In the evolution of the treatment of severe mental illness, first-generation drugs often produced tardive dyskinesia (repetitive, involuntary movements, such as grimacing and eye blinking). Second-generation drugs produced serious cardio-metabolic side effects, such as increased weight and diabetes, as well as abnormal lipids and high blood pressure. Fortunately, there is now a third generation of drug options available without these serious metabolic side effects, although there are still a litany of possible side effects, depending on the condition, the drug being used, and the patient receiving treatment. All these factors suggest the need for primary preventive – as well as therapeutic – options to take care of patients with mental illness.
In the past, mental illness was the “elephant in the room” and was not openly discussed. Today, mental illness often receives attention as a “hot topic” in the media. Both the past and present are suboptimal – there should be neither stigma nor sensationalism when considering mental health. According to the National Alliance on Mental Illness the most common psychiatric conditions are anxiety disorders (19.1% or 48 million) and major depressive disorders (7.2% or 17.7 million). While many patients with mental illness openly share their stories on social media, still only 50% are receiving treatment.
Social media can be a double-edged sword with regard to mental health. Lack of direct personal interaction, physical isolation, dependency on approval (receiving “likes”), and fear of missing out (FOMO) may contribute to anxiety and depression. Body image anxieties may also result from unrealistic comparisons to edited photos on social media platforms. Diagnosed mental disorders are increasing in prevalence in young children and teenagers, the main users of social media. The long-term impact of these trends remains to be seen as this generation grows into adulthood. The other edge of the sword is that the digital age offers easier access to help. There are more than 800 mental health apps that may be of value to patients who might not otherwise seek professional advice. Even virtual reality is finding a place in the treatment of various psychiatric conditions.
At present, focused ultrasound is a promising, but unproven, application of advanced technology to treat psychiatric diseases. Focused ultrasound is not the usual type of sound that someone might associate with music or spoken words. It is even different than the typical sound waves used in medical imaging, such as an ultrasound image of the gallbladder or a fetus in utero.
Focused ultrasound is noninvasive and does not involve any harmful radiation. It can act like a virtual scalpel when multiple ultrasound beams are focused to converge on a target as small as a grain of rice, while leaving the surrounding tissue completely intact. This technology is often used with MR guidance, and it has already been approved by the US Food and Drug Administration for some brain applications – namely, to treat a small area deep in the brain for essential tremor and tremor-dominant Parkinson’s disease. The experimental study of focused ultrasound as a potential therapeutic option for psychiatric conditions is a result of the medical community’s increased understanding that many mental illnesses are brain disorders resulting, at least in part, from abnormal functioning of specific neural circuits that connect various anatomic locations in the brain.
For several mental illnesses, focused ultrasound has the potential to ablate targets in the brain, which would negate the need to undergo invasive surgical procedures generally reserved for patients who are refractory to conventional medical therapies. Such surgeries include radiofrequency ablation, where electrodes are inserted into the brain, and Gamma Knife radiosurgery, which involves ionizing radiation.
In Japan, neurosurgeons have had success using Magnetic Resonance-guided Focused Ultrasound (MRgFUS) to produce promising results in treating patients with obsessive-compulsive disorder (OCD) and depression by ablating a target deep in the brain called the internal capsule. Additional similar studies in Canada, are now recruiting patients. In the US, OCD and depression studies will likely be initiated in 2020.
In addition to ablating neural circuits, focused ultrasound can also noninvasively neuromodulate (change the amount of neural function) certain areas of the brain. This is analogous to the more invasive deep brain stimulation (DBS) procedure, where physicians place electrodes deep in the brain to stimulate or suppress neural activity. This application of focused ultrasound is currently being tested in US patients with epilepsy to see if they can decrease, or suppress, the overactive neurons. Another group of researchers is evaluating the use of focused ultrasound to treat patients with addiction by neuromodulating the nucleus accumbens, a small area deep in the brain that is less accessible to invasive surgical procedures. This nucleus is integral to the reward circuity that is abnormal in patients suffering from addition. Scientists also hypothesize that focused ultrasound neuromodulation may have beneficial effects on the abnormal brain circuits in patients with depression, OCD, and anorexia.
It is too early to say for certain how focused ultrasound will ultimately fit into the armamentarium of treatment options for patients with mental illnesses, and many questions remain unanswered. Among those questions are whether focused ultrasound would represent an adjunct or alternative to existing therapies, and for which conditions. One thing is certain: The noninvasiveness of focused ultrasound is an attractive alternative to drugs and invasive procedures, both of which typically come with greater risks and unwanted side effects.
In the end, focused ultrasound may prove to be most beneficial to those patients who are resistant to conventional treatments. However, focused ultrasound procedures also appear to be a cost-effective alternative to traditional treatments, in part because they decrease the need for long-term medical therapy and follow-up. Our vision is to develop focused ultrasound to directly improve the health of individual patients with mental illness and to benefit society as a whole by reducing healthcare costs.
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Suzanne LeBlang, MD, is the Director of Clinical Relationships at the Focused Ultrasound Foundation.