Dr Grammer: “…if you haven’t responded to four meds, four different trials of medications, the chance that the fifth is going to work is about 5%. Okay, if you receive TMS, the chance that you will respond, depending on which study you look at is about 66%. Okay, and the chance that you’ll be asymptomatic, meaning totally better, is about 40%”.

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Beyond Depressed is a mental health podcast for people who want to know the science behind emerging treatments and if those treatments are right for them or a loved one. New therapies using psilocybin, magnetic stimulation, ketamine and medical marijuana are bringing people much needed relief. Together, we’ll take a deep dive into depression and how therapy, medications and drugs can help you feel better.

Beyond Depressed is hosted by Dr Geoffrey Grammer. Dr. Grammer is a decorated retired Colonel with the United States Army and is currently serving as the Chief Medical Officer for Greenbrook TMS. He has experience in psychiatry, internal medicine, and behavior neurology.

Disclaimer: The following podcast is for information and educational purposes only and should not be considered official medical advice.

[Life to Live by Grace Mesa (Instrumental Version) ends]

Dr. Grammer 

Welcome back everyone to the Beyond Depressed podcast. I’m Dr. Geoffrey Grammer and I’m joined again by Joe.

Joe Clements 

Hi, everyone. Good to be back.

Dr. Grammer 

So Joe, I think this is a really important episode, because we’ve already sort of set the stage for what is depression? How do we do therapy? Or what are the schools of therapy? How do we select medications, but in 1/3 of all patients, medications and therapy will not bring about an adequate level of symptom relief. And so for listeners out there, it’s important to know that we now have other evidence based FDA approved options. And the one that we’re going to talk about today is something called transcranial magnetic stimulation, or TMS therapy for short. So I’m curious, have you ever heard of transcranial magnetic stimulation therapy?

Joe Clements 

I have, only because I know you. So here’s the thing I think is most common misconception about it, which I think we should get out of the way right away. I think when people hear transcranial magnetic stimulation, they’re thinking of electrodes being strapped to your head and being electrocuted. That is not what this is. Correct?

Dr. Grammer 

Correct. Correct. So, so you’re right. A lot of people I think, misunderstand the treatment modality otherwise known as electro convulsive therapy or ECT, or shock therapy. And that’s, I think, been, unfortunately unfairly immortalized in a couple of movies, including One Flew Over the Cuckoo’s Nest and A Beautiful Mind. And with ECT, you’re talking about sending an electrical current across the head to induce a seizure. And while that can be a very effective form of treatment for depression, unfortunately, it does have some pretty substantial side effects. It’s logistically fairly burdensome, and it has a fairly negative stigma associated with it. Now, TMS is totally different, totally different. Unlike ECT. With TMS therapy, the patient is awake during the entire thing. Unlike ECT, it is done on an outpatient basis that can be done over your lunch break before you go to school or work or on your way home. Unlike ECT, afterwards, the patient is able to drive operate heavy machinery. And there’s no memory loss associated with TMS therapy, unlike ECT. So what is it right? Well, if we get back to something we talked about earlier, which is certain psychiatric illnesses are associated with abnormalities in brain function, particularly either over activation or under activation of different areas… Are there specific parts of the brain that are known or common, which is that under over activated area for depressed people? Yeah, so one model of what we call neural network dysfunction, meaning these pathways that seem to be not functioning correctly in depression is a path that goes from the dorsal lateral prefrontal cortex, which is a fancy way of saying here to… And for listeners, he just pointed to the top left of his head, like almost over his left eye. Yeah, yeah, like left, left temple, left eye about halfway over there. Exactly. And that goes to an inside part of the brain called the anterior cingulate gyrus. And what happens in some people with depression is that left front, outside part of the brain is underactive, and that inside front part of the brain is overactive. Because the left front part of the brain actually inhibits it holds back that inside anterior part of the brain or front part of the brain. And that front part of the brain that I’m talking about that inside front part of the brain is actually one of the areas that’s kind of like a thermostat for emotion. And when it’s overactive, we experience sadness. So, if we can exercise that left outside part of the brain, or what I’m going to call it going forward, the dorsolateral prefrontal cortex or DLPFC, then it reestablishes control over the anterior cingulate gyrus, which is that inside front part, then that resolves depression? How do we get there, right? Well, a couple of things, in patients with strokes that have strokes in that DLPFC area, there’s higher rates of depression. In functional scanning in people with depression, that area’s underactive, and in animal models, when we introduce a lesion into that area in like a rat or something like that, there’s a depressive model for rat, they also become depressed. And then we see that other kind of lose control and over activating that creates the sadness. So how do we get that area functioning again? Well, somehow we’ve got to get energy from outside of the body to the brain to make those nerves in that area activate. And so you know, what are the different forms of energy that we can use? Well, we talked about ECT earlier. The problem with ECT is electricity needs some sort of conducting substance. Your skull is not a very good conducting substance. There’s not a lot of water there so it requires a lot of electricity, for example. So it’s hard to target electrical stimulation to the brain in a very focused manner. And so you end up bathing the whole brain, and that causes the seizure, for example. You could use sound waves, right, where you agitate the nerves with sound waves, but when you have a point of sound, and it goes out, it tends to spread – becomes less vocal. And I don’t know that mechanical agitation is the best way to make those nerves do what its going to do, its like poking someone. We can use light, but again, light doesn’t go through tissues very well. So what about magnets? Well, magnets actually go through a solid fairly well, they stay fairly focused when they go through a solid. And when that magnetic field hits the brain tissue, it makes the nerves activate. And there’s actually science behind this. There’s something called Faraday’s Law, where you have this electromagnetic field that when it hits a substance that conducts electricity creates current. We’ve talked in many other episodes about nerves activating, okay. What I mean by that is nerves, believe it or not actually have a voltage potential across their membrane. And when they activate, that voltage potential flips and it carries current down the nerve, so they’re literally biologic wires. So when we put the magnetic field down onto that nerve, it creates current, the nerve activates, and it sends a signal down. When we change the frequency or the number of times per second, that we do that, we can actually exercise the nerve, or we can inhibit the nerve. And therefore we can go into different regions of the brain, and either amplify them, or inhibit them, depending on if it’s underactive, or overactive, respectively.

Joe Clements 

So what you’re able to do is you’re able using… you’re able to stimulate a very specific part of the brain, you’re stimulating those nerves to fire. So that would be activating. How do you inhibit?

Dr. Grammer 

So if we do a slow frequency… Our background Alpha frequency in our brain is usually about 10 pulses per second, or 10 Hertz. And so a lot of times when we’re doing stimulations we’ll do 10 hertz or higher to amplify that alpha frequency. So two of the most common devices that are out there that are FDA approved that have scientific basis behind them, one uses what we call a 10 hertz sequence, the other uses an 18 hertz sequence. And so those will take the background rhythm and further amplify it, exercising them, okay. But if we do a one hertz sequence, or one pulse per second, it sort of disrupts that natural Alpha rhythm, and it will rest the nerves, it will actually cause them to kind of quiet down a little bit. So one model for this just to help people kind of put this in context is we talked earlier about anxiety potentially being associated with over activation in certain regions of the brain. So breaking that down a little bit further, there are some models that have the right front part of the brain, overactive in anxiety. So if we take the coil, we place it on the scalp, and we stimulate one pulse per second over that area, it quiets down that overactive region associated with anxiety, and can actually help alleviate the anxiety. And that was actually shown to be the case in a randomized sham-controlled double-blind trial in 2016 showing benefit over kind of fake treatment, and it actually worked. And that still is done actually pretty extensively clinically today. So yeah, in slow sequences, inhibit, and fast sequences, activate.

Joe Clements 

So almost like when you listen to fast paced music, you feel more active, energetic, you listen to some slower music, you feel more relaxed, calmer. Similar thing except instead of music, it’s the magnetic field, or the magnetic poles hitting a certain part of of your brain stimulating the nerves inside of that brain to fire at a different rate.

Dr. Grammer 

Yeah, I would say, if you’re trying to do pop dancing at a club, and they start playing a waltz, it’s going to be harder.

Joe Clements 

Mhm. Slow it down a little.

Dr. Grammer 

Exactly.

Joe Clements 

So how was this therapy developed? How did it come about that some scientists or doctors were like, Oh, if we pointed magnets right here, that we can make people feel better. We can resolve some psychiatric problems for patients.

Dr. Grammer 

Yeah, TMS or transcranial magnetic stimulation therapy has been around since even into the 80s. And it was initially used to stimulate peripheral nerves like an arm nerve. And for the same reasons that we talked about, like in the old days, you’d have to take a needle and put it in there and try to isolate the nerve. But it would be great if you can do it in a non invasive way. And so indeed, if you take a magnet, a powerful magnet, and then just to be clear, these aren’t like refrigerator magnets, these are like MRI, 1.5 Tesla field generation magnets like real things. And so if you do that over the arm, you can actually stimulate things like the radial nerve and make the hand contract and things like that. Well, there was a conference one year and someone said, Well, what if we do this over the head? And like a lot of things in psychiatry, I’ll volunteer, that’s exactly what happened. I was like, I’ll sit in the chair. Let’s try it and then they made the guy’s arm Twitch, and they’re like, whoa, that’s really cool. We can stimulate the motor cortex and make the guy’s arm twitch. And, and so that got people thinking like, Well, how could we use this in a second? illnesses, and then starts this, like long, long history of studies that are just kind of trying to figure out what works. And it’s kind of funny because in the old old days, put this coil on someone’s head, they would do a single tap. And it’s what it feels like, feels like someone’s just tapping your head and be like, Do you feel any better? No. And so finally, we figured out you have to do like 1000s of taps. And so with each treatment, we can do anywhere, most people do somewhere between 1980 to 3000 taps per treatment. And that’s usually 20 minutes give or take, depending on the intervals that people use. And that’s what works. So then one of the companies actually did a large, double blind, randomized sham control trial. And this is important for listeners to realize because…

Joe Clements 

When you say, sham con… that’s placebo controlled?

Dr. Grammer 

Exactly, exactly. And so… So somebody is not getting an actual magnetic pulse, they’re just sitting with the device and they’re just kind of sitting there, but they don’t know they’re not getting the real thing? Right. So there’s two ways you can do a sham within TMS one is passive, and the other is active Sham, passive Sham, they usually put an aluminum shield between the the magnet and the casing. So the field gets blunted, and it never reaches down to the brain. So it makes noise, but you don’t feel much. Other people have actually given a low level of electrical current with each pulse. And so you still feel something and but it doesn’t stimulate the brain. And indeed, in both trials with both passive and active sham TMS was shown to be more effective, which was actually really, really cool. And they actually asked the patients in the trial, are the subjects in the trial, do you think you got active or sham and they guessed wrong, and the operators actually doing the treatment didn’t know what the patient was getting. The kind of coil they used in the original one, you just have them lined up on a wall and you just plug it in, and the computer would tell you wrong coil and you plug another one in wrong coil, you plug one in it goes right coil, and then you treat with that one, and you didn’t know what you’re giving the patient. So when people look at getting a device kind of medical treatment, you need to understand the FDA didn’t used to require that kind of evidence you could pass, you know, be able to do a trial where you just take 100 people and give them TMS and 40% of them get better. You’re like, woohoo, we worked. But unfortunately, there’s a huge placebo effect. And again, we could have a whole talk on placebo and what that actually means. But the bottom line is, if you do something medically to somebody, there’s a chance that that may actually get them better, even if the treatment has no valid effect. And so you always want to Sham. So what was nice with TMS was they actually held the manufacturers to a much higher standard where they had to do that weight of evidence to say it really worked. And so they finished up the trial and received FDA approval in 2008. For the very first device, that was the neurostar device by Neuronetics. And then since we’ve had brainsway also receive FDA approval, and then a variety of other manufacturers kind of raising their hands saying, Hey, we’re just like them, and they also got approval. And so right now in the US I think there’s seven manufacturers out there that are designing devices for treatment.

Joe Clements 

And to be clear, for the listeners, these are legitimate, like clinical devices that you can’t, you’re not going to go buy these on at Walgreens or on Amazon, these are pieces of medical equipment that need to be used by a doctor, needs to be around to prescribe how it’s going to be used. You need medical professionals to oversee what’s going on. It’s a very similar I would say to when you go to get like an MRI.

Dr. Grammer 

Yeah, exactly. And for the same reasons, you might not be able to get an MRI, you may not be able to you know be an appropriate candidate for TMS. Now, granted, like all things, part of what a good doctor is going to do is help figure out ways to administer treatment to you safely. But if you have a history of seizures, for example, then there may be an increased risk of developing a seizure in the middle of TMS therapy that’s extremely rare, but it can happen. So if you do have a known seizure disorder, then that’s something to definitely let your provider know. If you have metal above the neck line, it’s a magnet, right? So the metal can either move or heat up, usually more commonly heats up. And so that’s a factor to consider. That being said, there’s a lot of you know, if you have a pacemaker, for example, it can mess up the pacemaker if you’re not careful. So there are different medical clearances. So it’s real important people realize like, Yeah, this is a legitimate device, it sits in an office, it’s got its own dedicated electrical outlet. There’s a lot of training that goes into how to do the treatment, how to figure out where to give the treatment, and then how to do it safely in someone with their unique medical conditions.

Joe Clements 

So let’s talk for a minute about what that therapy looks like. So talk therapy, you go to meet with your therapist once a week, or once every whatever it is, with antidepressants, you’re probably going to take something every day. What is the what is the treatment like for a patient who gets TMS? What does therapy look like?

Dr. Grammer 

Yeah, so, so for the very first treatment, you’ll come into the center, you sit down and what is literally a dental chair that reclines and then behind that dental chair is the actual device that sits on what we call a gantry arm which is just a magnetic lock handle that puts the coil onto the head. And the coil looks about the size of a hairdryer basically, with a curve on it that sits onto the head, or in a case of a different device manufacturer helmet that sits on the head, and you place it down onto the person scalp. And for the very first treatment, you have to figure out where to treat and how much energy is needed to treat. Okay, so the way we figure that out is we go to an area of the brain that controls some sort of externally observable function. And in this case, it’s trying to make the thumb Twitch, okay, where the thumb twitches on the brain is in a very specific spot along the motor cortex, because we know where that is, we can then measure a certain amount forward to get to that dorsal lateral prefrontal cortex. Okay, so what we’ll do is we’ll put the coil over the motor cortex will kind of move it around while giving different energy levels, and we’ll make the thumb twitch, okay, once we find that spot, we figure out the minimum amount of energy needed to make that thumb twitch. And then depending on the sequence we use, we come forward anywhere from five and a half to six centimeters and treat it that site, the treatment occurs in what we call stimulation trains and rest intervals. So it’ll usually tap kind of like a woodpecker for two to four seconds. And then there will be a rest interval, anywhere between 11 and 26 seconds, depending on the sequence you use. And so it’s not like it’s continuous, it’ll go, you know, tap, tap, tap, tap, tap, rest, rest, rest, rest, rest, rest, rest. And it does that over and over again, for with the newer sequences, around 20 minutes, the older sequences were around 40 minutes during the time, you can watch TV, you can look at your phone, you can listen to music, talk to a friend, you have to wear hearing protection while you’re there. And then when it’s done, we remove the oil from the head, we set the chair up, and you go and drive home, you have to do that five days a week. Okay, for six weeks, that’s what we call an induction. And then there’s usually a taper phase three, two, and one. That sounds like a lot. But if you’re depressed, I would argue that taking care of yourself for 30 minutes a day, is actually not a selfish lift at all. In fact, we probably should be doing that anyway.

Joe Clements 

And with any other sort… I’ve heard you compare this to physical therapy for the brain.

Dr. Grammer 

Yep.

Joe Clements 

With any other sort of injury, let’s say you tore your ACL, tore your meniscus, threw your back out, you would go to physical therapy, about like that, to recover from that injury if you were trying to recover, if you were young enough to be able to recover pre where you were and get back to running or playing or whatever else. So it’s not unusual that a treatment regimen would be like that.

Dr. Grammer 

Yeah. And I think it’s interesting. And that is sort of a new phenomenon psychiatry that we haven’t really seen since the old psychoanalytic days where we’d see people multiple times a week. So it can feel a little bit unfamiliar. But once most people start it, they actually find the overall experience to be valuable and enjoyable to the point that there are a lot of patients who actually are somewhat saddened when they get ready to kind of finish their treatment because they enjoyed coming in and taking 30 minutes for themselves. So yeah, it really isn’t nearly as onerous as people think. Now, why is all that important? Well, like we talked about in a previous episode, if you haven’t responded to four meds, four different trials of medications, the chance that the fifth is going to work is about 5%. Okay, if you receive TMS, the chance that you will respond, depending on which study you look at is about 66%. Okay, and the chance that you’ll be asymptomatic, meaning totally better, is about 40%. So if you’re playing the odds, once medications and therapy have been shown to not be effective for fully treating your depression, you’re much better off going to TMS than trying a sixth or seventh med.

Joe Clements 

Well, what are the side effects of TMS? Why wouldn’t somebody after the first medication failure, just explore TMS?

Dr. Grammer 

Well, one is most insurance put sort of conditions on what they recover TMS, for now, TMS is covered by almost every insurer out there, including Medicare and Medicaid. And they usually require that you’ve tried at least two medications for them to say, yeah, we’ll pay for this for you to get this. And so that would be one reason why people don’t go to it. First line is just to make sure they have insurance coverage. Candidly, I always look at sort of three things that that are barriers to care. One is awareness, and that is probably the predominant issue, which is why this is such an important sort of episode, if you will, most of the people just don’t even know what’s out there. Right. And so we want to improve awareness. The other is geographic availability, because you do have to go every day. You need to find a center that’s close to where you live, and there’s still sort of an expanding number of centers out there that are trying to fill all the community needs. And then the third one is fiscal viability, not all TMS providers are astute at taking insurance. And so you need to definitely find a provider if that’s what you want to use to pay for it, who will file with your insurance company and network with them and so forth. If you meet those three things, I think that it makes it kind of within reach of most people.

Joe Clements 

So eligibility, who is a… what is a depression patron? A patron? Patron of depression is not what anybody wants to be. A patient of depression, that would be a good candidate for TMS?

Dr. Grammer 

Yeah. So basically, if you have  moderate to severe depression, and almost everyone who feels depressed, is going to at least have moderate depression, a lot of mild depression is like someone’s like, I’m not even sure if I’m depressed. I see. So I don’t want to get people to get caught up on that, right. Like, if you think you’re depressed, you’re probably depressed you, you know, we can, we can help figure out the severity for you. Because again, insurance companies are gonna require a certain severity of symptoms. And then, if you’ve been on at least two medications, and had some course of psychotherapy, and have not gotten the relief that you would like or expect, then you’re a candidate for TMS therapy. It’s actually not a huge lift, as far as you know, to the patient. And it’s readily available in a lot of places. And I think the number one reason why people don’t get it isn’t because it’s not the right modality, it’s just because they just don’t know about it.

Joe Clements 

So biggest thing is, it’s a relatively new treatment. I mean, first one was approved in 2008, you said. Yep, end of 2008. End of 2008. Do you see a time in the future where you know, something like TMS or even some of the things we’ll talk about in future episodes are the things people go to first after talk therapy?

Dr. Grammer 

Well, that’s a good question. I think, with TMS right now, it’s currently been FDA cleared for treatment of depression, obsessive compulsive disorder, and believe it or not smoking cessation. Now, depression, is covered by most major insurance. OCD is covered by a few. Smoking cessation is really, really new. And I’m not aware of any payers paying for that yet. But there’s ongoing studies to try to show the cost benefit analysis of that. So hopefully, that’ll be available to folks. And again, this is a non drug modality with no systemic side effects. Because we’re not introducing a foreign substance into your body, we’re using the body’s natural physiology to correct an underlying deficit. Right. So I do think that in the future, it will be used more often, we’ve already seen that it’s sort of an escalating use over the last decade. But the other thing, and this is why your question I think is intriguing is, it gets back to the subtypes of depression. And we’re not at a point quite yet where we could say, Hey, this is what’s wrong in your brain, and therefore, you’re more likely to respond to TMS than meds. But a lot of work is going into that. Okay. And certainly there are providers out there who are like, hey, I can scan your brain and tell you exactly what’s wrong. But I’m telling you right now, at least here and end of September 2021, like that science doesn’t exist yet. It’s being done in academic centers, they’re working hard at it. But when we get to that point where we can do that sort of functional assessment, we may be at a place where we say, hey, you need this kind of therapy instead of meds instead. So I think that’s coming. It’s just a little early to have that be primetime. So for now, unfortunately, it’s going to be didn’t get better with meds. Now it’s time to move to TMS.

Joe Clements 

Okay, so what is, and I think we’ll end up talking about this for the other treatments and future episodes as well. What is the interactivity between antidepressants and TMS? Do you take your antidepressant when you’re doing TMS? Do people who have TMS often get off the antidepressants? Does the TMS enhance the effectiveness of the antidepressant? What is the relationship there?

Dr. Grammer 

Yeah, it’s  sort of like yes to all right. And it depends on the individual. In the clinical trials, patients were washed off of all medications when they were treated with TMS therapy, and it worked. So it wasn’t like you need to be on an antidepressant for it to be effective. In real life, I think what happens is a lot of people get put on antidepressants, and it works a little bit, for some. And if you try to wash them out, a lot of times they feel worse. So I think it can be added as a complement to medications and therapy, not necessarily always as a replacement. But that being said, we have some patients who come in or I have patients that come in that are like, Hey, I have problems taking these meds for whatever reason, you know, for all kinds of reasons, right? And I don’t want to take them. Can I be treated with TMS instead? And the answer is like absolutely, absolutely. Because one of the nice things about TMS is there is a fairly good durability of action. So let’s say you come in and that means how long it’s effective for them. So if you come in and I treat you with a full course of TMS you have a two thirds chance of staying well for up to a year with no further need for TMS therapy. And if you get retreated and you responded the first time, you have almost a 9 in 10 chance of responding again the second time. So I have some patients, I just had someone fairly recently who I saw like half a decade ago, treated them, they got better, they stayed well. And then for some reason, this year, they they had a return of symptoms, we treated them again, and they got well again, and I’m like, I’ll see you in another half decade. And for that particular person, that’s all they need. They don’t need meds, they don’t need to talk therapy, they just do that periodically, I have other people that come in that need to get treated more frequently, because that’s just where their depression is at. And we may treat every three to six months, if need be. There are some models where we do intermittent sessions, like what we call maintenance sessions. So once every week or so, not a lot of payers cover that. Some do. For some people, that becomes what sustains them, helps them stay well. I see women who, and this gets a little bit more complicated, but I see women who are trying to get pregnant or are pregnant, they don’t want to take meds during pregnancy.TMS may be an option for them because the magnetic field isn’t going to reach the uterus. So…

Joe Clements 

Anti depressants, most of them can’t be taken during pregnancy. Correct?

Dr. Grammer 

Some can. I mean, there’s… that’s a whole separate thing. I, Yeah, that that’s a good reason for another podcast. Because, yeah, women can take antidepressants during pregnancy. There are some risks associated with that. But there’s also a lot of risk associated with being depressed while you’re pregnant. So you have to weigh the risks and benefits depends on the severity and which antidepressant they need to be on. Some are safer than others. But what I don’t think is acceptable, and I’ve seen this way too much is someone will be reasonably well controlled on like Zoloft. And then they’re like, Oh, I got pregnant, and their Docs like, you got to go off Zoloft. And then they get profoundly depressed and their nutrition falls off and all that kind of stuff. And I’m like, you’re at higher risk now because you can’t take care of yourself, because you’re feeling so bad than if you just stayed on the Zoloft, which actually has a fairly okay, safety profile. In addition, and just because this is so important. A lot of people worry about problems with organ development and being on any kind of medication. Well, your organs develop by the first trimester in the first trimester, first three months. And so for some people, you’re like, Okay, let’s, let’s take you off for the just beginning of the pregnancy here. But in the second trimester, let’s get it back on. And then usually a couple weeks before they’re going to deliver, you can say, alright, let’s take it off again. And that can dramatically improve the safety profile without necessarily the complete sacrifice of, like, hey we’re going to do nothing while you’re pregnant. But in the meantime, TMS? While, indeed, I can’t show a study that has 10,000 people, the laws of physics…

Joe Clements 

probably still apply to.

Dr. Grammer 

Yeah, just like make it hard to understand how it could have a negative effect. And there are some studies that show that when you do treat with TMS, it doesn’t affect sort of endocrine function, all the things that we are concerned about in pregnancy. So it does seem to be reasonably safe as another option for people.

Joe Clements 

So what should a patient do? If they think they would be eligible, they’ve had a couple medication failures, talk therapy doesn’t work, like, what should they do to find out about TMS therapy?

Dr. Grammer 

Yeah, I would say first off, there are some good resources out there. So you want to read online, and honestly, if you Google transcranial magnetic stimulation therapy, that’ll at least get you familiar with what the devices look like and who the different manufacturers are and who the providers are in your area. The other thing is to make sure that you ask I mean, it’s it’s kind of interesting, because I see patients, honestly, just about every day, who never asked their provider, hey, is there anything besides these meds? Until they, like heard a radio ad or something? And then they’ll say, well, like, Oh, I heard this ad about TMS. What do you think they’re like? Yeah, you could give it a shot. Here’s a group that does it. And then they go there and they’re like, holy cow, if I’d… I’ll be honest with you. And this is kind of a personal story. So we haven’t talked that much about it. But my background, I actually did a double residency in internal medicine and psychiatry. And then I did subspecialty in geriatrics and neuro psychiatry. So I’ve been a primary care doc, I’ve worked in ICUs. I’ve been a general psychiatrist and patients psychiatrists. I even did electroconvulsive therapy, and of all the things I’ve done in medicine, TMS has been the most transformative. And that’s why I that’s one of the things I do now. Because nothing else is quite so dramatic, at least in my experience for a lot of folks. So every day I see patients who get better with TMS therapy, who will say I wish I’d known about this years earlier. Holy cow, I finally feel like I thought I should have been feeling all these years. And I look at depression as kind of like a lock and key. And you know, this is a good take home message. There is a little bit of trial and error in this but we want to find the right key for your lock to get you feeling better. And doing the same thing, trying the same key over and over again. Oh, Prozac, Paxil, Zoloft, like it’s the same key. At some point, you got to do something fundamentally different. So ask your provider, what else is out there besides this and see what options might be available to you.

Joe Clements 

And I mean, that’s a good close. I think we’re about out of time. So tell the listeners a little what do you have coming up in the next few episodes because just like TMS, there’s actually a number of emerging treatments and available treatments for depression that aren’t antidepressants and talk therapy.

Dr. Grammer 

Yeah, absolutely. So we’re also going to be talking about ketamine, and the nasal form of that is called spravato. That’s FDA cleared now for treatment of depression. We’re also going to talk about psilocybin. While it’s not FDA cleared yet, there are several manufacturers that are beginning to pursue what we call phase three trials, which is sort of the end stage of proving that those compounds work for depression. And I will tell you, I mean, that’ll be an interesting episode, because the high dose psilocybin treatments have quite a dramatic narrative associated with those that are pretty exciting to talk about. And we’ll also be talking about medical marijuana. And I think, while, not necessarily preferred treatment for depression, it may be helpful for folks with anxiety and with pain and other conditions. And we want to make sure that we help people understand the best ways to take that and consume that for their medical needs. So some really exciting stuff coming up. So encourage our listeners to continue tuning in. I do want to thank everyone for joining today. And again, please, please, please make sure you’re asking your providers, hey, if this isn’t working completely, what else can I do? And you know, Google transcranial magnetic stimulation therapy. I want to thank Joe, you joining again, and appreciate your questions.

Joe Clements 

Happy to be here. Thank you.

Dr. Grammer 

Yeah, stay tuned. Thanks.

Joe Clements 

Bye everyone.

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