Alex Danvers, PhD (Host): Hi. This is Alex Danvers. And welcome to Behind the Miracle, the Sierra Tucson podcast, where we talk about the stories and science behind what goes on here at Sierra Tucson Mental Health Facility. Today, we're talking to Michelle Chacon. Michelle Chacon is our longtime TMS Coordinator here at Sierra Tucson. This is our first residential facility ever to get a TMS device, and she's been working at it since we got it, so she's one of the longest running TMS operators in a residential facility in the United States. And we've got a lot of kind of new things that are going on. So, I'm really excited to talk to her about the TMS Program here at Sierra Tucson.

Michelle Chacon, RN: Thanks, Alex. Glad to be here.

Host: I wanted to start, Michelle, just by asking you a little bit about yourself. How did you get involved in mental health and, more specifically, TMS?

Michelle Chacon, RN: Well, my background is that I'm a registered nurse for the last 25 years. And I had been working in behavioral health probably about 10 years before I started at Sierra Tucson. I came on board here specifically to help launch and run the TMS program. And I've fallen in love with it.

Host: Yeah. I recall hearing that you were recruited specifically by our CEO.

Michelle Chacon, RN: I was. I was, that's true. TMS is something that I guess, you know, she had a premonition that I would absolutely love doing it. And I do.

Host: Yeah. And what's fun for me getting to work with you is you call yourself a brain nerd, and hearing how you keep up on the research and hearing how you're always interested in learning new things. Is that something that you had an interest in first, or was it working with TMS that led you to feel like a brain nerd?

Michelle Chacon, RN: Actually, you know, I had a background in Behavioral Health, but I was coming from more of a Community Health, Public Health standpoint, and a little bit of work in detox and treatment recovery. But once I got into the position of TMS coordinator, I think that's when I really fully embodied the "brain nerd" moniker. So, it's something that, I guess, you could say I've grown into.

Host: Yeah. I think the work that you do here, we get great reviews and we actually see a lot of people improving from TMS. But before we get too deep, I guess we should probably explain in broad strokes what TMS is.

Michelle Chacon, RN: Yeah. TMS stands for transcranial magnetic stimulation. So, this is a therapeutic tool that can be prescribed to people, typically with something such as major depressive disorder or OCD, whereby we use this device to send these pulsed magnetic currents to certain targeted areas of the brain in order to help modulate the way that the brain is functioning.

Host: Yeah. So, there's a lot to unpack there, right? I think in terms of a session, right? So, if somebody comes in and they're interested in TMS, how does it start? They start with a consultation with you, right?

Michelle Chacon, RN: Correct. The consultation involves meeting with me for half an hour. Largely, I'm explaining what TMS does, how it can help them, how does it work, who is it for, who would it not be for. So, I also do a brief screening for any contradications and discuss what the course of therapy looks like.

Host: Yeah. So, assuming I were a patient and I know some of this stuff, but the most common thing we'd use it for is probably treatment-resistant depression.

Michelle Chacon, RN: Correct.

Host: And that would be if somebody's depression, I guess, depending on what the insurance company says, but who has tried antidepressants and they haven't worked for them, right?

Michelle Chacon, RN: Indeed. TMS is something that is FDA cleared to forward the treatment of major depressive disorders. So, what that means is that ideally the person would be diagnosed or have a diagnosis of major depressive disorder, and have tried traditional treatments without success. So, that could mean medication or antidepressants, and it could mean therapy, CBT or DBT. If they haven't had relief from their symptoms, TMS could potentially be the next step in treatment.

Host: Yeah. And I think with TMS, we know that electrical stimulation can change the brain's activity. And for a long time, people have heard of ECT, like electroconvulsive therapy. And that's kind of a pretty severe treatment for people who are really almost in a catatonic state often. But this is different, right? This is for people who are at a worse, you know, not maybe at that level.

Michelle Chacon, RN: Correct. So, that's one of the most frequent questions that I get as a matter of fact, "Is this like ECT or electroconvulsive therapy?" Well, what we know clinically is that ECT does work. The problem is that there are quite a few side effects that might be intimidating to people who are looking for some kind of treatment that might help them.

In addition to that, there are some side effects that would include like memory loss, things like that. So with TMS, it's almost as if they took the concept of ECT knowing that brain stimulation can help depression and they fine tuned it using instead of electricity or an electric current, using a magnetic field, which is something that is used or has been used in MRIs for 50 years or more, with the benefit of that being that there's no anesthesia necessary, it's not designed to induce a seizure. People are awake and alert during TMS, which is not the case with ECT. So, it's almost like a refinement and an improvement on something that we have used in psychiatry for years to treat depression, but without the downsides.

Host: Yeah. And I think one of the things that I hear you talk about a lot is there's a fixed course treatment of TMS. And after that, people have remission from depression, that's what the research shows, but they don't need to take medications for a while.

Michelle Chacon, RN: Correct, that can be the case. Many people will look at TMS if they are interested in maybe reducing the medication burden or reducing the amount of drugs that they are currently prescribed. Some people don't want to be on medications or take pharmaceuticals at all. You know, TMS is something that is considered to be non-invasive and generally pain-free, although there's some discomfort that might be involved. People stay awake and alert. It can be done on an outpatient basis even. It's relatively simple, fairly effortless. If folks have depression, other things haven't worked, this would be a good next step.

Host: With our program here, we've had some big changes recently, and I guess recently in the last year and a half or so, right? But we got a new device called the MagVenture. And do you want to explain what's like better about that and what that decision to get that device was based on?

Michelle Chacon, RN: Yeah. So, we upgraded to the MagVenture a little over a year ago, and it's been fantastic. There are several different manufacturers out there. We were using the NeuroStar previously, upgrading to the MagVenture, which has something called Express TMS, where the treatment takes three minutes. Previously, the standard treatment for depression took 19 minutes, all the way up to 37 minutes, so it was a pretty big time commitment. By reducing the treatment time to three minutes, we can actually do more than one treatment in a day. So, we're doing something more of an accelerated sort of course of therapy. Rather than spending eight weeks doing a treatment each day, we can knock out the whole course in two to three weeks.

Host: Yeah. And to sort of give background, it's usually 36 treatments that are recommended, right?

Michelle Chacon, RN: Correct.

Host: And so, folks are here for 30 days typically. That previously just wasn't enough.

Michelle Chacon, RN: Right. There wasn't time to do a traditional course of TMS in the span of time that most people would be here. With the three-minute Express TMS, we're able to do more than one treatment a day and shave weeks off of the whole course of treatment. And so, they can actually complete the therapy while they're here.

Host: I remember when I got here, you talked to me about the SAINT trial. I feel like this was something that was kind of new and exciting. Do you want to talk a little bit about that?

Michelle Chacon, RN: Yeah. The SAINT trial was a study that was done at Stanford. It stands for Stanford Accelerated Intelligent Neuromodulation Therapy. And so, what that involved was doing up to 10 TMS treatments a day on people who happened to be inpatient at the time and completing 50 TMS treatments in the course of five days. The remarkable thing about this study is that 89% of people went into remission. Although the study was small, it still was FDA cleared using that device. And so, I think the big takeaway for us was that there's not really a ceiling that, you know, has been found for how many treatments a day is too much, or how many can you do a day? So, modeling what we are doing here off of that, we are doing two to three treatments a day. We're still spreading it out over a couple of weeks. We're certainly not trying to cram it all into a single week or a single five-day period, but we can spread it out through the time that they're here. And so, it falls somewhere between what the SAINT protocol is and the traditional six to eight-week course of treatment.

Host: Yeah. And I think one of the nice things about Sierra Tucson is people are here, they're away from their normal life and, you know, in some ways, we have a captive audience. It's not like, "Oh, I'd rather stay home and watch TV than go to my treatment today." We'll just, you know, get them out and try and get the entire course done. Because sometimes when you go back to your hometown or wherever you're from, you might not have access to it.

Michelle Chacon, RN: Right. That's one of the biggest advantages of doing TMS here is that you're already here. So, it's as simple as, you know, your TMS treatment being woven into your schedule on a daily basis in between your therapy groups, meals, et cetera. So, it makes it very effortless versus having to drive to a clinic five days a week for six to eight weeks. We can complete the whole thing while people are here. The convenience factor alone is certainly worthwhile, I would say. .

Host: Yeah. I think there's a lot of other research going on in TMS right now. And there's other FDA-approved protocols. Do you want to talk about anything that you've been reading recently and then maybe how that's informed what you will sometimes recommend for people?

Michelle Chacon, RN: Right. So, you know, when we first began doing TMS here, we were doing what we would call the standard or traditional or classic treatment, which was 37 minutes long. We were able to shorten that down to 20 minutes, still kind of a length of time to have to sit in a chair having this treatment being administered every day. The three-minute treatment is something called theta-burst stimulation. And what this is, is that the pulses are patterned in a way that makes it as effective in only three minutes' time. It is something that's also FDA-cleared.

In addition to that, there are some new uses for TMS. As I mentioned earlier, OCD, TMS is now FDA-cleared to treat OCD as an adjunct to medication. And this is good news for people who have OCD because treatment options may be very limited for them. And the newest FDA-cleared indication for TMS would be peripheral nerve stimulation. So, this is treatment for pain. This is kind of a radical thing, because it doesn't involve drugs or any sort of sedatives. So, this is treating the pain peripherally where the magnetic pulses would be directed directly to the area that is painful. And so, this would be indicated for something like neuropathic pain, nerve pain largely. This is brand new, so just FDA-cleared within the last six to eight months.

Host: That's great. I think the other leading part that I wanted to ask you about is these new protocols that you've developed. You've kind of been up on the research, you've looked into other uses. So, what have you developed for Sierra Tucson?

Michelle Chacon, RN: Right. So, in addition to the FDA-cleared indications that I just discussed, which would be major depressive disorder, OCD, and nerve pain or neuropathic pain, we have developed some protocols that we can use for, I guess, you would call it off-label use. So, there's research that shows that TMS can be helpful for people with generalized anxiety disorder, PTSD or post-traumatic stress symptoms. This can also be used for certain addictions such as alcohol use disorder, stimulant use disorder. As a matter of fact, in Europe, this is CE cleared in Europe for treatment of stimulant use disorder and for pain. So, these uses may someday become FDA-cleared in the United States. But right now, we are able to do them off-label based on the studies that we have that we have looked at.

Host: Yeah. I mean, and I think maybe it's for good context, right? This is kind of doctor-prescribed, so a doctor would come in. And luckily, you've actually created educational materials for all of our doctors.

Michelle Chacon, RN: Correct.

Host: And this extensive training course. And then, they can decide case-by-case basis, you know, here's the standard TMS, but maybe you're really dealing more with anxiety than with depression. Maybe we can do a modified treatment based on what you have found in the research.

Michelle Chacon, RN: Absolutely. So, looking at some of these research studies, there's a lot of good evidence that TMS can be useful for far more than just depression or OCD. So, we have available to us a device that can change the way that the brain is functioning or operating, I guess you could say, in the sense that we can modulate neuronal networks and either excite them or inhibit them. So when we're, for instance, treating anxiety, we're going to use a lower frequency with our treatment to help inhibit some overactive neural networks and, in effect, helping to alleviate some of the anxiety symptoms.

Host: Yeah. I think that maybe is a good way to bring up the broader idea of a lot of the effects of TMS are thought not to be just from, you know, I hit this one area, but it's from a network of brain areas that are interacting, right? And you can either strengthen or weaken connections between them.

Michelle Chacon, RN: Absolutely. In a simplified sense, TMS can do one of two things. It can either be excitatory or inhibitory. So, at higher frequencies, we use this magnetic field to excite these neuronal networks into performing better or performing the way that they're supposed to be. If we're using a lower frequency, then we're inhibiting those neuronal networks. So, it is also kind of about location, location, location.

Host: Yeah. And I think what's come up, you know, when we look at all of our different protocols, there's a lot of emphasis on the dorsolateral prefrontal cortex, which is an easy area to access. It's kind of in the front on the forehead. But then, how that connects to other things, right?

Michelle Chacon, RN: Well, everything in the brain, when you think about it, is connected. So, TMS doesn't have to penetrate deeply in order to be effective. If we are reaching those superficial neurons, say, in the cortex, we're talking maybe two to three centimeters depth. Once we stimulate those neurons, they in turn will stimulate other neurons and, ultimately, the entire network will be affected. So, for example, when we're treating depression, we're targeting this corticolimbic system. So, by targeting these neurons that are very superficial depths in the cortex, we're ultimately stimulating this whole network that goes to deeper structures in the brain, such as the limbic system.

Host: Yeah, I think just remembering from when I started grad school, I was like, "Oh, I'm interested in understanding how emotions change things, right? Because, you know, do they make us unreasonable? Do they make us have these negative side effects? But a lot of those structures are really deep inside the brain. But at the same time, that connection between the prefrontal cortex and those deeper structures can help us regulate them. Is that maybe a good way to say it?

Michelle Chacon, RN: Absolutely. That's a perfect way to define it. Once we stimulate those superficial neurons, in the prefrontal cortex, it could be lateral, it could be medial, then we're going to be affecting by default deeper structures in the brain because those form networks. So, it's really more of a circuit-based than simply just a small set of neurons in one location. We're trying to light up a whole network.

Host: Yeah. Do you mind if we kind of go over some of the details of these treatments? I think what's interesting to me is the way you've described them. So for stimulant use disorder, you talk about TMS to improve control, judgment, and decision-making.

Michelle Chacon, RN: Yes.

Host: So, how does that kind of work in that context?

Michelle Chacon, RN: So, the interesting thing about stimulating the dorsolateral prefrontal cortex or any part of the prefrontal cortex is that the prefrontal is sort of your executive center, so to speak, judgment, planning, decision-making. But also, what we find is that when we are stimulating that area for depression, something happens with the dopaminergic networks in the brain. So, based on all of the treatment that's been done over the years on people who have depression, we noticed that it stimulates those dopamine networks to work properly. This translates over to stimulant use disorder since there is some dopamine dysregulation there. But in addition to that, addiction of course involves impulse control and judgment and decision-making, and those things are obviously coming from the prefrontal cortex as well.

So, this is where stimulating the same area, the left dorsolateral prefrontal cortex, which is the same area that we treat for depression, stimulating that area also helps to reduce cravings and prolongs time between relapses. So, the studies have really shown that this is really helpful for stimulant usage. As a matter of fact, as I mentioned before, this is something that's used in Europe as a default treatment for stimulant use disorder or stimulant addiction. So, we've found some great success using that same protocol here, so modeled exactly after the same protocol that, you know, all the studies were based off of.

Host: Yeah. We just started this year, right? This is the first time we were able to find somebody who was a good candidate, specifically with a stimulant use disorder, and was helped by this, right?

Michelle Chacon, RN: Right. And so, working in conjunction with our Addiction Medicine specialists, we developed these protocols and patient selection obviously is going to fall to the medical provider, the addiction specialist, or psychiatrist who's working with that individual. But in general, the great thing about TMS is that it's relatively safe, and can be accessed by most people if given that there's no metal objects in the head or neck or pacemaker or seizure disorder, other neurological disorders. So, this is something that can be done on almost anybody. It's a very low-risk treatment.

Host: Yeah. And I remember we talked about like monitoring this person. So, as you were coming in every, you know, few days, you were seeing, "Hey, I'm not having as many cravings," right?

Michelle Chacon, RN: Correct. So, you know, using different tools to actually measure outcomes, this is where this comes in handy. So, we were using the stimulant craving questionnaire. Simultaneously, I noticed improvement in the mood as well. So, it's a commonality amongst many folks who are trying to, you know, treat their stimulant addiction that, in the early days, depression is a big part of that. And it's obviously tied into that dopamine network. TMS is helping to reregulate and rebalance those neurotransmitters. And so, they're getting a boost in mood as well, helping to prolong the recovery time.

Host: Yeah. So, it's just kind of like better kind of control or self-control in some ways, right?

Michelle Chacon, RN: Indeed. Right.

Host: Yeah. Yeah, that's cool. I think, as I was kind of like looking before our meeting, I was looking at all the different ones here, there are all different variations of dlPFC. But the other ones like alcohol and PTSD and anxiety, I think it's right as opposed to left dorsolateral prefrontal cortex.

Michelle Chacon, RN: Correct.

Host: Yeah.

Michelle Chacon, RN: Right. So, when we're going to treat the right side, there's different connectivity there. For PTSD and for alcohol use disorder, we're actually going to position that magnetic coil over the right dorsolateral prefrontal cortex as opposed to the left. The frequency certainly is going to play into that, either we're going to use an inhibitory or excitatory frequency. The interesting thing with treating PTSD is that there's been some research showing that both low frequency and high frequency can be effective in managing the symptoms, but most of the research does lean towards a higher frequency treatment, which is almost counterintuitive. You would think that you'd want to quiet those circuits down, but it does help treating high frequency by waking up that prefrontal cortex, which can help with top-down control. So, as we know with the overactive amygdala that has kind of hijacked things in PTSD, symptom relief actually comes from stimulating and sort of reawakening that prefrontal cortex to be able to manage the overactive amygdala.

Host: Right, which is related to kind of a fear response and all the stuff that goes on and people get caught in it, right?

Michelle Chacon, RN: Yes.

Host: Yeah. There's a lot of other kind of stuff on the horizon. And I know one thing that we didn't talk as much about in the SAINT trial, but that we have talked about between the two of us is this idea of picking the right location on kind of an individualized basis as kind of a future direction for TMS.

Michelle Chacon, RN: Right. I mean, I see that personalized TMS is starting to take hold. And I actually see it as probably the future direction of TMS if we can pinpoint an individual's circuitry that we want to target rather than just sort of doing our best to guess if the location that we're treating is actually going to be reaching that specific neural circuitry, then, eventually, we would be able to come to a place where we could look at an individual's brain connectivity, and target treatment based on that. So, it's truly, truly personalized medicine.

Some of the other exciting things that are coming up in TMS, like I mentioned that recent FDA clearance of peripheral nerve stimulation. And so, I'm hoping that we can bring this into Sierra Tucson as a part of our pain program. Once we look more at the research, I think that we'll find that there's a lot more uses for TMS. And this could potentially even be, I guess, dare I say at the future of Psychiatry. If we can modulate the way that neurons are firing, the way the brain is working, you know, and even change the way networks are operating, then we might be able to do a lot more with people that doesn't involve things like overloading them with pharmaceuticals. So, it's really some exciting directions that I see this going in.

Host: Yeah. I think there's a nice piece to be really focused and targeted, that, you know, comes out in that personalized piece. But if you're taking an SSRI, that's not targeted to one location of the brain. That's, you know, throughout. And, clearly, those have effectiveness and those are helpful for a lot of people, but it would be nice to have another alternative and to be able to say this is what you need based on your brain.

Michelle Chacon, RN: Right, absolutely. And while antidepressants work for a great many people, there are also another number of people for whom they do not work. You know, as a matter of fact, the STAR*D trials, which involved 4,000 and some people, showed that with the more antidepressants that people had been on or cycled through, the less effective that they would be, I think ending up at like 6% efficacy by the time you've reached your fourth or fifth antidepressant.

So, there's sort of like diminishing returns with even switching to different ones or trying them in combination. Some people, there's just really not going to be any relief found with antidepressants. So, it's nice that there are other options and TMS would happen to be one of them. You know, again, the fact that it's low risk, it's relatively easy, painless to do. And now, it's only three-minutes long, three to six minutes total. There's really not any reason why most people wouldn't want to give it a try.

Host: Yeah. And just to talk a little bit more about how it fits into maybe a typical treatment toolbox, how do you feel that it fits with the rest of Sierra Tucson. Does it interrupt other types of treatment? Do you feel like it works well with other types of treatment?

Michelle Chacon, RN: Oh. This Is the perfect place to do it. I think one of the best things about TMS is that there's no downtime afterwards, since it doesn't involve any sort of anesthesia or sedation. It's not like that people have to go and sleep the rest of the day away following a treatment. They're really right back to their regular activities. So, it can be woven into everything else that's being done here. It's very effortless. When people come for a treatment, hop in, and then hop right back out and move on to, you know, another appointment that they have, another lecture, group, a meal. It's really easy to work into all the other programming that we do, and we do quite a bit. So, schedules can be jam-packed for these residents. Being able to fit TMS in is pretty simple.

Host: Yeah. I think one of the things that I've seen with research on TMS is the idea that it might also enhance neuroplasticity. Is that something that you've seen?

Michelle Chacon, RN: Yes. So, there is some research. What's really interesting is that TMS doesn't just, you know, make neurons fire or inhibit neurons from firing. But ,you know, what's been discovered through clinical studies and MRI studies with TMS is that stimulation can actually increase blood flow and glucose in the brain, especially the prefrontal cortex. And also, it enhances the release of a neuropeptide called BDNF, or brain-derived neurotrophic factor. And this is something that plays a key role in neuroplasticity. So, you could look at it like TMS is helping the brain to learn while the treatment is going on. It's very passive. People don't really have to do anything during their treatment. But the treatment itself is actually doing all of the work, the magnetic field, so to speak. This is going to help the brain learn how to keep those neural circuits active once we've gotten them jumpstarted.

Host: I think that's awesome. And so, it's kind of this idea that your brain becomes more flexible. You're maybe more able to pick up new information. I was, again, kind of asking the leading question, but I think when you're in the middle of therapy, you can be receptive or not very receptive. But if your brain is already in a place where it's flexible and ready for growth and learning, that seems like that would help out.

Michelle Chacon, RN: Right. So, I think that's the beauty of it. I mean, we've seen such good outcomes over the years while we've done TMS here. And I have to believe that it's not really just them doing TMS, but the fact that we've integrated it into the other programming in general. There's a synergistic effect, I think, that happens when people are doing TMS, and it's sort of awakening that prefrontal cortex, and it's allowing a greater impact as they walk through the rest of their treatment, doing various therapies, going to lectures. It is really helping the brain to, so to speak, maybe absorb all of that a little bit better.

Host: Well, I think, we've had a lot of the questions that I had prepared, a lot of the ideas that I wanted to cover. Is there anything else that you wanted to say about TMS or that you're excited about on the horizon.

Michelle Chacon, RN: I would just say that, you know, anyone who's considering TMS as a modality to look into it. It's really something that may look intimidating, but it's not. And since it's been FDA-cleared to treat at least major depressive disorders since 2008, it's not brand, brand new. So, this is something that, you know, is not experimental. And there's a lot of research and science that actually validates its efficacy. So, don't hesitate to look into it, even though it might seem a little bit scary.

Host: Yeah. Maybe it seems a little sci-fi that you can, like, stimulate your brain, you put a little bit of magnetic energy in your brain and all of a sudden you're getting better. But yeah, it's been around for a while. And it's been helping people for a while.

Okay. Well, thanks very much, Michelle, for talking to me about TMS. And thanks, everybody, for listening to another episode of Sierra Tucson's Behind the Miracle.