Photo: Richard Bermudes, M.D.

The evidence for FDA-cleared interventional treatments for treatment-resistant depression is robust and has been demonstrated across multiple large trials and meta-analyses. These treatments include electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and esketamine. In fact, ECT is the oldest approved interventional treatment and is often referred to as the “gold standard” for patients with treatment-resistant depression. However, psychiatrists are hesitant to refer patients, and many consider interventional treatments as “alternatives” rather than integral to the treatment of depression (see box at top right). Prior to practicing TMS and ECT, I was in the same boat; I had very little direct patient exposure when it came to incorporating interventional treatments into my clinical practice. An article posted November 20, 2020, in Psychiatric Services highlights some of these issues. The article was written by Dr. Rebecca Barchas, a physician who received ECT for her depression and had a phenomenal treatment response:

Discover The World's MOST COMPREHENSIVE Mental Health Assessment Platform

Efficiently assess your patients for 80+ possible conditions with a single dynamic, intuitive mental health assessment. As low as $12 per patient per year.

“I was ignorant about something very important—the full range of patients who could receive the broad spectrum of benefits from electroconvulsive therapy (ECT). I rarely referred patients for ECT and always thought of it as a last resort. I was not sufficiently knowledgeable of the benefits of ECT until I myself was the beneficiary.”

Not unlike ECT, TMS and its far-reaching benefits are not widely understood. After our practice, Mindful Health Solutions, purchased our first TMS system in late 2009, we received very few referrals from psychiatrists in the region. Most psychiatrists were not familiar with the technology and had little-to-no experience with the modality. Many believed that TMS did not work, and those who referred patients thought of it as a treatment of last resort. Insurance did not adequately cover the treatment, and many psychiatrists felt the treatment was too costly. Even today, more than 10 years after FDA approval and with broad payer coverage, most of our patients “self-refer.” Like many of our ECT patients, they wish their physicians would have referred them earlier. In fact, some of my pharmacotherapy patients whom I delayed referring in the past have said to me, “What took you so long?”

Why are psychiatrists so hesitant to refer patients for interventional treatments? There has not been a systematic review of psychiatrists’ attitudes, but two separate surveys examined psychiatrists’ attitudes toward TMS and ECT (see here and here).

When psychiatrists were asked if they knew how to refer patients for TMS treatment, 67% had a negative response. However, referral knowledge did change positively if there was a TMS or ECT program at their institution. Surprisingly, the majority of respondents disagreed with the statement “I know and understand the indications for TMS,” and only three of 122 respondents indicated that they strongly agreed.

A survey of psychiatrists’ understanding of ECT found that although most psychiatrists had a favorable opinion of ECT, those who viewed ECT as a “treatment of last resort” referred patients sparingly. Other factors that decreased the probability of referral included patients’ negative attitudes toward ECT, the logistics of arranging support and transportation, and financial constraints.

Most psychiatrists receive very little exposure to interventional treatments during their training. In a 2010 survey, most programs devoted less than four hours of lecture time to ECT. Even when there is a TMS, ECT, or esketamine-ketamine program at their institution, only a minority of trainees are exposed to these clinical service lines. Many private practices with high clinical throughput have electives for third- and fourth-year residents, yet only a very small number of trainees are hosted in these settings each year.

So, how can you begin to educate yourself and incorporate interventional treatments into your clinical practice? My recommendations are as follows:

  • Contact local interventional practices near or in your community. Some of these practices offer ECT, TMS, and esketamine-ketamine, but some offer only one modality.

  • Consider committing a few hours to interview the interventional psychiatrist in your community or shadow the service, especially if you have not had exposure to ECT, TMS, or esketamine-ketamine during your training.

  • Refer! If 30% of depressed patients do not obtain sustained remission after four trials of antidepressant medication, the average full-time general psychiatrist could refer three or four patients a month for an FDA-cleared interventional treatment to improve the patients’ chance of sustained remission. Consistent referrals of 30 to 40 cases a year will give you an indication of the clinical significance and utility for your patients.

In the center box, I listed the information to include in a referral, and in the bottom box, I described the characteristics of an “ideal referral partner.”

In future columns, I will discuss who is an ideal patient for ECT, TMS, and esketamine-ketamine as well as discuss why patients hesitate to try interventional treatments. ■

Barriers to Interventional Treatments

  • Belief among psychiatrists that interventional treatments should be used as a last resort.

  • Lack of education and exposure to interventional treatments.

  • Misconception that interventional treatments are not covered by insurance.

  • Patient acceptance: “How will patients react if I refer them to ECT?”

  • Patient retention: “Will I lose patients if I refer them to an interventional psychiatrist?”

  • Conceptualization of mental illness: “situational depression.”

Information to Include With a Referral

  • Diagnosis or indication—for example, “treatment-resistant depression.”

  • Concise summary of treatments tried in the last two to three years.

  • Prior interventional treatments.

  • History of suicide attempts.

  • The patient’s insurance and demographic information.

  • Your contact information as the referring psychiatrist or an office contact.

  • The role you want to play in the treatment going forward (for example, full transfer vs. co-management).

Ideal Referral Partners

The interventional psychiatrist does the following:

  • Provides more than just one interventional therapy.

  • Accepts insurance and has an efficient system of authorizations.

  • Highly regards patient service and experience.

  • Communicates clearly with referring psychiatrist and has transparent interoperability of electronic medical record.

  • Utilizes measurement-based care and aggregates/tracks patient outcomes.

  • Spends time with the patient and the patient’s support or family and is accessible to staff for supervision of services.

  • Provides FAQs on the procedures that are accessible on websites with clear and concise information.


  • Grover S, Nguyen JA, Viswanathan V, Reinhart RMG. High-Frequency Neuromodulation Improves Obsessive-Compulsive Behavior. Nat Med. 2021;27(2):232-238.

  • Berlim MT, Van den Eynde F, Daskalakis ZJ. High-Frequency Repetitive Transcranial Magnetic Stimulation Accelerates and Enhances the Clinical Response to Antidepressants in Major Depression: A Meta-Analysis of Randomized, Double-Blind, and Sham-Controlled Trials. J Clin Psychiatry 2013; 74(2): 122-129.

  • Slotema, CW, Blom JD, Hoek HW, Sommer I. Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)? A Meta-Analysis of The Efficacy of rTMS in Psychiatric Disorders. J Clin Psychiatry 2010; 71(7): 873-884.

  • The, UK. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis.The Lancet 2003; 9360: 799-808.

  • McIntyre, RS, Carvalho IP, Lui L, Majeed A, Masand PS, Gill H, Rodrigues NB, et al. The Effect of Intravenous, Intranasal, and Oral Ketamine/Esketamine in Mood Disorders: A Meta-Analysis. J Affect Disorders 2020; 276: 576-584.

  • Barchas, RE. My Benefits From Electroconvulsive Therapy—What a Psychiatrist Learned by Being a Patient. Psychiatr Serv 2021; 72(3): 347-348.

  • Stern AP, Boes AD, Haller CS, Bloomingdale K, Pascual-Leone A, Press DZ. Psychiatrists’ Attitudes Toward Transcranial Magnetic Stimulation. Biol Psychiatry 2016; 80(7): e55-e56.

  • Dauenhauer LE, Chauhan P, Cohen BJ. Factors That Influence Electroconvulsive Therapy Referrals: A Statewide Survey of Psychiatrists. The Journal of ECT 2011; 27(3): 232-235.

  • Williams NR, Taylor JJ, Snipes JM, Short EB, Kantor EM, George MS. Interventional Psychiatry: How Should Psychiatric Educators Incorporate Neuromodulation Into Training? Acad Psychiatry 2014; 38(2): 168-176.

  • Dinwiddie SH, Spitz D. Resident Education in Electroconvulsive Therapy. The Journal of ECT 2010; 26(4): 310-316.

Richard A. Bermudes, M.D., is the chief medical officer at Mindful Health Solutions in San Francisco and an assistant clinical professor of psychiatry at the University of California, San Francisco. He is also the co-editor of Transcranial Magnetic Stimulation: Clinical Applications for Psychiatric Practice from APA Publishing. APA members may purchase the book at a discount here.

Why Are Psychiatrists Hesitant to Refer Patients For Interventional Treatments? | Psychiatric News

Hot daily news right into your inbox.