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The Brave New World of Procedural Psychiatry

November 18, 2019

By Andrew Penn, RN, MS, NP, CNS, APRN-BC
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

I was recently going through a bag of wires and adapters, trying to find a mini USB cable to charge an older electronic device that I own (newer devices use the not surprisingly smaller micro USB). Perhaps you have a similar bag, or a drawer filed with adapters, cables, and wires for gadgets you no longer own (remember the Palm Pilot?!). Divorced from their cables, I am still reluctant to throw them out, uncertain if I will need them in the future.

I’m noticing a similar problem now that I’m in the middle of a clinical psychiatric career, especially since I am teaching the next generation of practitioners. Which of our treatments  do we throw out, and what do we keep as we begin to adopt new practices?

It is becoming increasingly clear that the practice of psychiatry will be changing from one in which we ask our patients to take a daily pill to one where we deliver procedures that have enduring effects. Most of the buzz at this year’s Psych Congress was not about a new pill—it was about treatments such as repetitive TMS (rTMS), esketamine nasal spray, psychedelic-assisted therapy, botulinum toxin injections for depression, brexanolone infusions for postpartum depression, and long-acting injectable antipsychotics. It’s clear a brave new world has already begun to arrive in psychiatry, and those of us who are used to daily psychopharmacologic interventions may start feeling like that bag of wires in my desk.

Of course, we’ve always had an enduring somatic treatment in psychiatry: electroconvulsive treatment (ECT), but stigma and institutional barriers have left this effective modality underutilized. Lest we forget the most common enduring form of treatment in psychiatry, psychotherapy, where the benefits of behavioral change and insight can endure for years after the treatment has stopped. Of course, this process can be slow, discouraged by insurance, or difficult to access.

This difference in paradigm—from daily medicines to episodic procedures—has been characterized by my friend and colleague Dr. Charles Raison as the difference between a gas grill and a campfire.1 While both produce heat, the gas grill only makes heat when the gas is on. As soon as it is turned off, the heat quickly dissipates. A campfire, on the other hand, requires preparation and circumstances favorable to burning. But once a campfire gets going, it continues  to make heat with little need for outside intervention. Occasionally, another log needs to be thrown on the fire, but in general, the heat continues to be produced with little need for additional intervention.

Most of us who prescribe medications are used to thinking about our patients like gas grills who need close attention and a steady supply of medications in order to maintain the changes that were occasioned by the drugs. But what if we didn’t need to do that? What if a short course of intensive intervention changed the state of an illness from chronic to in remission? How would that change the care we provide and the systems through which we provide it? More importantly, how would that change the experience of the patient seeking care?

I’m curious to hear your thoughts in the comments below.


1. “The ghost in the machine? Examining change phenomena in psychedelic assisted psychotherapy.” Presented at Psych Congress: San Antonio, TX; October 24, 2016.

Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and recently published a book chapter on this modality in The Casebook of Positive Psychiatry, published by American Psychiatric Association Press. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing, where he teaches psychopharmacology, and is an Attending Nurse Practitioner at the San Francisco Veterans Administration. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy,  treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.


Submitted bydmlinke on January 15, 2020

Very interesting article, and certainly something those of us who have been around for a decade or two should be cognizant of. I've changed my practice location in the past couple of years, now practicing exclusively via telepsychiatry and seeing patients in an entire different state. I was somewhat surprised by the difference in practice between what I was used to seeing locally vs my new site. I'm sure that much of it has to do with public funding, but have seen more "old fashioned" treatments in the new area, including lots of lithium, haldol, etc., with it often being more difficult to implement things a little newer on the spectrum, such as Invega Sustena. With this in mind, will be very interesting to see how things in this area progress with the transition to more procedurally focused treatments!

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