of the alternate assessment instruments such as the MINI-SCID as well as the Hamilton Anxiety Scale, CGI-S, and CGI-I scales.
- The Fellow will become conversant with the process of protocol development, design of consent and HIPAA forms and generally become knowledgeable of the many requirements that need to be met in order to satisfy the requirements of the IRB such that safe and ethical research can be conducted with human subjects. In this regard the Fellow will complete the required Perelman School of Medicine Patient Oriented Research Certificate (PORC) program before being allowed to function as an investigator on clinical trials.
- The Fellow will be mentored on the process of writing of scientific manuscripts. Initially he/she will conduct this jointly with the Fellowship Director but as his skill develops and allows he will be encouraged to take a leading role. A specific goal of co-authoring no less than 3 publications over the course of the Fellowship has been set.
- As the opportunity arises the Fellow will be exposed to other modalities of somatic treatment such as Deep Brain Stimulation (DBS). As educational opportunities arise the Fellow will be expected to partake in ECT on occasion. However this will be limited to an educational role rather than a service one.