How Transcranial Magnetic Stimulation Plays A Role in Treating Anxiety, Depression, PTSD and More, with Martha Koo, M.D.

ABOUT THE EPISODE:

Transcranial magnetic stimulation (TMS) is a highly effective but obscure treatment in psychiatry. It received its first FDA clearance for the treatment of depression in 2008 but has since proven itself to be effective for a host of other issues – depression, OCD, smoking cessation, bipolar, PTSD, cognitive impairment, and even autism. And a huge bonus? Side effects are practically non-existent.

If that doesn’t get your attention, consider this: The FDA recently cleared TMS for depression in adolescents aged 15 and up, with studies currently being conducted on efficacy for substance use disorders.

In this episode, I speak with Dr. Martha Koo, president of the TMS society's board of directors. Martha received her degrees from Princeton and UCLA and is double-board-certified in psychiatry and addiction. She has also participated in the evolution of TMS for decades. She’ll explain who TMS is for, how it works, what it’s capable of, and why there may be an explosion of its use in the coming years.

EPISODE RESOURCES:

• Neuro Wellness Spa
• Your Behavioral Health
• Clear Behavioral Health (Mental Health & Addiction Services)
• TMS Society (find a provider)

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Transcript

Martha: 0:02

We prescribe meds in, in children and teens because we feel we need to do something, right? And some work, but, but, you know, outcomes for adults are pretty poor. Only a third of people will achieve remission. The outcomes are worse for teens. That's why so many of them end up on five, six medications and, and we, obviously we try because they're symptomatic and so we want to do something, but I think the outcomes with TMS are definitely without the side effects and I think more efficacy.

Brenda: 0:39

Welcome to Hope Stream, a podcast where you'll hear interviews, conversations, and encouraging words for parents of teens and young adults who struggle with substance misuse and mental health. I'm Brenda Zane, your host and a fellow parent whose child struggled. I'm so glad you're here. Take a deep breath and know you're not doing this alone anymore. Hi friend, do I have a fascinating episode for you today. I was fortunate enough to meet Dr. Martha Kuh who is the Chief Medical Officer for Your Behavioral Health in Southern California and conveniently She also happens to be one of the foremost experts in TMS or transcranial magnetic stimulation. I asked Dr. Ku if she would sit down with me and do a deep dive on TMS because I knew so little about it. But I've heard from a few parents that their kids have used it and so, of course, I was curious. Dr. Khoo completed her undergraduate studies at Princeton University and her medical training at the David Geffen School of Medicine at UCLA. She obtained her psychiatric residency training at the Resnick Neuropsychiatric Institute at UCLA and her subsequent psychoanalytic training at the New Center for Psychoanalysis. Dr. Khoo is board certified in psychiatry and addiction medicine. She's a pioneer in the development and application of TMS and opened the South Bay TMS Therapy Center in 2009, which has evolved now into the Neuro Wellness Spa, where Dr. Khoo is medical director and offers medication management, TMS therapy, and MERT. She's president of the board of directors of the Clinical TMS Society and an active member. Of the American Psychiatric Association, the New Center for Psychoanalysis, the American Society of Addiction Medicine, the American Society of Ketamine Physicians, the California Psychiatric Society, and the Southern California Psychiatric Society. So I think by now you know why I felt she was the exact most qualified person to have this conversation with. We talked about everything from how TMS actually works, what the treatment experience is like, etc. Who benefits from it, what conditions it can be used for, and whether or not someone has to be 100 percent abstinent from substances and or off of their psychiatric medications in order to undergo TMS treatment. Dr. Koo was very patient with my smattering of questions and is without a doubt one of the most brilliant minds I have had on the podcast. I cannot wait for you to learn as much as I did, if not more. So take a listen to this extremely educational conversation between me and Dr. Martha Koo. Welcome Dr. Koo, I'm thrilled to have you here today. Thank you for taking some time with us. I can only imagine what your schedule looks like, so I really appreciate the time to be here and to share your knowledge with our listeners.

Martha: 4:02

You're very welcome, Brenda. It's really an honor to be here. And I am so grateful for what you do in the community. It's a big need, right, for families and to have the support that you offer. So it's fabulous.

Brenda: 4:17

Thank you. It is. It's a pretty special place. I never really know how to explain what we do to people because I think people just don't really get it. You know, it's kind of like think of your health club, but it's for your head and your heart and the rest of your family. I don't know. It's really difficult to explain, but we're lucky to have, you know, you and others from your organization supporting our members with understanding of mental health issues, which really are for the most part, the underlying. reason for the substance use to varying degrees, obviously. Which, you know, when I think back, I did not know that when, when my son was struggling, he didn't have, you know, like a bipolar or anything like that, but really struggled with ADHD and some depression. But if somebody would have said, Oh, he has mental health problems. I probably would have said, No, he doesn't, you know, so I think there's just a lot of misunderstanding on the, on the part of parents about what our kids are really dealing with. I'm sure you, you probably see that as well.

Martha: 5:23

I absolutely agree. And it's, it's, it's. I think those are the cases that are, I think, the most challenging. When somebody has a diagnosed mental health issue prior to any substance use, and I think families are already also a little bit educated in, in the, in the space, right? If they have resources and they are able to do that, it makes a big difference. That's when, when, when the first thing that's coming up is the substance use. I think it becomes very challenging, especially, right, in that younger population, because we also have an understanding that as, as our kids are growing up, we, you know, they are going to experiment with drugs or alcohol. And so it gets, I think, very lost in the, We need to, well, is this normal development? Is this a little bit of acting out? You know, when does it cross over and is it really a problem? And then at that point, you know, the focus is on sometimes the addictive behaviors when the problem really had started years before with, you say, like things with self esteem or mood or anxiety or ADHD.

Brenda: 6:29

Yeah. Yeah. And if you're, if the doctors don't tell you that there could be a link to substance use, which no one told me, it never occurred to me ever, like that the ADHD might have something to do with the substance use until later when my son was like, well, duh, mom, like that was the only time I felt normal. It's like, okay, well, if somebody would have, like, You know, informed me early on, so anyway, we were extremely grateful.

Martha: 7:00

Yeah, I think that comes also historically, you know, historically in psychiatry, we I think a real detriment to individuals as we separate it out. You know, even addictions, we call them, besides substance use disorders. So we separated out addiction and mental health, which is, is such a ridiculous, right, bifurcation. And I think that has lent itself to this concept of two very separate entities. It's always seemed very strange to me, right, because my view of, of most addictive behaviors, right, whether we're talking about substances or we keep talking about eating disorders, shopping, right, addictions, that, that they're really symptoms of of deeper underlying problems or other comorbidities. They rarely, rarely arise in a vacuum. And so right now, right, anybody in sort of, Current modern psychiatry thinks it's very bizarre, right, to think of addiction separate from, from mental health or mental illness. So it's, yeah, but unfortunately it took years of that, right?

Brenda: 8:03

Right. And we're still not all the way there. So I think there's still, there's still a ways to go and you've spent your career really has been in this space. So talk a little bit about your background, you know, and what leads you to be, we're going to talk about TMS, which I'm thrilled to finally dive into, but just give us a little bit more of a robust background on, on you.

Martha: 8:25

Yes. So I'm a psychiatrist you know, board certified in adult psychiatry. I'm also board certified in addiction medicine and I'm a psychoanalyst. So I spent a lot of time on my education on the biological interventions for psychiatry, as well as psychodynamic, right? Underpinnings of, of mental health. I initially Open to private practice. I did private practice psychiatry psychotherapy for many years and during that time. I was also following Novel treatment interventions for mental illnesses. I had started at UCLA doing some outpatient ECT, which is electroconvulsive therapy and I At that time, that was the mid 1990s, right, heard of evidence that we were exploring and research the ability to perform an ECT type intervention with magnets. So rather than causing a seizure and using electricity, right, developing novel ways to stimulate the neurons in a magnetic formulation. So I'd been tracking that I opened a TMS practice in 2009, and it was very successful. through that TMS practice that I also met my partner who is now the, the CEO of Your Behavioral Health, where I am currently the chief medical officer. So at YBH is where we have And a whole array of services, the whole, I mean, our mission at YBH is really easy access to comprehensive care. And we've worked very hard to have insurance based offerings that cover every need, right, from outpatient psychiatry. So this is where we have the med management, we have the transcranial magnetic stimulation, we have psychotherapy, all the way up to highest levels of care. So detox. Residential treatments for mental health as well as dual diagnoses, and then in between the partial hospitalizations and the intensive outpatients. So we have a whole ecosystem of care which allows us to, to really give this comprehensive continuity of care to someone can enter the system at the highest level of care sometimes at detox. Thank you. All the way downstream and at the end being outpatient psychotherapy and doing transcranial magnetic stimulation. Or sometimes they enter just, you know, in terms of a therapy or a med management person and they, you know, we find out over time, right? They're struggling more. They have a deeper episode of their bipolar illness or, or, you know, or unipolar depression, or they end up having an underlying substance use disorder that wasn't necessarily revealed day one, and they end up you know, sometimes stepping up to a higher level of care when needed. So Your Behavioral Health offers all of that. We also have an arm, it's not insurance based, which is our three sober livings for young adult males, which have extremely incredible outcomes, be they're very sort of long term structured sober livings where we include the clear behavioral health therapy components, as well as the neuro wellness spa, medication management and TMS offerings.

Brenda: 11:25

I think it's so unique and it, and it shouldn't be unique that you have all of that under one roof and that somebody could move through. The various components of what they need without bouncing around to, right, like 11 different providers because it's confusing enough for an individual or for their parent who's trying to help them navigate this whole system to have to figure out like, where are we going for medication? Where are we going for therapy? Where are we going for, it's just so complex. So. If you don't live in Southern California, it's too bad because you could have all of this. You don't live in Southern California,

Martha: 12:12

move out here because we have all of this for you. You're absolutely right, Brenda. Yes. I think the main, this collaborative care is the piece that's so missing out there. And it's, it makes it very, you know, the, our house manager at at a sober living can pick up the phone and call the psychiatrist, right? Call the therapist, the case manager, the therapist, and the PHP IOP, right? Can reach out and, and speak to, you know, the, the nurse if needed. So it's, it's, I think that amount of support and just the whole treatment team integrated around each patient and client really makes us able, right, to provide the best care that we do. And it makes the journey so much better for each client and individual patient.

Brenda: 13:00

Oh, for sure, because I think a lot can get dropped right in between if you're moving from one system to another. First of all, you're not completely 100 percent in, you know, the best functioning situation if you're dealing with this. And so if, if important information gets dropped between providers about a diagnosis or medication or whatever it could be, that can make a significant difference in what you recommend or whatever. So why do you think, like, why aren't more programs? combined like this where you have everything under one roof? I say one roof. I know you have multiple roofs, but in general, like within, within the system, like you're working within one system.

Martha: 13:50

Yeah, I think that's a great question. And I think it has to do with behavioral health care being very separate, the same as a lot gastroenterologist in one place. And I think with behavioral health care, We see the same thing, right? You either, often people are coming down the psychiatry route, and so then there's the medical side, or they're coming a therapy route, which would be the therapist, right? Or they're doing the rad T, you know, addiction counselor route. And it's rare that that everyone's getting together from those different backgrounds and, and specialties and educational platforms. So I think that where, where medicine should go also really, right? Because that's the same problem, right? That we have in medicine and you hear it all the time, right? Somebody really needs to get to an orthopedic and they have to go to their internist first, right? And, and then maybe they go to a physical therapist and they finally get to the orthopedics and they get sick. If it were all in one house, it would, it would certainly be, be better care for everybody. So I just think it's where it's. That's sort of the nature of the educational pathways and that, that it's been hard to, to integrate those and, and combine those, those resources.

Brenda: 15:06

Well let's dive into, thank you for all of that. I think that's really helpful background and sounds like you have a rich history with some of these treatments that you don't hear about a lot. So transcranial magnetic stimulation. I know. enough to fit on my pinky finger, fingernail. So please help us understand this treatment modality, who it's for, what it does, so that we can really be a little bit more educated when it comes to making some decisions about what we might want to research for, for our kids.

Martha: 15:42

Very happy to. This is one of my favorite things to talk about. I often tell people it's, I think this is the best thing I'll see in psychiatry in my entire career. It's, it's a pretty amazing intervention. So as you said, TMS stands for transcranial magnetic stimulation. TMS actually has been around since the 1980s surprise, right, because so many people do not know about it, but in medicine we, we initially used TMS for brain mapping purposes, right, to identify sort of what parts of the brain were responsible for what sort of functional activities. It wasn't until 2008, right, that TMS was FDA cleared for the treatment of depression. So the first FDA clearance of transcranial magnetic stimulation, which was a specific protocol to use for the treatment of treatment resistant depression, which was failing one antidepressant medication happened in October of 2008. So as you can see, TMS, as an FDA cleared intervention has also been around for 15 plus years and still very many people don't know about it. It is currently FDA cleared for depression, anxious depression, obsessive compulsive disorder cigarette cessation, and depression. and actually migraine with aura. It is also effective, however, for bipolar depression. There's a lot of, you know, this is not now FDA clearance, but a lot of great research in terms of addiction, recovery definitely PTSD, cognitive impairment autism. So, so, when I describe what the technique is and you'll understand why it makes, a lot of sense that, that we just need to learn more in neuroscience about sort of where to target on the brain. So what TMS is, it uses a high intensity magnet, you can think of sort of like an MRI strength magnet. But rather than an MRI, which is very global when you go in, and it sort of gives you a big picture of maybe your whole brain of your whole abdomen, what we do with the magnetic energy with TMS is we can focally target and stimulate a specific neurocircuit in the brain. Right, so we look at the brain. The brain is composed of nerve cells, which we call neurons, right? These neurons can be Induced to fire, right? It's how neurons communicate, right? They just talk to each other, they fire off and they, we can have them do that electrically like with the ECT, which is electro stimulation, or we can create a magnetic field, an electromagnetic field, and that will cause the neurons to fire or medication, right? We can, that's a chemical that can cause the neurons to fire. So we use this high intensity magnet, we fally, target and stimulate a specific neuron specific circuit in the brain, which is based on what we're trying to treat. So, we know in depression, for example, that dorsolateral prefrontal cortex, which is about over your left forehead, right, or under your left forehead, sorry, and that is connected to deeper brain sections, your amygdala gyrus, and then it loops back around to your dorsolateral prefrontal cortex. So that one loop is something that we actively stimulate and target for depression. If we're treating OCD, we Look at a different circuit. Anxiety we're typically treating on the right side. And This is why often it's called, like I think you heard Lindsey mention it earlier, right, for HopeStream, that we call it physical therapy for the brain, because people often don't think of nerve cells in the same way as maybe muscle cells, but you know, you go to the gym, you're working your muscles, you're growing them, and with, with neurons, it's the same thing. We get them to fire, we get them to fire correctly and regularly, and it treats the underlying illness. So we know enough in neuroscience, right, to know which neurocircuits are involved in which illnesses. Right now, obviously, the science is, is increasing every day, right? And we know that it's really not going to be as simple as, as even circuits. There's big networks in the brain and it's how the networks combine with each other, but this is sort of where we are with the state of the science. As a process, It requires somebody to come in to the office five days a week, typically for six weeks, and then there's a three week taper of six sessions, so a nine week process can drive yourself to and fro, there's no anesthesia, there's no sedation, there's no cognitive impairment, so there's no need to interrupt any of your daily activities. takes about 30 minutes each session. And most people are noticing significant improvement after the first two weeks. So unlike medication, right, which we typically get on a dose, take some, you know, seven to ten days to get up to a therapeutic dose, and then three to four weeks to work, with TMS most people are, are noticing significant improvement around eight, nine, ten sessions, which is, you know, within the second week. So it's another thing that we really love about it. It's when you come in the very first day in the process, it's important that we calibrate the device obviously to your head, right? So we have protocols that are FDA cleared but where we're tweeting on your head is individualized to you. So we do two things for that. We find the place on your head where we get hand movement on the opposite side, so over your motor strip, and the least amount of magnetic energy required to get that hand movement is called your resting motor threshold. And we dose the treatment based on a percentage of your RMT. So just like a medication has a dose in milligrams, we have a percentage dose that we use for TMS. It's based on your resting motor threshold. And where we find that hand movement also dictates where we treat. So we move forward from that over your left oroflateral prefrontal cortex, let's just say if we're treating for depression. But the, the spot where we get your resting motor threshold also helps us determine on your brain where we want to treat. The device itself, it looks like a chair, sort of like a lounge chair. A person comes in and sits in the chair. They have a nice head support system, which is a pillow that inflates, just not to help their neck and help them not move their head. And the device has a little weight to it. It's, it looks like a, you know, pillow. Like an iron, sort of, maybe, you could think about that, with that about a weight. And the sensation is odd. I tell people it's a little uncomfortable in the beginning. It doesn't hurt. We don't have people quit for it. But there's a little scalp discomfort. You feel a tapping on your scalp. There's nothing actually tapping. That's the magnetic energy or the force. But then there's, you know, the neurons are firing underneath. And in the very beginning, it's an odd sensation for your brain, right? And our bodies are very smart, right? Our mind body connection. And so in the beginning, there's a lot of energy that goes over like what's going on over there. And it's a hard, it's hard to put in words. It doesn't hurt like a pain, but it's a weird sensation. And we typically accommodate to that in, you know, three to five days. So there's a little scalp discomfort. Some people get a little headache day one or two, easily avoidable with some Tylenol or Motrin, and that's really it. So another thing we love about TMS, right, besides that it works faster than, than medications, is that it's really, you know, there aren't the side effects we get with meds. No dry mouth, no weight gain, no sexual side effects, no, no emotional numbing, no, no cognitive cloudiness. And it's more than, you know, twice as effective as medication. So in general, the outcomes are twice as effective. So like I said, it's an amazing, amazing procedure. I so appreciate you let me talking about it because it is still not known as much as it should. And I think over the, you know, the, the subsequent decades, we're going to see FDA clearances for many, many more indications. Oh, I forgot a really important FDA clearance. Just this year FDA cleared for adolescent depression. ages 15 and up. Wow. Crazy, right? So and I think we're going to see more and more of that. And I would look for things like PTSD ASD addiction as being primary areas where a lot of research is being done in terms of FDA clearances for TMS.

Brenda: 23:47

Yeah, well, what I was going to ask is when I heard you say that it helps for smoking cessation that instantly made me wonder if this is something that would be, you know, you know, where my brain goes, okay, what about. You know, THC. What about opioids? Like, is that in the works?

Martha: 24:07

It's very much in the works. It's been in the works for years. And we have a lot of data already. You know, people have looked at many, this is the hard thing about, as we were referencing in the very beginning, a little bit of the challenging thing with substance use disorders, because it's not one thing, right? As well as we're looking at, when we're looking at substance use disorders, we're looking at things like cravings, right? versus impulse control versus mood states. And so people have looked at all those things, you know, when they looked at TMS, they looked at does it help cravings? Does it help actually maintain, you know, sobriety? And then there's all the substances, right? Cause, you know, as you mentioned, there could be cocaine, there could be alcohol, and, and it's hard to get sometimes very a good research trial going when we're dealing with this because often there's more than one substance that's being used. Complicates it, right? There's the comorbidities of the depression, the anxieties, as well as we're looking at you know, either patient reports or patients do have to show up and be willing to do urines, right? Like, are we just trusting their, you know, what they're saying in terms of are they sober or not? So it's a challenge, they're challenging studies to do, but there are many of them showing really good efficacy for all those Parts. And then as we know in substance use disorders, it can't be in a vacuum, right? Just like depression. I can, somebody can come in and do TMS, but if their sleep hygiene is a disaster, you know, and they're not socializing and they're not exercising, they're not eating well, right? Like it's going to be very hard for the TMS to work. And I think it's the same thing when we look at this, like the TMS, I, I know, and I feel very strong, I should say now, I feel very strongly. really helpful for addiction if the person is also not motivated, right, to be in sobriety and working whatever program works for them, whether it's a therapy or whether it's a 12 step, then we also, it's going to change the outcomes and the results. Yeah,

Brenda: 26:06

absolutely.

Martha: 26:07

We know a lot about the neurocircuitry of addiction and there's a lot of really good studies going on. Colleen Hamlin does many of those at the University of South Carolina. And she does a lot on addiction and TMS.

Brenda: 26:22

Interesting. And when you, when you say it's FDA approved for X, Y, or Z, and it's not FDA approved yet for X, Y, or Z, what does that mean? Does that mean it cannot be offered for the things that it's not FDA cleared for? Or is there just a difference in insurance coverage or what, what does that actually mean?

Martha: 26:42

Excellent question. It really boils down to insurance coverage. And fortunately, not all FDA cleared indications are covered by insurance, right? This is constant battle we have. So just like with medications, right? Medications, I think a good way to think about it is medications come out, they're FDA approved for certain indications. Most insurances are not necessarily covering those medications because of cost, right? Until sometimes they flip over to a generic formulation. So with TMS, We first have to get the FDA clearance. We just use the word clearance for devices, we use approval for meds. So FDA clearances, which there's been then these big FDA, right studies proving efficacy. So we get the FDA clearance. Then it usually takes a while for the insurances To Agree that they're covering it And then we go from there. So, unfortunately I would say yeah, if it's FDA cleared And on the insurance this gets recovered Many of these things are FDA cleared But many insurances are still not agreeing to cover But I would say in depression, OCD generally across the board, really good coverage. Adolescent depression will be there very soon, I know. It's just that it hasn't been, met the, you know, FDA clearance that long. Those they think are, are, they're really solid. So I would encourage any, you know, most people their insurance would absolutely cover TMS for depression. Depression, anxious depression OCD.

Brenda: 28:17

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Martha: 29:48

This is another great point I should make about the addiction and the people that we treat at YBH or the neuro wellness portion of YBH for addiction is we often use. what we call magnetic e resonance therapy. That's same TMS technology, same actual TMS device, right, same process of the MT determination, but rather than a set fix protocol that we have dictated by the diagnosis, we actually use EEG guidance first. And so we take an EEG of the brain, we send it off to the lab, and then they send us a protocol. And so we typically use MERT, the Magnetic E Resonance Guided TMS, for autism, PTSD people recovering from addiction, like once again, if it's addiction and then depression, anxiety altogether though cognitive impairment are the, are the big ones. And traumatic brain injury, we get amazing results with traumatic brain injury. Yeah, so those sort of five indications. With ASD, what we see, the, the three biggest we see are increased social reciprocity So I mean, I have some parents crying in my office because their child hasn't, they haven't had one night sleep through for 12 years, 10 years. And language. So, we've had children that had, you know, had language, lost language, and then can recoup language. So, those three things, I think we see the most commonly. Now MERT is not an FDA cleared intervention. There's, there's good data. There are two big FDA clearance trials going on for PTSD currently. So, I'm hoping, I'm hopeful, first quarter of next year we'll have FDA clearance MERT for, for PTSD, but data's still out. But, but there is a lot of, you know, there's a lot of clinical experience already with it. And I see really great outcomes. So when I mentioned the addiction, what's very interesting is, so we do the EEGs, and then every two weeks we repeat the EEG. And what's really nice about that is patients get to see, right, how their brain is changing and that's really valuable. That's so much, that's part of in mental health, right? Because so much feels like this big black box in our skull and, and what's really happening. And yeah, so we use. When somebody comes for depression or anxiety or OCD, we use the, the evidence based rating scales. You're probably familiar with that. People listening, like we have what's called a PHQ 9, which is a set of symptoms for depression, or you have the GAD 7 for anxiety, we have the Y box for OCD, and we have the patient's name. We fill those out every two weeks, and it's an objective measure and we always see those scores going down. With the MERT, we do actual the EEG, and then we repeat that every two weeks, in addition to the scores that are the subjective report from the patient. And it's, and, and it's very cool to, like, the patients get to see that and how it's changing and improving, and I think it just adds to the excitement as their symptoms are getting better also.

Brenda: 32:53

Oh, that has to be really great. Just that self efficacy of like, oh, I'm doing this because what strikes me is this is quite a commitment from a schedule standpoint. So it seems like it would be really encouraging to be able to see Visually, like, see your brain changing, so that could be really rewarding. I wanted to ask about trauma. So you talked about PTSD, so if somebody, I don't know, does everybody that have, has trauma have PTSD, or is this something that would work for trauma? Like, how does that all work together?

Martha: 33:29

This is a hard question, right? Everybody have trauma, have PTSD, and, and no, right? We, and we don't quite understand all of that, right? We're all different biological, biologically, right? I would say, and I think addiction is also another great That's a good way to analogy for that. Right? Some of us could drink alcohol, and then even if we're stressed we might drink alcohol, but we're never going to become an alcoholic. We're never going to have that. We just don't have those genetics. And I think it's sort of the same thing with PTSD, right? Some people have very traumatic events, and yes they were traumatized, and they're able to process it in recovery and, and heal. and recover and go about their business. And then some people end up with these residual after effects that we call PTSD. It's actually interesting now in the community, there's a lot of talk about it really shouldn't be called disorder because people really feel it's an appropriate human response to the the experience that they've had. You know, unfortunately, this goes back to what we're talking about, like insurance coverage and DSM. If it's not a disorder, it doesn't go in the. Diagnostics is a cool manual, and if it's not in the DSM, we can't bill for it. So, it's a little bit of this wacky loop. But, but, you know, why do some people end up with, with PTSD post trauma and some people don't? Once again, a confluence of factors, right? I think basic biology, basic temperament. temperament upbringing, right, coping skills around them, resources, all those things play a factor. And yeah, it seems like the, you know, the, the MERT looks, like you say, I'll be very interested in these FDA trials coming out, but it, it, from our experience, we've had really good success with, with PTSD using the MERT technology.

Brenda: 35:16

Is this something that you could potentially be doing at the same time or would you suggest stopping something like EMDR while you're doing TMS?

Martha: 35:25

No, absolutely. They can be done simultaneously. And we at NeuroWellness. com you can talk to my staff. I'm a staff member. Real Sargent on this. It's like, I don't like anybody ever to be leaving TMS and not be in individual therapy. I mean, I really, you know, any, no, any biological intervention in my mind, no matter how powerful, is is, is insufficient enough, right? We all need to also then process, I don't, I'm not saying anybody has to be in psychoanalysis or therapy forever, but it's really, we will get our best outcomes, right? If we are combining, I think, some type of therapeutic process with with our biological intervention. So for some people that could be mindfulness, it could be meta, you know, meditation, but you absolutely, combining the EMDR. with the TMS is, is the best outcomes, right? And I just remind people, I mean, even, you know, even if when you're, you know, if we get somebody in complete remission from their depression with TMS, for some people, it's, they've never felt that way, right? They've struggled for years with depression. And it's a whole new way of seeing the world and interacting with the world. And that alone can be, I don't, I mean, I have to say traumatic because it's positive trauma. But you know, I, I laugh all the time when I think of trauma We don't do this in psychiatry anymore, but formerly, you know, in the, I guess it was in the 90s, we used to rank everybody on their, like, stressors, right? It was a part of this part of your diagnostic, your forearms, your diagnosis, and, and you were ranked on your stressors, and the top three, right, were buying a house, starting new jobs, and having a baby. Right? I think getting married maybe was there. So it's like these things that are very positive in life, right? Also come with a lot of change and challenges and can be stressful. So I think this is the same thing sometimes coming out of a depression. It's the very time we need to be in therapy and get the support so that we are, you know, continuing our, you know, our good habits and reinforcing our self views that are healthy versus the ones that maybe we've carried around for years. So long winded answer, but yes, EMDR plus TMS would be fabulous.

Brenda: 37:40

Okay. And or other therapy. And or other. And support. Yeah.

Martha: 37:43

CVT. Whatever. Yeah. Whatever

Brenda: 37:45

works. What I was thinking when you were saying that, it's so true about if you, if you really do overcome something like PTSD or depression, it's not just probably what it is. How you are moving through life, but all of the people in your world around you are used to you being a certain way. And all of a sudden now, and maybe it's not all of a sudden, right? It's probably over time. You become someone who's very different and that has to be confusing for the people in your life that love you, your kids, your spouse, your parents.

Martha: 38:17

To

Brenda: 38:18

be like, wait a minute. She's very different than she used to be. And that, you know, creates like those ripples in the whole system of now we all probably have to do a little bit of adjustment to, to this change.

Martha: 38:32

Yeah. Yeah. The, the family dynamics and how we really try to avoid having an identified patient, because. So So you know, I don't know if that's an issue that you and I share, but it's just in my mind it always goes back to it's a, everything's a family system issue. And right, if one person alone tries to change in a family, there's a lot of pressure sometimes to differ. So you're right, whether it's an adult and a couple and somebody's, you know, used to being married maybe to their depressed partner. partner who is quiet and doesn't like to go out a lot. And all of a sudden they're talking all the time and, you know, want to go socialize or have all these interests. It can, it can be really difficult, right? Some of the reason why they got together, maybe in some of the, the balances there are going to be tweaked. And so it's important and right, same thing with like. You know, obviously recovery from addiction, right, that there's all these dynamics that have been set often for years when someone's active in their disease and then, then they're sober all of a sudden and getting better and there's, oh my goodness, all this trust that needs to be, you know, regained and, and, and anxiety a lot, I would say, and, and family members that needs to be contained because otherwise that's, Big triggers, right, for the people in recovery. We can't relate to them in the same way and try to control and be anxious, right? But that was needed for so, I don't know, needed. That was, that happened for so long. It's hard to break those patterns. So,

Brenda: 39:56

yeah. Yeah. I did remember a couple of other questions. One is, can somebody be on medication. So maybe somebody is on an anti anxiety or antidepressant and, and they're hesitant to like stop doing that to do TMS. How do those two work together or how do you handle that?

Martha: 40:16

Yes, absolutely. The vast majority of people are on medication. So what's happened is they've tried a medication, And it hasn't worked for them, you know, it may have partially worked, but they didn't get them in complete remission. So if they're on a medication that they feel has done something, and they're tolerating it, we ideally love to leave them on. We add the TMS, TMS gets them in complete remission. And we do know, right, that staying on a medication sustains the response. So very important information that I did not state prior is, you know, TMS is not a magic pill. Bullet cure forever, right? All of these illnesses we speak about, we, we consider them chronic, right? Now, not chronically symptomatic, right? Our goal is we get somebody in remission, just like cancer, you get somebody in remission, and you want to keep them there, right? But if we look at substance use disorders, depression, anxiety, you know, those are chronic illnesses, we get them in remission, and then we need to work hard to keep them there. You know, it is common Most common that at some point in life, someone will have another depressive episode or You know, their OCD will flare up. And so the idea is We have the TMS we get them in complete remission. They stay on the medicine and then we just track them 80 percent of people are still in remission in about a year is what the data shows Some people need to come back in six months once it's covered the great thing about insurance coverage for TMS is insurance companies do understand this and And once it's covered, if it works for somebody, then they typically will pay for it twice a year. That's a really good thing. If somebody's on a lot of polypharmacy, we do try to encourage them, you know, we get them better, and then we want to be able to simplify their medication regimen, hopefully get them down to one or two meds if that's feasible. If somebody is really having a lot of side effects, then we would also encourage them to taper if that's their choice. We typically would start at the TMS, make sure it's working, right, make sure they're getting better, and then, then maybe taper them off their medications during the taper time of TMS.

Brenda: 42:20

For somebody who is currently, let's just take marijuana, let's leave some of the harder drugs out of it, but if you're a regular or recreational marijuana user, could you do TMS? What is the recommendation for that?

Martha: 42:37

Yes, absolutely. Right. I mean, I think we've seen in the current, you know, sort of the younger generation that cannabis use is, is thought about a little bit like, you know, Maybe in, in the older generation, how we would think about alcohol. Ideally right in psychiatry, if somebody's coming to us, we, we are saying to them, you know, do you know that cannabis or alcohol, like these, these are mood or anxiety altering substances. And while you're here getting this treatment, like ideally, Right? We're not, you're not doing those other things because that's going to be the best chance. Even if we think those don't, don't cause it, you know, there's always the question of they're certainly not helping it, right? It would just be like, we don't want somebody sleeping two hours a night. Like we know a good night's sleep is going to support everything. That being said, If it's not an actual use disorder to that degree we absolutely can do TMS. People are allowed to have, you know, a drink on the weekend, or they're allowed to have their cannabis used several times in the evening, you know, several evenings a week, I should say. And it, it doesn't interfere with the efficacy, and there, there's actually been some publications with cannabis because it is such a, it's such a, you know, a, a prevalent

Brenda: 43:45

And if somebody is not lucky enough to be in Southern California where you are and they're looking for a provider, is this something that's available prevalently? And if not, how do you find it? And then also, what are the qualifications that we should be looking for of somebody? Who's providing this because

Martha: 44:07

I

Brenda: 44:11

don't want anyone that's not qualified putting any magnet on my brain. So I want to make sure I

Martha: 44:17

know who to love that question. So great. So TMS is actually really pretty available across the United States and also in other countries. I am the best place to look. I'll sort of tell, I'm current president of the Clinical TMS Society. It's an amazing organization and you can find it at clinicaltmssociety. org and Going on there, we have a, you know, a patient family page where you can look up providers, you can put in your zip code or your city, and you can see who's around you. So I think that would be, in my mind, the best resource. Just go to the Clinical TMS Society's website, and you'll find a lot of providers. I think that is one also. good way when you're looking at the provider. I would hope they're a clinical TMS society member because that is where we stay up to date, right? On all our learning and our, our, we have pulses courses for certifications and trainings. We have our annual meetings. So I think if somebody's a clinical TMS society member, it does say something about them. So very accessible. I would say almost every state in the United States. What to look for, I think there, there's the expertise and then there's the, the practical. So I would say if we knock off the practical first, which is what we focus on and really try at Neuro Wellness Spa is like, you're going every day. So It needs to be geographically close enough. The hours, right? What are the hours? You know, we're open seven to seven. People come early. They can come late. They don't have to interrupt their work or their school. They can come in the middle of the day. We have parking right behind the building. You can walk right in and run up. So I think some of those practical things because you don't want the treatment to be really stressful in and of itself, right? In terms of the expertise, I think, or, or the questions, the, the, The really good ones to ask are, you know, how long has the, the psychiatrist or in some places it's a nurse practitioners actually finds, you know, neurologist maybe, how long have they been providing TMS? I think looking at how often the mental health, you know, specialist is evaluating you is really important, right? So at our sites and also who calibrates the device and then recalibrates and checks. So at our sites, our medical directors do all the calibrations. We don't let any techs do those. They see the patient every two weeks, minimally. They're onsite though, available for questions if there's issues. There is a TMS tech that treats in between, right? There are some sites where you see the doctor for the consult. Okay. or the NP for the consult, and then they just prescribe it, and then you're seeing the TAC for the entire nine weeks, and I don't think that's the best oversight or care. So that's a good question. Asking what device they use. There are now many devices on the market. They're not all FDA cleared for the same indications, and they all haven't been around for the same amount of time, so I think knowing what device, and then knowing what their protocol is. Which you could also get because we do, different devices have capacities for different types of protocols, which can get just to like leave it simple, it's, it's sort of just what, what can we do to get the best outcomes, right? Because there's different types of pulses and frequencies that we can add to ensure the best outcomes. And I think those would probably be the main things, right? So making sure that. It's easy to get to where you need to be five days a week, a certain time and access, and then where you're going, right? What device you're using, what protocols they have, how long experience they've had, how much contact you have with the, the mental health professional who's going to be evaluating your progress throughout the time.

Brenda: 47:57

Wow. Well, thank you for the deep dive. I feel like I kind of went to mini, you know, college here on DMS really. really helpful. I think it's so encouraging to hear about some of these things and, you know, it's frustrating that this has been around since the 80s and it's, you know, just now sort of getting its legs or at least getting a little bit more well known because the, the medication situation is really difficult, especially, I was so encouraged to hear you say 15 out of the last 15 year olds because what we hear and what we see with our members, You know, especially as their kids will be on five or six different medications at the age of 16. And it's so difficult. Yes. And then you mix in, you know, a diagnosis and then you mix in a cannabis use disorder and it is just a ball of confusion. So

Martha: 48:50

yeah,

Brenda: 48:51

this is really nice to know there's a non medical intervention to at least try, right?

Martha: 48:58

Yes. My, my children are older now, but I would. Absolutely do TMS on my teen, right, over medications, hands down, right? Just safety, efficacy for long term durability, and, and we just know, I mean, we, we prescribe meds in, in children and teens because we feel we need to do something, right, and some work, but, but, you know, outcomes for adults pretty poor, we didn't go over that big study, right? When you start somebody on an antidepressant, we know only a third of people will achieve remission, and then we've tried them on two we capture maybe 20 percent more, so when you think about it, 10 people going to see a psychiatrist, and maybe they've tried two trials of meds, you're still leaving half of them completely not at a level you know, in remission from their illness. The outcomes are worse for teens. So that's why so many of them end up on five, six medications and, and we obviously we try because they're symptomatic and so we want to do something. But I think the outcomes with TMS are at least with Definitely without the side effects and I think more efficacy and the teens, they don't want to, you know, it's hard to take a medication, like, also, just that age, right? They, you know, it's what I love about TMS. We're not putting anything inside. We're literally telling somebody, you have all the tools inside your own brain to heal. We're just giving it a little nudge, right? And I think that's a different message sometimes than you have to take this pill. And to feel better? Or what is this doing to me? Is this relieving me? Right? That's changing, or is it this? And then the dependencies issues that come up, right? So I think there's a huge advantage in the adolescent population for TMS. I agree.

Brenda: 50:34

Amazing. Thank you so much for the time. Appreciate you being here. In the show notes, we'll make sure that there's links to Dr. Koo's organization, Your Behavioral Health, and also to the TMS Society. So you can look and see where there's a provider. Thank you.

Martha: 50:50

Thank you.

Brenda: 50:52

Okay, my friend, that is a wrap for today. Don't forget to download the new ebook, Worried Sick. It's totally free and it will shed so much light on positive tools and strategies you can use right now to start creating those positive conditions for change in your home and in your relationships. It is at hopestreamcommunity. org forward slash worried. And guess what? We have moved the entire podcast to our website at HopeStreamCommunity. org. So now when you want the show notes or resources, or if you want to download a transcript, just go to HopeStreamCommunity. org and click on podcast and you will find it all there. You can search by keyword, episode number, guest name. And we have created playlists for you, makes it much easier to find episodes grouped by topic. So we're really excited to have that done and hope you like the podcast's new home. Please be extraordinarily good to yourself today. Take a deep breath. You've got this and you are going to be okay. You're not doing it alone. I will meet you right back here next week.