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TMS Depression Treatment Discussion

By April 22, 2021April 26th, 2021No Comments
Depression

Everyone out today is finding you. Well, my name is Zach Currier, and I have the pleasure of being joined by Ben Spielberg. How are you doing today, Ben?

I’m doing pretty well. How about you?

I’m doing great.

It’s it’s a pleasure to have you. You are the founder and CEO of TMS and Brain Health in Los Angeles. And Santa Monica is super excited about what I’ve seen to see some of your interviews, pretty high profile stuff that you’re doing out there and so super excited to have you today and be able to speak to our community. Why don’t you tell us from the beginning of where you kind of got into mental health and these types of modalities that you’re offering and where you are now?

Yeah, definitely. So before I start, I want to say hi to everyone. I’m waving and also apologies for the beard, which is kind of mid, mid-lock down right now here and here in California. So, you know, I’ve been in the field of mental health for over 10 years now. And at first, I started working in substance abuse treatment centers, doing different modalities, but mostly neurofeedback, which I don’t know how familiar you are with neurofeedback, but it’s essentially a way to monitor someone’s brainwaves and then sort of teach them how to change their brainwaves, which correspond with clinical symptoms. So

I’ll refer to as brain mapping. Right. Yeah. So the brain map, usually we do that initially. So you kind of get the baseline levels for how the brain is working compared to sort of a normal population, if you will, or a neurotypical population, I guess. And after that, you kind of set the computer to provide some sort of feedback based on where you’re doing the training. So, for instance, if you have someone get the brain map and we see sort of abnormally slow brain activity in the frontal cortex, then we would tell the computer to sort of play a sound when someone is exhibiting faster activity in the frontal cortex. And so sort of you do this for 20 to 40 sessions and you get a lot of relief depending on what the symptom is, but really effective for addiction, for pain, anxiety, PTSD, and things like that. So anyway, I did that actually while I was in undergrad and I kind of realized that I wanted more of the hard science, so to speak. So I then went to Columbia and I studied neuroscience. I got my master’s there. And when I was in grad school, I really became focused on this sort of overarching field of neuromodulation, which you could also call interventional psychiatry. So basically, there is there are so many different modalities that are available that a lot of people don’t know about that don’t just include medication management and therapy, which is mostly what psychiatrists do in this country. So basically, I kind of I researched a lot of a lot more about neurofeedback. I learned about transcranial magnetic stimulation. And I actually started working at a TMS clinic in New York in grad school. And I would even do brain mapping to sort of see if we can predict any off-label placements for TMS or off-label protocols in my master’s thesis ended up being on ketamine as well, and sort of the electrical, electrical, physiological underpinnings of what happens during ketamine administration. So we would actually hook up people to an EEG machine so they would get their brain mapped and then we would give them ketamine and we would watch in real-time how their brain changes, which was pretty interesting. So I kind of I kind of did all this. I got my master’s and then I realized that. A few things happened, so one is that I saw that the FDA sort of cleared this order TMS protocol. So TMS used to be 40 minutes and then and the FDA cleared a 20-minute protocol, basically decreasing the space between the pulses. And then the FDA cleared this order three-minute protocol. So I thought that was pretty interesting. So I kind of we started doing it a little bit more at the clinic I was at. And then I started to develop this real personalized approach with TMS. So basically we have all of these parameters, right? We have frequency. We have placement on the head. We have duration of stimulation. We have a number of sessions. So all of these things can really be modulated if you know how to do it, to highly increase the effectiveness of the treatment.

And so so I sort of came up with all these different protocols and we and that’s that was kind of the impetus for starting my own clinic here in Santa Monica and now downtown Los Angeles as well.

That is amazing. That is so cool that the vast experience that you’ve got to have and how you sort of supplemented your work experience with the science behind it and being able to, like you said, if you know how to do it right, know the theta-burst side of thing is going from 40-minute procedures. right to three minute kind of theta bursts, which is just

Right.

Yeah, for sure. I feel like there’s so many questions I could ask you. But first of all, I mean, you talk about interventional psychiatry. Why do we need to intervene? What was wrong with psychiatry? What was limited about psychiatry before sort of TMS came about or ketamine started being used?

Right. Right. Good question. So, you know, psychiatry is right now, it’s mostly medication management and it’s psychotherapy. And both really have their place. Right, especially psychotherapy. I think the question is sort of what happens when those modalities don’t work because unfortunately, they don’t work for everyone. And so therapy, after a few months, if you’re not going anywhere, usually someone will start to try medication. But unfortunately, the research shows that basically every trial of medication that doesn’t work decreases the chance that the next subsequent trial will work by about 50 percent so that by the time someone has tried to medications for depression, the likelihood that a third medication is going to work is going to be like less than 10 percent, which is low. Right. And so so the modalities like TMS, the research shows the effectiveness of like sixty-six percent right either respond or remission, depending on how you want to calculate that. Our personal data, because of this sort of personalized approach that we have, we see success. And in the 90 percent low, 90 percent range and research with ketamine, which is another modality that we do, is hovers between like seventy-five to eighty-five percent and it works very fast as well. So I think that you know, interventional psychiatry really provides a need sort of almost procedure-based need when the other modalities don’t work, because at the end of the day, depression is something that is in the brain. And so if you’re not really modulating it with talk therapy, then what are you really doing? Right. Are you really targeting what the actual cause is? So I think that’s kind of the question and that’s the reasoning behind why we do what we do.

One hundred percent. And it’s interesting that you bring that up because I’ve interviewed and talked with so many psychiatrists or people who run TMS machines. Right. And everyone’s numbers seem to be a little bit different. Everyone’s a little bit different as some people say. One issue that we have is sometimes people fall asleep in the chair and it’s like, well, that’s not good. If the brain’s not running, then that’s not going to be effective. Some people are set it and forget it. And they watch Netflix for a while. Right. For treatment. Other people use that time to do the talk therapy. It sounds like more of what you’re doing. So why don’t you speak to a little bit of how your background, how your knowledge like has kind of given you at least you know a leg up or allow you to be as successful as you have, whereas sometimes other places again may say, hey, this will help six out of ten where you’re saying really, we believe nine out of ten are going to see significant improvement based on your skills and things like that.

Right? Yeah, I guess I just want you to brag for a little bit.

I think the key with what we do is really the personalized approach. So first of all, you know, we have different modalities. And I mentioned that ketamine works really fast. And so sometimes what we’ll do is someone will do like one or two ketamine infusions while they’re starting TMS just to kind of get their brain to remember what it’s like to not be so depressed. And then you kind of provide the TMS on top of it so that they don’t need the ketamine anymore. And it kind of works out time-wise really well. But, you know, just for the people who do TMS alone, if they don’t want to do ketamine, if they’re looking for a non-medication approach or insurance or whatever the reason may be, it’s really about knowing how to adjust all of the parameters. So we tend to start. With one specific protocol, but after a few days is when we really start to personalize things, so if someone has irritability, we kind of know-how to adjust things. We may adjust the duration, we may adjust the power level. We may just the placement. If someone has insomnia, we’ve developed a really amazing protocol for insomnia. It doesn’t work for everyone. But I would say it works for about 50 percent of people within five sessions or so. And so part of what we do when we when we target sleep is we kind of know that the brain uses sleep to help reset, to help kind of store memories and grow in general. It’s kind of its just sort of a healthy resilience mechanism for the brain. And so we’ll target mood, we’ll target sleep, energy level motivation, things like that. So during the session, we’re always checking in with people, asking what their symptoms are, what’s going on in their life, and then we’re using that information to change the treatment parameters.

Amazing. Yeah, this is sort of been the year of the insomniac, right? Yeah, definitely messed up with work being shift. Right. We’ve seen sleep go out the window for a lot of people more drinking more, you know, staying up late and then you’ve got Netflix, more video games, you know, this and that. So I think it’s so important to address that. Why it’s important and then how you guys have been able to help people who have really struggled with it chronically, right? Yeah. Yeah, super important.

We have no we adjust TMS quite a bit. What you tell us a little bit more about ketamine. I mean, some people realize ketamine is that Special K is not the street drug. What’s a little bit of the history of ketamine? How is it advanced even to FDA approval? Right through the Spravato of CAD scan? Right. Right. You tell us a little bit of of what kind of the journey there and how you guys use it and what that entails if someone does receive ketamine treatments there.

Yeah, definitely. So it’s pretty interesting. So, you know, obviously, it’s been used as an anesthetic and as a pediatric anesthetic for I know it was FDA approved in nineteen seventy, I believe. So it’s been used for fifty years in the United States in the ’90s, you know, it became really popular as sort of a club drug like ecstasy and MDMA, and people kind of abuse them at raves and things like that. But what we found is that you know the dosage of ketamine really, really affects how people feel. And so if we use a subanesthetic dose so, you know, less than 10 percent of what people are using in anesthesia, it can actually provide really rapid antidepressant effects, which is fascinating because every other antidepressant basically takes like four to eight weeks to really start working and ketamine because it has sort of a different mechanism of action in the brain. It’s only some people notice relief after just one session, which is really, really amazing to see when people walk into the office and they have you know, you can kind of see you see depression on someone’s face, especially being in an environment like this. You know, if someone’s been suffering for a long time, you can tell. But then sometimes they’ll walk out of their very first infusion and they’re smiling and they just kind of they remember what it’s like to feel happy again, which is really amazing to see. So, yeah, it’s really effective for mainly depression, PTSD. We found this to be really effective before we do a few different versions of ketamine treatment. So mainly we have kind of created like a mindfulness protocol that we do before, after and sometimes even during the ketamine administration. So like visualization exercises, breathing exercises, because we you know, what I realized is that there’s basically this abundance of neuroplasticity that happens within twenty-four hours of the ketamine administration. And so if you can kind of capitalize on that, so to speak, and give the brain something to learn, it’s really going to soak it up. And so if you learn a way to self regulate yourself, then our theory is that it becomes a more effective intervention than it would be otherwise.

Wow.

Yeah.

You have intravenous and intranasal, do you have to do is this process take, I believe, right. You have to be monitored for some time.

Yeah, yeah. So we have we have ketamine infusion sort of a la carte. So the there’s the the general a treatment course of that is six infusions over two to three weeks. There’s kind of one specific dosage that we tend to start out. But just like with TMS, we try to personalize things as well based on their initial response. So we tend to go all over the place with dosage. There’s also timing of the infusion in your bloodstream. And we modulate that as well because that also has a big difference on sort of how long your receptors are saturated for sure. So, yeah, so those are the infusions we also have. This is one of our newer programs. We’re not even advertising it yet, but it’s basically a comprehensive treatment program that combines ketamine, nasal spray, TMS neurofeedback, as well as group therapy and individual therapy in one package, which is very, very powerful, as you can imagine.

Yeah. Speaking of powerful, we’re talking about some heavy-duty stuff, right? Ketamine treatment, TMS treatments. It seems like you’ve kind of gone out of your way to make this accessible to people who are who are concerned about their mental health to keep it a healthy mental state in their mindset and things like that. So are you for everyone are you only for severely depressed, severely anxious people, people experiencing suicidality, or where do people where do people meet you and TMS and Brain Health.

Yeah, it really depends on what the person’s goal is, so obviously we see a lot of people with treatment-resistant depression, treatment-resistant PTSD and anxiety, but we also have people who come in and maybe they haven’t tried any medications and they don’t want to be on medications. And that’s fine. And actually, that’s the way it is in Japan. I don’t know if you know that, but in Japan (train stops) Right. What they’re on train stops, right? There are train stops where you can get your TMS treatment. I thought I just heard that.

I didn’t I didn’t know that crazy I thought that’s where you’re going with that. Yeah. I just very accessible to the masses, what I’ve heard. But go ahead and say you’re

right. Yeah, I don’t know. They’re on train also hahaha to fact check that. We’ll see the edit there. Yeah. Yeah.

I can’t wait. Yeah. So so in Japan, TMS is a first-line approach. Right. And I think that makes more sense because, you know, medication is like a chronic treatment. So why would you do a chronic treatment when there is an acute treatment that you only have to do for four to six weeks to get relief that lasts sometimes permanently. So I think I think they kind of have the right idea. So sometimes we will see people who just don’t want to be on medication, which is fine. Obviously, everything is on a case-by-case basis, but I wouldn’t say it’s just for severe depression. I would say like moderate depression as well. If it’s something that, you know, I think if someone’s never been in therapy, maybe that would be a better that would be something that’s good to try first, at least for a few months, just because it’s less of an overall burden to their to their life and their time, obviously, with TMS to come in five days a week or at least as close to that as possible.

Yeah, right. Yeah. Whereas you said ketamine could be six treatments, but maybe a little bit is a longer stay in this and that. So it’s kind of right based on people’s lifestyles and what better, what better year to look into it than this perhaps. Right, exactly. Exactly. Yeah. We have a lot of people who who have kind of use this time as a way to give themselves treatment that they were avoiding for a long time. So. Yeah, yeah, exactly. Well,

I won’t let us get too into the weeds here, but I love to geek out with people like yourself as far as where you see the future of this going. We’ve talked in the past about things like civil sideburn and MDMA treating like ketamine is right. OK, we’re seeing this kind of psychedelic drug now, have these ripple effects for depression and for suicidality. And then it seems like we’re just scratching the surface of what could come. So without getting into too much. What are you excited to see on the horizon for whether it be TMS or other modalities? What do you see kind of the future of this becoming?

Yeah, so I think the biggest thing for TMS, I think we’re going to see a lot of new indications within the next five to ten years. So right now, obviously, it’s only FDA approved for depression, but I think we’re pretty close to PTSD, to chronic pain, to anxiety. Traumatic brain injury looks very promising as well. So I think that’s pretty exciting. On the neuromodulation front, ketamine, obviously a form of it, was FDA approved for depression and suicidal ideation as of last week, I believe. But the ketamine compound itself is still not FDA approved for anything. So I think we’ll see that pretty soon on the I’m not that excited about psilocybin. I know a lot of people are, but I need to see a little more data on that. But I am very, very excited about MDMA, assisted psychotherapy for PTSD. The research that I’ve seen on it looks very, very promising.

Excellent, excellent. And then maybe a little less fun subject to people have the opportunity to be reimbursed through their medical insurance with this. Is this all out of pocket, all out of network? How do you usually meet clients in that regard?

Yeah, so we’re so for TMS. We are in-network with all of the major insurance is except Medicaid, all the major PPO we’re in-network for. We also take insurance for the comprehensive program as well, which combines all of those modalities that I spoke about.

Amazing. Well, Ben Spielberg, this was an absolute pleasure. I appreciate you let me pick your brain and geek out a little bit and being able to share this with the community again, just that piece of not enough people knowing about what modalities are out there. Right. Right. Is beyond talk therapy. What’s beyond counseling, group therapy, med management. Right. These are things that are have actually been around for a while, even though they kind of feel like a well-kept secret. So I appreciate diving in and educating us with that. I wanted to give you just a final any final thoughts that you have that you’d want to leave us with today? Floor’s yours. Final. I don’t have any. You don’t have any. We covered it. Yeah, I think I think we’ve gone through it all.

Yeah, for sure. I think one of the cool things that you mentioned being this year, people sort of re-prioritize things. Right. And put prioritize their mental health. So, you know, maybe seeing it uptick and being able to treat more patients this year, which I think is amazing. And we wish you all the best. Keep up the good work and. Yeah, go ahead.

Thanks so much. Thanks for having me.

Take care Ben.

All right. Bye.

Bye.

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