Joey Wahler (Host): It's a technique used to treat mental health disorders. So, we're discussing transcranial magnetic stimulation, also known as TMS. Our guest, Dr. Sapna Purawat. She is Psychiatry Director and Founder of Mind Body Medicine. You can visit her website at stocktonpsychiatry.com.

This is Hello Healthy, a Dignity Health Podcast. Thanks for listening. I am Joey Wahler. Hi, doctor. Thanks for joining us.

Sapna Purawat , MD: Hello.

Host: Simply put, what exactly is TMS?

Sapna Purawat , MD: So, TMS is a non-invasive way to modulate the brain activity. So, it is a non-invasive technique, which you can use to stimulate specific areas of the brain. So, basically, what we do in TMS is we generate magnetic pulses, which goes through the skull and when these magnetic pulses reach the brain, they produce small electrical currentss. And these currents can stimulate the activity of the neurons in the targeted area. And when you are activating the neurons, it can be used to treat a variety of diseases, specifically like depression, anxiety, and chronic pain.

Host: Gotcha. And so, what can a patient expect during a TMS session and how long does each one last?

Sapna Purawat , MD: So before undergoing TMS treatment, it is crucial that you will go through a thorough evaluation by a psychiatrist to determine whether TMS is appropriate for your condition to discuss potential benefits, risk, and alternative treatment options. Once it has been determined that TMS session is good for you, you will do what we call as mapping. So, in this, we go through the TMS and put the coil on the skull and do the twitching, where we kind of locate the area of the brain which is targeted for stimulation. So, the first appointment, we also go through the benefits, risks, and side effects of TMS. Placement of the coil is the first thing which we do. And after that, once we know where we have to target and the effectiveness of the stimulation, then we start delivering the series of magnetic pulses to the targeted brain area. Usually, if the treatment is being provided for depression, then people come for at least six weeks of treatment. And each week, they come for five days. Typically, a session lasts between 20 to 40 minutes. You are awake and alert during this treatment. You can carry on with your activities of daily living after the treatment and before the treatment. And so, that's what it entails.

Host: Gotcha. Now, you mentioned there, doctor, once it's determined that this is suitable for a patient, what makes someone suitable? What might, if anything, make them unsuitable?

Sapna Purawat , MD: So, if you have implant, like cochlear implant or internal pulse generator, if there is a medication pump like a pacemaker or other implanted devices, those make them unsuitable. If you have metal of any kind in the head or brain area, if you have a history of epilepsy, if there is a vascular, traumatic, tumor, infection of brain, that makes them unsuitable. If a woman is pregnant, that makes them unsuitable for TMS.

Host: Now, you also mentioned, we're talking about a typical commitment of at least six weeks, five days a week, 20 to 40-minute sessions. And so, once someone makes that commitment, typically speaking, when would these TMS treatments start to show some results?

Sapna Purawat , MD: Usually, it takes four weeks to start seeing benefits. But along the mark of two weeks, you will start noticing a difference. But it does take six weeks to receive full benefits from TMS.

Host: And so, what type of expected outcomes and success rates have you found from this in your experience?

Sapna Purawat , MD: As you know, the burden of mental illness is very high. It has been FDA-approved since 2008 for treatment of depression. Approximately one out of two patients experience significant improvement in depression symptoms. Approximately one out of three have complete symptom relief after the full TMS treatment. So, that is a very big number. For

FDA has recently also approved TMS devices and protocols for conditions like obsessive compulsive disorder and migraine headaches. TMS is showing promising benefit for chronic pain conditions like neuropathic pain and fibromyalgia. We are also researching the benefits of TMS in posttraumatic stress disorder, Parkinson's disease, and stroke rehab. Just to give you the wide population which depression impacts, it's a leading cause of disability worldwide with an estimated 350 million people who suffer from major depression.

Host: Yeah. Definitely some eye opening numbers that you just gave, to say the very least. And so, I think you'd agree, doctor, that most people associate the most common treatment of mental disorders as involving therapy of some kind and/or medication. So, would TMS be done instead of or in addition to that?

Sapna Purawat , MD: Right now, the way it is approved through your insurance is if you have failed antidepressant treatment. So, if you have failed four medicines, which you have tried for treating depression, you have not received remission, or if you had side effects and you had to stop taking the medications because of that. But if you want to pay out-of-pocket, it can also be a first-line treatment of depression. There are some people who do not want to try medications, who want to just go ahead with transcranial magnetic stimulation, it is an option.

Host: And when you mentioned side effects there, what potential side effects or risk are associated with TMS?

Sapna Purawat , MD: TMS is generally considered safe when it is administered by trained professionals. But just like any other medical procedure, there are some potential side effects and risks associated with TMS. Discomfort or pain, so as I mentioned that magnetic coil would be placed on the scalp, the discomfort is very mild and transient. It just lasts when they are getting the stimulation. It also depends on the person's pain tolerance. Headache is one of the common side effects, particularly during the sessions. Headaches are usually mild to moderate. They resolve on their own. We don't need to medicate patients for that. Muscle twitching and tingling sensations can happen. It is more kind of an uncomfortable feeling. It is not harmful. Since we are doing magnetic pulses, sometimes patients can have temporary hearing effects like ringing in the ears. The side effect which we have to be on watch out for is seizures. At times, patients, it increases the seizure threshold, so we have to be careful. But again, chances of that happening is very rare.

In some cases, if TMS is given for depression, it might trigger hypomanic episodes if a person has an underlying bipolar disorder. And that is why it's very important that you go to a trained professional so they take a thorough history of you, so we are not missing out any potential disorder where you might not be a good candidate for TMS.

Host: Okay. So, I want to ask you a couple of other things that are related to this. But first, you gave us a brief overview at the top of our conversation. How would you explain to people in layman's terms, those listening, what exactly is happening to them, to the brain that's having this impact with this treatment? In a nutshell, how does it actually work?

Sapna Purawat , MD: Sure. Basically, what happens is the neurons are basically electrical currents. We cannot give electrical current to our body because the skull, you know, we have barriers. So, what we are instead using the magnetic pulses of the TMS. So, the magnetic pulses pass easily through the skull and into the brain tissue. So when these magnetic pulses reach the brain, the neurons, as I said basically, they are generating electrical pulses. So when they meet with this magnetic current, there's small electrical current which goes on in the brain. And what happens is this stimulation increases the excitability of the cortex, of the brain cortex. And as I said, we map and we direct the magnetic pulses at the area where we want to treat the depression. And specifically, that area is called prefrontal cortex. That's where we target the magnetic pulses to go. And we stimulate the cortex and then it releases the neurochemicals which are required to treat depression.

Host: So, is it safe to say then, doctor, that the results that this yields when it's successful, that these are things that these patients cannot achieve on their own, yes?

Sapna Purawat , MD: Yes. So, it is a clinical depression we are treating. As I said, most of the time, the insurance have a strict requirement that patients have failed three or four medication trials. So, we have tried three or four different types of medications, reached the maximum dosage on that, and a patient is still having symptoms of depression. As I mentioned, the success rate is about 30 to 60%, and that is a very big number when you talk in terms of treatment of depression.

Host: Absolutely. A couple of other things I want to ask, one being, are there any other alternative psychiatry treatments or therapies for mental health issues that you can recommend?

Sapna Purawat , MD: We all have stress in this world, you know. So definitely, we want to be self-aware of it. There's no substitute to self-care, incorporating strategies into daily routine. You work towards building you, building more balance in your life and resilience. When we are doing all that, we still have some unresolved issues which we can go to psychotherapists for.

So, there are different types of psychotherapy which we use to talk about our thoughts, feelings, and behaviors. Most commonly used is cognitive behavior therapy for depression, anxiety disorder. There's a huge talk about mindfulness and meditation, which can be used to create moment awareness, reduce stress, anxiety, and depression. Regular exercise and physical activity, they reduce symptoms of depression and anxiety, improve quality of sleep, boost self-esteem, and increase overall well-being. Nutrition, you are what you eat. That's very true. We definitely want to focus on more green vegetables, fruits, omega-3 fatty acid, vitamin D, sunlight, all those have benefits for mental health. I emphasize a lot on sleep hygiene and sleeping during the night time and more awake during the day time because, again, light therapy regulates your circadian rhythm, improves mood, and decreases symptoms of depression and anxiety.

Host: Right. Now, in summary, what would you tell someone listening that may be considering TMS, perhaps as a result of our conversation, but may also be hesitant to get started for whatever reason? How would you advise them?

Sapna Purawat , MD: Yes. One of the proven and safe treatment method, which has been FDA approved since 2008, basically, we are using magnetic pulses to stimulate the neuronal activity. The technology has been used through MRI scanners. Basically, we have been using it. MRI has been used for years and has been safe.

What we are doing here is we are just using it over a small part of the brain. It is a painless procedure. It is very short compared to any treatment which you would do. You would only have six weeks of treatment, and the effects are much long lasting. It does not involve surgery. Anesthesia or sedation is not required. It does not impact your whole body. It's not like a medicine which impacts other systems of your body. So, it's very localized. So again, as I said, each TMS treatment takes approximately 20 to 40 minutes before and right after treatment. You can come and go and resume your normal everyday activities. You are alert and awake during the treatment.

Host: Well, folks, we trust you're now indeed more familiar with transcranial magnetic stimulation, TMS, Dr. Sapna Purawat, really interesting alternative approach. Thanks so much again.

Sapna Purawat , MD: Thank you.

Host: And for more information, you can visit dignityhealth.org/stockton. Again, dignityhealth.org/stockton. To reach the doctor again, you can visit her website@stocktonpsychiatry.com. Her phone number, (209) 290-1700. She's located at 1811 Grand Canal Boulevard, Suite Three, Stockton, California, 95207. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. Thanks again for listening to Hello Healthy, a Dignity Health podcast.