In this video MindPath’s TMS Director, Sandeep Vaishnavi, MD, PHD, answers questions about Transcranial Magnetic Stimulation (TMS) and how this non-invasive outpatient therapy has helped thousands of people with depression. Dr. Vaishnavi is a licensed psychiatrist at Mindpath Health in Raleigh, NC.

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Video Transcript:

Hi everyone, I’m Dr. Sandeep Vaishnavi. I’m the medical director of the transcranial magnetic stimulation or TMS program at Mindpath Health here in North Carolina in the US and I just wanted to discuss a little bit about this technology and how it can be helpful for patients with major depressive disorder as well as obsessive-compulsive disorder or OCD.  I’d be happy to take any questions from anyone so if you want to go ahead and send in your questions now either by live chat or by other means and then I can go ahead and answer those questions. Let me just talk a little bit about what TMS is.

TMS stands for transcranial magnetic stimulation and what that technology is basically a way of using magnetic pulses to directly impact the brain. What we’re doing with TMS is that we’re actually directly stimulating different circuits in the brain and by doing so, by targeting certain circuits we’re able to improve symptoms of neuropsychiatric disorders such as major depression or obsessive-compulsive disorder. Now this technology has been around for a number of years, but it has been approved by the FDA for major depression, specifically, for at least ten years or more and it’s been used on thousands of patients across the country and indeed the whole world with a lot of good results.  We’re going to talk a little bit more about some of those results in just a bit, but I wanted to kind of give you an overview first of TMS and kind of where it fits in in terms of treatment for depression.

So as we know there have been a lot of medications that have been approved for a major depressive disorder and of course there’s talk therapy, different types of evidence-based talk therapy and all those can be very useful for patients with major depression. Unfortunately there’s a substantial portion of patients who don’t respond to these treatments and that’s where brain simulation techniques such as TMS may be quite helpful. So specifically, what we usually do with TMS is that we have patients who’ve been through medication management, they’ve been through talk therapy, and they could be having both of those ongoing but then also they start using TMS. The way TMS works, as I mentioned earlier, is that we’re using magnetic pulses so we’re really using the benefits of the electromagnetic field, which is by the way what all of our modern technology is based on, so everything from your radio to your TV to your cell phone to Wi-Fi internet all that is based on the same general technology using the electromagnetic field. Now we’re at a point where we’re able to use that technology to directly impact circuits in the brain and it seems kind of normal now that we’ve been doing it for such a long time but you really have to step back and think about how remarkable that really is. We’re able to actually change how your brain circuitry works by using this magnetic technology, this TMS technology.

This is something which really has never been done in the history of humankind before relatively recently so it is really kind of a remarkable technology where you can do this in an outpatient setting where there is no anesthesia. It’s done in the clinic, it’s not painful in terms of regular ongoing pain, there is some discomfort that can occur initially as you adjust to it but ninety-eight percent or so of patients and clinical studies have been able to do just fine tolerating the treatment. It is an ongoing treatment, in that is that it is five days a week for six weeks typically. Then there’s a weaning period over the next three weeks.

Each session is typically around 20 minutes or so and the first time that we do TMS we do personalize it to each individual so we basically find the right strength of the magnet and the exact right location of the magnet for that individual. We then check on that on a weekly basis because different things like your amount of sleep or medications can change the strength of the magnet that we need to use so we can look at that on a weekly basis, but, overall, typically each session is twenty minutes and five days a week for six weeks, as I mentioned. Then in the seventh week we typically have three sessions, then in the eighth week typically two sessions and then one session in the last week. It’s basically three-two-one sessions over three weeks at the end of the six-week initial treatment.

One thing which is remarkable about this technology is that [based on] the data that we the benefits can be quite long-lasting. There was a study, and a number of studies now, that looked at sort of long-term outcomes with TMS and from what we know when people have looked at it a year out (a year was just chosen for this study), but when people look at it a year out what was found was that the majority of patients who received benefit from TMS continue to receive TMS at that one-year point. Now, the only caveat of course is that with TMS that doesn’t mean that you stop all other treatments for depression. Oftentimes people do continue on medications and therapy and really the way you look at TMS as it’s not a cure for depression, unfortunately we don’t have a cure for depression- no medication, no therapy is a cure for depression. Depression is a relapsing remitting disease, in other words it tends to be chronic and relapse, and so there are additional episodes that can occur. However what we’re doing with TMS is that we’re literally causing changes in your brain, which I’m going to discuss a little bit more in just a minute, changes in your brain, really rewiring your brain in really a fundamental way so that there are long-lasting effects.

Then what we typically see is that the benefits that people find with TMS is that it sort of gets them to that next stage. Let’s say you’re in a very deep depression you’re not able to get out of that depression what TMS can do is get you to that next stage where you’re able to actually function a lot better and then you can do things to help your brain do things that are good for your brain and good for your mood, such as good nutrition, such as stress management techniques, such as exercise, social interaction etc. So things that we all know that are good for us and that are good for our brains. Often times when people are in the throes of deep depression they can’t do those things, I mean they know that they should do those things, but they can’t make them self or bring themselves to do those things. TMS is one method I think, but a powerful method by which you can get to that next stage and then do the things that that you know will be beneficial for you to help maintain your mood.

The other thing to mention is oftentimes medication benefits are actually better after TMS so the medications may be helpful to help maintain basically the benefits of the TMS. The other point to mention is that if you’re on multiple medications for depression it may be possible to streamline your medications so that you’re not on so many or on such high doses after you’ve had TMS so there are many things that can change after TMS but we do think that it can definitely present some long-term benefits.

It’s really based on this concept of neuroplasticity. Basically, the idea here is that your brain is always changing, even as an adult, we know kids have a very plastic brain in other words kids learn very quickly. We all know that kids can pick up languages much faster than adults, for example, but even as an adult of course you can learn new things and you are learning new things all the time. So the brain is able to change; the brain is able to learn and learning, by the way, is causing physical changes in the brain. What we’re doing with TMS is that we’re actually helping the brain change in a faster way.

The basic concept, just to kind of boil it down here, is that with depression, in particular, the emotional brain is on and overactive, it’s basically on too much. Emotions are important, of course, I mean we need emotions to survive. Actually, this has been studied. People who have neurological disorders where they don’t have good emotions, like fear for example, don’t survive very long. There are reasons that we have the emotions that we have, and so we want to have emotions, but what we don’t want is to have emotions that are not in line with what’s actually going on externally.

In other words, let’s say something bad happens in your life and that makes you sad and down- that’s appropriate right? What may not be appropriate is that that sadness, that lack of enjoyment persists for weeks and weeks and months and months and so that’s the emotional brain being overactive. The cognitive brain actually helps modulate; it helps kind of control of that emotional brain activity. The cognitive brain’s job is not to stop the emotional brain, the cognitive brain’s job is to modulate the emotional brain to make sure that the context is right. In other words, after maybe a few weeks of sadness let’s say, or let’s say a few days of sadness, your emotional brain doesn’t continue to keep going and going and going. That would lend yourself to a diagnosis as major depression. So the cognitive brain is able to modulate it, kind of tap it down, and have the appropriate emotional response.

With TMS what we’re doing is we’re actually activating the cognitive brain. We’re actually strengthening the cognitive brain which in turn helps the cognitive brain modulate the emotional brain, so it’s an indirect way to modulate your emotions but a very effective and a very powerful way to do that. Just to give you a sense of how powerful it can be—in usual clinical care, so looking at studies that have looked at the outpatient clinic or clinical care setting, what we find is that up to two thirds of patients may actually have a significant benefit from TMS. Now these are patients who have tried and failed medication and therapy and have tried everything else that they can for depression, so even among this really tough-to-treat patient population we find that approximately sixty percent or two-thirds of patients do get significant benefit. When I say significant benefit that means having at least a 50% reduction in your depressive symptoms as measured by standard clinical rating scales. So this is a real benefit, a really clinically significant benefit and most patients do get that benefit. In fact, one-third of patients can go all the way to remission. Remission is where the depression symptoms are so low that that they are essentially almost non-existent, they’re very much normalized.

Our goal always with any treatment for depression is to get to remission, because remission, of course, is good for everyone involved and it also may help in preventing having further episodes. In other words, it may help prevent relapse of the depression, but it may not. You may not get to that point of remission, but you may get to the point of having a clinically significant response which is that 50% reduction in your symptoms. Again, two thirds of patients get to that point where they get clinically significant reduction in their symptoms. That’s quite impressive I think, especially in this patient population, so I do want to convey this to viewers that there is hope for people who have had who’ve been struggling with depression. With this new type of technology it’s really a paradigm shift, it’s really a new way of looking at depression, and it is something that can be complementary to medication and therapy. There’s no contradiction here at all in terms of these different treatments.

The other thing is that in terms of the practical aspects of TMS treatment, you don’t need a doctor’s referral, you can call on your own and set up a consultation here at Mindpath Health. We do offer a free phone screening consultation and you can actually see how to contact us here on the screen so feel free to contact us and to kind of get through that screening process. If you’re a good candidate on a phone screen we would then set up a an in-person or virtual consultation and then we would, if you’re a good candidate at that point, go ahead and file to your insurance. The good news about insurance is that a lot of insurance companies are covering TMS. Most of our patients are going through insurance and getting coverage, so insurance companies have realized that this is something beneficial for them, for their bottom line as well because this is a treatment that works for a lot of people and it helps lower costs overall.

In terms of the practical aspects of TMS, the benefit of this again, besides the efficacy that we just talked about, is safety. It is a treatment that is generally very, very safe. It is done in the outpatient setting, you don’t have to go to the hospital, there’s no anesthesia, none of those kinds of things, which with ECT electroconvulsive therapy, of course, there is. That is still a very potent and used method for treating depression where nothing else seems to help and ECT definitely has a role still to play, but ECT is definitely more invasive. You do have to have anesthesia because with ECT there is induction of a seizure and it has to be done in a safe environment; it has been done in the hospital environment. There are a lot of logistical issues with that. You’d have to have someone be able to take you from the hospital because you’re recovering from anesthesia, so there are a lot of logistical hurdles there, but again still a very important treatment for certain folks.

You can think of TMS as sort of an in-between step. You have your medication management you have your therapy and perhaps you haven’t had the benefit from that, then TMS could be your next step because it is more potent than the other treatments but it is more invasive of course. We are assimilating your brain, and so it is more invasive than those other methods, but it’s actually less invasive than ECT, because you don’t have anesthesia and so forth as I mentioned.

As an outpatient procedure one of the benefits of TMS is that you can come in [and] have your brain stimulated and leave you. You can drive yourself; there is no downtime with it. It is on a daily basis as I mentioned for six weeks, but people can do it on their break or whenever they can come in. It is something that that doesn’t cause any problems for the rest of the day and that’s not the case with other treatments like ECT because with ECT there can definitely be cognitive issues, memory issues, and things along those lines and that’s not the case with TMS. There is no cognitive impairment, no memory problems, or attention problems with TMS and if anything, it may actually help because depression itself can cause some of these problems and improving the depression will actually improve your cognition. So you’re able to resume your normal activities after treatment.

It is something that we’ve been doing now for a number of years here at Mindpath Health. Overall, in terms of safety it is a very safe procedure. There is a very low risk of any significant problems. The main side effect of people are going to have, if [there are] any side effects, are related to the fact that we have this magnetic pulsation on your head and so there is a literal tapping on your head that you will feel. Especially during the first few sessions there can be some discomfort and in people who are vulnerable to tension type headaches they may have headaches. Again, for the vast majority of people they are able to tolerate that. In fact, your brain actually gets used to this quite quickly and usually in the first few sessions people are able to kind of get through it and then don’t have any problems for the rest of the treatment. This has actually been looked at in terms of people’s discomfort it really goes down dramatically after the first few sessions, so for the vast majority of people they’re able to be comfortable while they’re getting TMS.

You’re in a chair and you have a helmet, or the magnet [because] there are different types of TMS, and they look a little bit different but the two types of TMS that we have here at Mindpath Health are the two that are FDA -approved. With both of them you’re sitting comfortably, you’re getting your brain stimulated for a certain amount of time. It’s actually just seconds and then there is a break in between and then again you are simulated for a certain number of seconds, and then again there’s a break, and then again simulation. So it goes back and forth and typically again for about 20 minutes.  That’s sort of the logistical part of it, safety wise. As I was saying it’s very safe, but there of course are some risks and those are risks that we would talk about at the consultation by looking at your individual case and seeing if you are indeed a good candidate for this treatment. Not everyone necessarily will be, but a lot of people will in fact be good candidates because it is so safe and again it is very effective for a lot of people.

One thing of course we’re all thinking about right now is the Coronavirus pandemic and how to manage this sort of treatment safely. And I will tell you that here at Mindpath Health we’re doing a number of things [for your safety]. One is that we’re doing a touchless TMS. Once you have been approved for treatments you know you’re going to go ahead and start treatment you will be notified by your cell, we will text you while you’re in your car so you don’t have to go in and be in a waiting room or anything like that. So when we’re ready for you to go ahead and start treatment, we’ll text you while you’re in your car in the parking lot. And we’ll open all the doors so that you don’t have to touch anything- you can go right into the treatment chair. The other thing is that we are very conscious of using personal protective equipment, PPE as it’s called now, with masks provided for all the patients. As well, of course, all the clinicians [wear masks], and by the way there is always a TMS technician in the room with you, and they will have a mask on as well. We have hand sanitizers available everywhere that we’re using quite a lot and we’re keeping social distancing as best we can. After fitting the helmet on you and getting started then there’s no need to be actually close to you so we’re six feet or further away from you while in the room. Those are all ways to sort of minimize the risk and, of course, we are cleaning very thoroughly between each patient.

Also you should note that the different TMS’s have different ways they do this but basically for both of the major types of TMS, that are FDA-approved and we have them here, the contact between the magnets and your head is with something which is disposable or is personal to you. It’s not that it would be the same thing that’s touching other patients, so hopefully that they can also be reassuring. With the NeuroStar TMS, one of the major forms of TMS here, there is a contact that is on the magnet. It’s actually a sensor that makes sure that you have good contact with the magnet and the helmet has good contact and it also is disposable, so we change that between every patient. With the BrainsWay TMS, the other type of TMS that we have available, you have a cap, which is a fresh cap for you, it’s personal for you and no one else uses that. There are various ways that we have to sort of, again, mitigate that risk and so ultimately it is it is something that has to be done in person, but I think there are there are lots of ways to minimize those risks and we’re following all the CDC guidelines. [As well we are following] anything else very closely- any public health announcements, any recommendations that are coming from public health officials, and we’re following them meticulously.

The other point I just wanted to make in terms of certification for clinician’s physicians who are doing TMS. Just to give you my background I’m the medical director, as I mentioned, of our TMS program and so I have been trained in neuroscience, cognitive neuroscience, (that’s my research background) and medical, my training is after medical school I did a psychiatry residency. I also did a psychopharmacology residency and after that I did a fellowship in behavioral neurology and neuropsychiatry. My residences were done at Duke University and my fellowship was done at Johns Hopkins, and I’m board-certified in General Psychiatry and also certified in behavioral neurology and neuropsychiatry. Now the other physicians in our program are also all trained well and certified. They also have been through training with TMS courses. Different places around the country including Duke University have been doing training courses for doctors and for clinicians, and our doctors go through those training courses as well. I am mentor to all of our doctors and sort of help train them as well in terms of TMS, so I feel like we’ve got a good group of doctors who are well trained.

We actually have very good results. I mentioned overall the results kind of nationwide and in terms of clinical trials two thirds of patients can have significant improvement. Our treatment results are actually well above that and so we’re very proud of that and very happy about that and we want to have the best quality program possible. We’re doing everything we can to do that to improve your symptoms.

In terms of where we are, we have TMS available at various locations. I’m actually based in Raleigh, Situs Ct, in Raleigh. We also have TMS available in Durham and we do have another TMS machine at another Raleigh clinic, and we’re hoping to expand across the Triangle over time. At this point we have four TMS machines at these various locations so we can do a consult anywhere and we can actually do that virtually right now especially in the context of coronavirus. The consultation is in fact through a platform that we use, a software program that we use. It is an easy to use program where you can see the clinician and they can see you and we can discuss and do a consultation together. [When we do this we] look at the pros look, at the cons, at the benefits potentially for you individually, and so we do that and then once we get it through insurance, insurance hopefully approves it then we can find the location that is closest to you. Like I said we do have multiple locations and so we should be able to find a location that works for you.

That’s it overall. I’ve been kind of answering some questions that have been coming in as I’ve been talking and if you do have any other questions feel free to ask me and I would be happy to answer them. Alright well thank you very much I’m just going to hold on and see if there are any other questions that may arise and if not otherwise I hope you have a good day and stay safe out there.

All right I do have a question that that has come up, which I want to address in the in the last few minutes here. One of the questions is related to [technology and approval]. Yes, this has been approved. This technology, TMS, has been approved for a number of years for depression and the question is really related to OCD. So how does it work with OCD? I’ve been focusing mostly on depression because the approval has been for depression since 2008. With OCD that’s actually it’s a newer approval by the FDA it’s just recently been approved for this disorder. I want to talk a little bit just briefly about that. With OCD, obsessive compulsive disorder, it can be a very difficult disorder to treat, and there is a very high rate of folks who don’t really respond very well at all to typical medication therapy as well as talk therapy, even the best evidence-based treatments that we have.

What we do with OCD treatment is it’s a bit different actually than what we do with depression. With OCD it’s actually with the BrainsWay OCD coil—that that magnet specifically. So unlike with depression there are many manufacturers, but with OCD it’s specifically with this particular manufacturer called BrainsWay and they have a particular type of TMS that they use called Deep TMS. It’s called deep TMS because it actually stimulates deeper into the brain and it’s more pervasive. That is the stimulation go through a bigger slice of the brain, bigger portions of the brain, than the other TMS devices that we have. So with OCD it’s also a daily treatment. It’s also over six weeks, however the difference is that there’s actually a behavioral component as well- there’s an exposure therapy component to it. Let me explain this a little bit.

Let’s say you have OCD or your loved one has OCD and you have a fear of contamination, a fear of germs. Of course right now with the coronavirus pandemic a lot of people have that but if it’s to the point where it is pathological, it’s really bothering you, it’s not just sort of related to what’s happening right now what we would do is that at the first session we would actually find out a trigger. What’s the best trigger to sort of let you start thinking about the obsessions and the compulsions that you have? So sometimes it is a little bit uncomfortable because we are exposing you to what may be uncomfortable to you but there’s a reason for this, there’s a good reason for this. The reason is that we’re trying to get the brain to understand that, yes, it’s uncomfortable but it’s actually in the end tolerable. Nothing horrible will actually happen right?

For example let’s say you know you have OCD and you’re washing your hands over and over again repeatedly or you have OCD and you have a fear of saying bad words even though you really don’t do that regularly, but you have this fear. Whatever it may be, we’re going to come up with a particular trigger—it could be reading something, it could be a picture, or something along those lines that triggers it, some of these symptoms. We don’t want you to get overwhelmed with the symptoms, but we want you to have a moderate trigger or a moderate response to these symptoms. Then after you start thinking about that then we go ahead and start the brain simulation and the rationale for this is actually that we want to have the brain simulation occur while you have certain circuits that are active in the brain. By giving you that exposure we’re activating certain circuits in your brain and then we’re at that point we’re actually doing the brain simulation. With OCD we’re actually causing changes in that particular circuit by first getting that circuit to be activated and then using TMS. It actually has to be done in that particular order and the exposure stimulus may change over time depending if you get used to it etc, but we do that as well as part of our TMS program. It’s as I said it’s relatively new in terms of approval, but it is something that we have had patients for and we’ve had success with it as well.

So right now, it is in fact major depressive disorder as well as OCD that are FDA-approved and I do know that there are other potential indications coming down the pipeline. For example, the FDA is reviewing a study right now for using TMS for smoking cessation for people who are long-term smokers who have had a lot of difficulty in stopping their habit. There was a study that was done, a randomized controlled study, that showed benefit of TMS for that and of course the target is different for different indications meaning we’re not going to simulate necessarily the same part of the brain. It’s all based on what exactly the circuit is, so TMS is really applied neuroscience and it’s really understanding your brain circuitry and then being able to use that information to then improve the symptoms to basically improve that circuitry. [There are studies out about] smoking cessation potentially and cognitive impairment memory issues and PTSD, bipolar disorder. There are a number of indications hopefully down the road that the FDA will approve, but they are all based on this same general technology, TMS technology, which as I mentioned at the very beginning is really a very potent technology.

I would encourage you to look into it and contact us if you’d like to kind of explore this a little bit further. We’d be happy to teach you a little bit about TMS and how it works and then hopefully be able to do TMS and improve your symptoms and sort of alleviate the suffering that you’ve been going through for such a long time. All right, well thank you so much if there are no more questions, I’m going to end our session today. All right. Stay safe. Thank you! Bye!

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