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Redefining the Field of Neuropsychiatry through Neuromodulation of Brain Circuitry

In This Article

  • The Massachusetts General Hospital Division of Neuropsychiatry is redefining the field by developing brain circuit-focused approaches to patient care
  • Anatomical, physiological and behavioral information helps experts develop personalized treatment plans using device-based neuromodulation interventions targeting specific symptoms associated with disorders of cognition, emotion and behavior
  • Using their novel framework, the team is conducting translational research applicable to a range of neuropsychiatric disorders, including depression, bipolar disorder, obsessive-compulsive disorder, schizophrenia, addiction, Alzheimer's disease, fronto-temporal dementias, attention-deficit hyperactivity disorder and suicide
  • The first-of-its-kind fellowship at Mass General trains future specialists on research and treatment with device neuromodulation therapies across modalities

Neuropsychiatrists at Massachusetts General Hospital are changing the definition of their dynamic field—focusing on how brain circuits determine clinical presentation, training future specialists on ever-evolving interventions and researching novel neuromodulation techniques.

"Neuropsychiatry historically has been defined as the medical specialty that treats patients with neurological disorders who present with psychiatric symptoms" says Joan A. Camprodon, MD, PhD, chief of the Division of Neuropsychiatry in the Department of Psychiatry at Mass General. "The field integrates the paradigms and clinical tools of neurology and psychiatry—and to some extent neurosurgery—to treat very complex patients who often have been going back and forth from neurology to psychiatry. But the boundaries that define the limits between what is neurologic and what is psychiatric are blurred because they are artificial, and if one tries to define them operationally, they break down pretty quickly."

Dr. Camprodon and his colleagues use a practical clinical paradigm that identifies what cognitive, behavioral and emotional symptoms affect individual patients, and use this clinical information to determine the brain circuits that are problematic for a specific patient, not a specific disease. With that information, they design personalized treatment plans, including device neuromodulation interventions that are tailored to the individual patient's brain anatomy and clinical complaints.

"Our approach is different. We're trying to define neuropsychiatry not so much on who we see, but on how we see them," he says. "It's more about a clinical method anchored on brain circuits and their clinical dimensions. The relevance of this approach is that it brings anatomical and physiological formulations to psychiatric problems."

Evolving the Field of Neuropsychiatry

In addition to medications and behavioral therapies for these disorders, neuropsychiatrists are increasingly using neuromodulation devices such as transcranial magnetic stimulation (TMS), theta-burst stimulation (TBS) and implanted neurostimulators.

Neuromodulation can treat specific brain circuits that control behaviors and emotions like motivation and executive function. But first, Dr. Camprodon says, neuropsychiatrists must ask:

  • Which symptoms are particularly relevant to this person?
  • What are the circuits that process these dimensions?
  • Based on that, what are the treatments can optimally engage the circuits?

"It's not enough to say that a patient has depression and stroke or has post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). You have to go a little further and be able to dissect a clinical syndrome into the specific units of the emotional—behavioral and cognitive functions that are relevant to the individual patient," he says. "Using this approach, we can come up with not only a circuit-based biological formulation, but also use that patient-specific data to inform clinical decision-making and create individualized treatment plans. This is relevant for all sorts of treatment plans, but it's very relevant when you're thinking about treatment plans involving device-based neuromodulation."

The concept is just beginning to penetrate neuropsychiatry practice and is not widely used in the clinical setting. The Mass General team is trying to change that through a new fellowship and translational research.

Training the Next Generation of Neuromodulation Specialists

To help this paradigm gain traction, Mass General has created a fellowship to train specialists on the full spectrum of noninvasive and invasive neuromodulation therapies. Currently in its inaugural year, the Interventional Neuropsychiatry and Neuromodulation Fellowship is the first of its kind in the country.

"The field of device-based neuromodulation is relatively young, but it is growing extremely fast. There are different devices with different peculiarities, different technical challenges and different device-specific indications, but there's also a shared biological and clinical framework that integrates it all," Dr. Camprodon says. "At Mass General, we have deep expertise in all of them. We've started this fellowship to give psychiatrists and neurologists theoretical and hands-on procedural experience with the entire gamut of interventional devices."

The program deeply integrates psychiatry and neurology, and it combines clinical work with dedicated research time. The first fellow is set to graduate this year.

"We want to make sure that this vision goes beyond ourselves. When fellows graduate from the program, they can continue to help patients at Mass General or go to other places and take this model with them," Dr. Camprodon says.

Understanding Brain Circuits for Novel Treatment Approaches

The team is also advancing the fields of neuropsychiatry and neuromodulation through a robust research program. Most of the division's faculty are clinician-scientists focusing on the anatomy and physiology of human brain circuits and the behavioral computations those circuits govern, with the ultimate goal of creating new treatments or improving existing options.

Highlights of their translational research include:

  • A series of studies identifying biomarkers, including digital information from our phones or wearables, that can define specific disorders, better differentiate disorders from one another, predict who will do well on treatment and who will have side effects
  • Work to elucidate exactly how electroconvulsive therapies affect brain mechanisms. That information can be used to design more effective novel devices that engage the same biology with fewer side effects
  • Develop individualized image-guided neuromodulation strategies, including rapidly-acting interventions focused on reducing suicide risk in hospitalized patients
  • Efforts to design safe, inexpensive, portable, home-based neuromodulation devices to treat conditions such as Alzheimer's disease or neuropsychiatric sequelae of COVID-19, among others
  • Studies that successfully used artificial intelligence technology to diagnose attention deficit hyperactivity disorder (ADHD)

"When we think in terms of brain circuits and symptom dimensions, beyond traditional diagnostic labels, the limits between neurology and psychiatry become even less relevant, and we can apply this clinical framework to Alzheimer's disease, schizophrenia, stroke, borderline personality disorder, Parkinson's disease, depression and so many other diagnoses. Those definitions then become irrelevant," Dr. Camprodon says. "What's relevant is: What circuits are processing information? What are the maladaptive physiological signatures within those circuits? What tools do I have to modulate that? And how do we make those tools more effective and apply to more indications?"

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