Evo Terra (Host): Transcranial magnetic stimulation or TMS, what is that and how is it used in behavioral health? Dr. Dakota Carter, the Medical Director at Eisenhower Behavioral Health will tell us that and more.

Intro: You are listening to another episode of Living Well with Eisenhower Health, healthcare as it should be.

Host: This is Living Well with Eisenhower Health. I'm Evo Terra. Welcome to the show, Dr. Carter.

Dr. Dakota Carter: Thanks for having me. I'm glad to be here today.

Host: What is transcranial magnetic stimulation? I love those words.

Dr. Dakota Carter: It sounds a little scary, doesn't it?

Host: It does.

Dr. Dakota Carter: But it's actually a wonderful procedure that utilizes magnets to stimulate the brain for depression. It creates new neural circuitry. It creates more neurotransmitters that are often deficient in folks with depression and is a specific treatment to really help folks that aren't responding to traditional treatment for depression.

Host: So, I'm assuming that I just can't go grab the bar magnets from school and hold them against the side of my head and get this done. I'm assuming they are special.

Dr. Dakota Carter: No. The machines that we have are from a brand called NeuroStar. They're the size of a small desk. And it is a procedure that you have to come into the office for that uses a very, very specific magnetic coil and a very specific physical manifestation. I don't want to get into my college level physics, but it is definitely not your magnets you get at the pharmacy.

Host: Yeah, I would imagine not. All right. Well, let me ask the question about is this for everyone? Everyone who suffers from depression, can they have this procedure done or are there certain requirements?

Dr. Dakota Carter: There's certain requirements. So, it isn't a time-intensive treatment. Transcranial magnetic stimulation or TMS for short is a six-week treatment. And so, this is something that patients are going to be coming into the office five days a week and getting a daily session. And so just from that standpoint, it is a big undertaking to target symptoms. Folks that qualify for TMS, because it's also a more expensive procedure, have to have demonstrated some failure of treatment, traditional treatment, which is often classified like psychotherapy and then medication management. So, that breaks down more clearly to "Antidepressants didn't work, talk therapy didn't work, and now I need help."

Host: And now, we have one of these helps. That's fantastic. Let's talk about the benefits. And specifically, these are depression patients that are undergoing this. But kind of broadly speaking, what benefits do they see?

Dr. Dakota Carter: So when we look at my line of work, of course, I just talked about therapy medications. Medications come with side effects. And so, sometimes people can't tolerate those. There's significant problems from those and folks may need this treatment. When we get to the point where they have failed traditional treatments, there's not a lot of treatments that are out there that can be as beneficial as TMS with the least amount of side effects. So, you know, we hear about ECT, electroconvulsive shock therapy that some people have talked about. There's more information out there now about ketamine. And so, that's a type of medication that's used for treatment-refractory depression. TMS compared to those has least amount of side effects and also, with the evidence that we have, can have up to a 50-60% remission of depressive symptoms even compared to those procedures.

Host: Wow. That sounds like a pretty impressive track record. Now, earlier you said this was a six-week procedure, but no one's stuck in that desk with their head in that desk for six weeks. So, how long are these sessions? How often do they come in? Talk to me about that.

Dr. Dakota Carter: So, TMS sessions commonly last anywhere from 18 to 30 minutes. And so, I always tell folks you're coming in Monday through Friday. You get your set time. We're going to turn on a Netflix show and the magnets are going to do their work for 18 to 30 minutes. The good thing about this procedure though, is you can go to work before, you can go to work after, and it's not going to be any downtime compared to other treatments like ECT and whatnot that requires anesthesia, sometimes an inpatient hospitalization. This allows folks that are working have lives to come in and get treatment for their depression and return to that life without any type of interruption.

Host: So, this sounds to my ears, similar to lots of other sorts of imaging services that are provided where you go in, there's a machine, some technician says you're done and it's over, right? So, I'm guessing there's also no pain with this.

Dr. Dakota Carter: There's no pain with this. I will say that initially we do warn folks that they can take maybe an ibuprofen before treatment as the magnet does stimulate some muscle twitching usually at the site. However, that usually tends to be dose-dependent and is really based upon individual sensitivities. I've had folks of all ages, backgrounds, genders, X, Y, Z type demographics that have tolerated this completely without any pain, without the need for that ibuprofen and do really, really well with the treatment.

Host: Now, I'm also assuming that these magnets, that we're not moving the brain around. The brain's not made of iron. It's a non-ferrous substance, right? So, it's not the magnetics that we're looking at. It's more of what I guess the magnet waves that go through.

Dr. Dakota Carter: Yeah. It's the electrical circuitry that's being created. Again, going back the old school physics, the magnetic coil creates that magnetic field that generates electrical currents. Those currents then penetrate the brain. And that's where we start to see the brain develop the new neural circuitry. That's where we start to see the stimulation of neurotransmitters that are needed to treat depression. And that's why the direct stimulation is sometimes more effective than medication because it's directly to the brain where the deficiencies are.

Host: Right. So, how long does this last, these great effects you're seeing and the people that are benefiting from it? Is this six weeks and they're cured and it's all over? Or do they have to keep coming back for followup treatments?

Dr. Dakota Carter: Our brains are pretty unique organs. I will say that there's a handful of patients that can come in, get this treatment, and actually come off of medications and be completely cured. That is not necessarily the rule. A lot of patients recover, they respond to treatment and then, continue other treatments like therapy or maybe minimal medications going forward.

I do have a subset of patients that come in for maintenance. They're folks that their depression was very severe. And ultimately, they do need longer term treatments. Insurance also can cover re-treatment for some people. I've had patients that the effects have lasted a year, two years, and they've come back in for re-treatment. It's hard to say, but the vast majority, like I said, 50-60% remission of symptoms can be inclusive of anyone, and there are ways to sustain that through medication or retreatment.

Host: Now, you brought up insurance a couple of times. This is not some fringe science that's out there on the edges here. This is something insurance companies are paying for, right?

Dr. Dakota Carter: Absolutely. And there's a huge evidence base for TMS. In fact, TMS actually started back in the '80s and was first used for treatment-refractory depression in 2008. And so, it's been around for a while. Like I said, it's an office-based visit and all of the commercial insurances and Medicare cover this to help folks that are really struggling.

Host: Is this something people feel the effects of right away? Does it take a few days, hours, weeks for this to kick in?

Dr. Dakota Carter: It is different for everyone. Most of the literature and just my anecdotal experiences is that, three to four weeks into the treatment, folks start to have a pretty big response to that. We also are going to be tracking patient symptoms with self-report scales and validated scales in an effort to show sometimes those small improvements that in the big picture make a huge difference.

Host: And I would imagine that's important because, look, if I have a broken bone and I go to the doctor and they can take an x-ray and say, "Clearly, that's the break right there. Let's fix it," that's a little harder to do in a brain of someone suffering depression. So, I'm imagining that each of these therapies is somewhat different and somewhat unique to the patient that's having them, as well as the followup sessions. Am I on the right track?

Dr. Dakota Carter: Absolutely. I always tell patients that, you know, a lot of these other specialties can open up the body or can take measurements and understand what's going on. I don't have the ability to open up someone's skull. I can't look at the brain and take a look. And so, a lot of what we do is going to look at even small minimal changes. And I'm including folks getting up and getting out of bed, folks that are starting to notice that they're sleeping better, folks that are starting to notice that, you know, "My mood wasn't great all day, but for half the day. I noticed a little bit more energy, more motivation, more positivity." And we trend that over the course of the six weeks and afterwards, and demonstrate where folks were when they came in and where they're at when they leave treatment.

Host: A hundred years ago, not that long ago, 50 years ago, transorbital lobotomies were the thing. Is this the new one of those?

Dr. Dakota Carter: No. Because the good thing about this is lobotomies were created in an effort to disrupt circuitry. This is to make circuitry work better. And so if we look at the brain, as maybe like an electrician would, is folks with depression are having areas where the limbic system's not firing correctly. We don't have good circuitry. TMS is the electrician that's coming in and rewiring.

Host: Got it. Helpful. Anything that we did not cover that we should get to? We have good information here, so I'm not suggesting that we vamp.

Dr. Dakota Carter: No, I think it's good. I think, like we've talked about, it can be scary for some folks. It can be very challenging to come in for a procedure like this. But it's very much helpful, it's successful and just works. I think that's the biggest piece, is it works for folks who are truly struggling.

Host: Magnet therapy is oftentimes used in the less than scientifically provable or, you know, not a lot of evidence around some of this stuff that's out there for most magnets you can buy. There are people at the malls that are selling it, you can buy 'em online. What's your concern as a physician that does something that actually works, that we do have evidence behind and the magnetic bracelets someone can buy?

Dr. Dakota Carter: For sure. I think that goes back to our conversation upon the procedure and what it actually looks like. If folks do come in and want to start with TMS, TMS is set up, I always compare it to a dentist's office. There's a large chair, there's a large machine. That machine, you know, is very robust. The magnetic coil is very robust. There's a huge electronic component to it. And the treatment itself has been researched extensively, like I said, since the 1980s. And more and more research that's been utilized specifically upon the physics behind all of this has demonstrated not only changes to folks with depression. There's even more evidence coming out recently on OCD treatment. It's coming out on chronic pain treatment. There's even evidence in treating things like ADHD, eating disorders and even things like Parkinson's, tremors, movement disorders. And I would say that for us, having this at Eisenhower, the extensive evidence, the extensive research, and the proof's in the pudding. The patients that have improved, the patients that have walked out of the clinic feeling so much better, I think is the proof in the pudding.

Host: Yeah. I think so as well. Dr. Carter, thank you for all of this fantastic and interesting information today. We appreciate it.

Dr. Dakota Carter: Thank you for having me. And I am excited to offer this to the community and hopeful. If somebody hears this that's struggling, I hope that we can get them the support they need.

Host: Once again, that was Dr. Dakota Carter, the Medical Director at Eisenhower Behavioral Health. For more information, you can go to eisenhowerhealth.org/behavioralhealth. Again, that's eisenhowerhealth.org/behavioralhealth. If you found this episode helpful, please share it across your social media channels. You can also check out our full podcast library for other topics of interest to you. I'm Evo Terra. Thanks for listening to Living Well with Eisenhower Health, healthcare as it should be.