Montare Media presents Season 2, episode 3 of the Discover U Podcast: TMS An Effective Tool for Treating Depression
What if you’re pregnant or breast-feeding and can’t take psychotropic medicine for depression? Are you doomed to suffer? Have you tried antidepressants with little or no measurable improvement? There’s new hope with TMS.
JD Kalmenson interviews Dr. Merrill Sparago to explore the efficacy of TMS, a relatively new, and amazingly effective, non-invasive treatment option. Dr. Merrill Sparago, a prominent psychiatrist in Los Angeles, who is an expert in the use of novel therapeutics for the treatment of depression and related disorders. He has been using Transcranial Magnetic Stimulation therapy for over 10 years in his own lab with spectacular results. Dr. Sparago’s education includes a residency in perinatal psychiatry at the UCLA Women’s Life Center, where he did a research fellowship as well as served as a volunteer clinical instructor.
Dr. Merrill Sparago, is a prominent psychiatrist in Los Angeles, who is an expert in the use of novel therapeutics for the treatment of depression and related disorders. He has been using Transcranial Magnetic Stimulation therapy for over 10 years in his own lab with spectacular results. Dr. Sparago’s education includes a residency in perinatal psychiatry at the UCLA Women’s Life Center, where he did a research fellowship as well as served as a volunteer clinical instructor. He has given numerous talks about the use of TMS, including grand rounds presentations at Cedars Sinai Hospital in Los Angeles. Dr. Sparago maintains a private practice for adults, specializing in the treatment of depression, OCD, and perinatal mental health.
Host Kalmenson is the CEO/Founder of Renewal Health Group, a family of addiction treatment centers, and Montare Behavioral Health, a comprehensive brand of mental health treatment facilities in Southern California.
Learn More about Montare Behavioral Health: https://montarebehavioralhealth.com/about/digital-library/
Kalmenson is a Yale Chabad Scholar, a skilled facilitator, teacher, counselor, and speaker, who has provided chaplain services to prisons, local groups and remote villages throughout the world. His diverse experience as a rabbi, chaplain, and CEO has inspired his passion and deep understanding of the necessity for effective mental health treatment and long-term sobriety.
#mentalhealth, #depression, #depressionandanxiety, #tms, #neurologicalintervention, #healingdepression, #brainhealth, #magneticstimulation, #treatmentresistantdepression, #fdaapproveddepressiontreatment, #alternativeantidepressant, #neurowellness
JD Kalmenson: Welcome to another episode of Discover U, our podcast exploring innovative and effective solutions to issues in mental and behavioral health. I'm JD Kalmenson, CEO of Montare Behavioral Health, a family of dynamic and comprehensive treatment centers in Southern California. I'm honored to introduce you to our truly wonderful guest today, Dr. Merrill Sparago. Dr. Sparago is a practicing psychiatrist in LA who is an expert in the treatment of OCD and depression and has been using TMS, transcranial magnetic stimulation therapy, for over 10 years. His education includes a residency at Psychiatry at the UCLA Woman's Life Center, where he did a research fellowship as well as served as a volunteer clinical instructor. He's given numerous talks about the use of TMS, including Grand Rounds presentations at Cedars Sinai and St. John's, the March of Dimes, as well as...
I'm honored to introduce you to our truly wonderful guest today, Dr. Merrill Sparago. Dr. Sparago is a practicing psychiatrist in LA who's an expert in the treatment of OCD and depression and has been using transcranial magnetic stimulation therapy for over 10 years. His education includes a residency in Psychiatry at the UCLA Woman's Life Center, where he did a research fellowship, as well as served as a volunteer clinical Instructor. He has given numerous talks about TMS, including Grand Round presentations at Cedars Sinai and St. John's.
Dr. Sparago maintains a private practice for adult, specializing in prenatal mental health, which has broadened into expertise in the integration of novel therapeutics including the use of rTMS and ketamine for treatment of refractory mood and other disorders.
Thank you so much, Dr. Sparago, for joining. I'm so excited to discuss one of your areas of specialization today, TMS. We at Montare have offered TMS therapy for several years and found it to be effective and non-invasive. In fact, we are about to open 2 new treatment centers, a neuro wellness clinic at our new outpatient facility specializing in neurological interventions, and amongst them TMS, as well as utilize it in our woman's Trauma Center. It's a relatively new therapy. And I'd love to get your take on how you got interested in it. And perhaps for those in our audience who don't know what it is, would you be able to give us a brief description of TMS and what types of disorders it treats.
Dr. Sparago: Sure, wonderful. And I'm so excited to hear that you're expanding to all these different areas. It’s just great. And so, well, going back to the beginning, TMS actually has been around since the mid-80s. It came out in the UK by a very group of neurologists and neuroscientists. So, basically with the understanding that the brain is kind of its circuits and circuitry, and that if you apply... which is essentially Faraday's Law. Faraday's Law is that, when you have a magnetic field and electrical stimulation, you can create energy which depolarizes neurons.
So, I learned about TMS initially in 2006 when I was training at UCLA. And one of the attending physicians there had one of the early NeuroStar machines, and we had taken a look at that machine. And then I started using TMS in my practice around 2011, 2012. And so, as you mentioned, I do a lot of work with women's mental health and perinatal mental health. And what I wanted was women to be able to have an option to be able to have treatment for essentially depression without medications, because people were concerned about medications, whatever that might be. And TMS seemed like an exciting and novel and biologically-sound treatment to be able to offer to people.
And so, my interest in it started there and has expanded to treatment of lots of different patients primarily with major depressive disorder, but with other disorders that don't seem amenable to standard therapy, as well as the idea of people who just don't want to take medications for side effects or otherwise.
JD Kalmenson: That's an amazing gift that you're providing for these folks who really aren't able to tap into the traditional psychiatric interventions. I mean, traditionally, we utilize it for the treatment-resistant folk as well, who don't want the medications and who are resisting that. What are some of the studies or the success rates associated with TMS?
Dr. Sparago: Well, when you look at a lot of the initial studies for TMS, even that had FDA approval in some way, they had looked like they separate like antidepressants do. But what's really interesting and fascinating is that when people respond to TMS, having sham controlled trials or other type of trials, it is really market. And so, since 2009, even before that, with FDA approval, there's been study after study after study after study, and all the consensus guidelines is it works. And the incredible thing about it is it works, I've seen, when nothing else does. And when it works, it's a game changer.
And so, the general data and all the studies that are out there show a really profound efficacy for the treatment. But when you see it in the real world, when you see it in your office, when we see it with people getting better who hadn’t gotten better before, it's just wonderful.
JD: It's an amazing thing. Wow.
Dr. Sparago: Right.
JD: How would you say, physiologically, would TMS be different than medication? I mean, in other words, is it impacting the brain differently? If you were to do a functional MRI of 2 brains, 1 on antidepressant medication and other one treated with TMS, would they look differently?
Dr. Sparago: I mean, that's a really good question. I mean, I think just taking a step back with that question is the idea is, when you think about kind of the differences, when you think about a medication treatment, you're talking about just kind of a diffuse systemic approach. Right? So, medications can't choose different brain regions, unless there's receptors that are more of the brain regions. Whereas TMS is localized and focused. So, when you look at like an fMRI study, and you look at the fMRI studies that look at abnormalities and transmission in like depression, you can see that when people get better, those abnormalities kind of normalized. When you're looking at kind of the exact process of TMS versus medication treatment, to... let me say it this way, is the ideas the focal treatment of TMS, and the kind of more systemic or diffuse treatment of medications will create changes in the brain that approach remission. But the actual kind of circuitry and everything is probably a little different in terms of what's happening in each brain system. I mean, there are definitely studies that look at it and studies that look at what's called the anterior cingulate cortex and how that reacts and works. And those pretty much focus on the TMS studies.
JD: Right. I mean, the obvious sort of distinction that comes to mind is the constant necessity to take the medication. Whereas TMS, for my understanding, after 20 to 30 sessions, the efficacy... or even up to, I think, maybe 36 sessions, you'll correct me on the exact numbers, but...
Dr. Sparago: Sure.
JD: ... you should be able to, to feel those effects for a significant period of time before you need a tune up, maybe a year or 2.
Dr. Sparago: Yeah. Again, all good points. Where the idea of medication is daily therapy, and TMS, when you get treated for those 36 sessions, is daily based on the doctors week, which is 5 days, so we can get our weekends is off.
Dr. Sparago: But at the end of the day, and there's protocols where you can do it quicker in some way. But once you're done with the treatment and there are good follow up studies in my experience in my practice to is the treatment holds. Right? There are studies out to a year. But things happen in people's lives. They can remit.
Dr. Sparago: But when people respond, and there's been a cadre of different patients who have been on medications for a long time who have come off of them, and now they just get treated with TMS and they get maintenance treatments every so often. So, once you're done with the treatment, you're pretty much done with it outside of other protocols. But what I'm really getting to is the idea is, whenever you treat someone for depression and you bring them to remission, there needs to be sometimes the maintenance protocols. But the maintenance can be, instead of daily medication, an intermittent TMS session.
Dr. Sparago: Right, right. And you just tapped into something that was really going to be my next question. And that was, does TMS simply take away the depression or help alleviate some of those depressive symptoms? Or does it actually help you to increase levels of happiness? And if it does only take away some of those depressive symptoms, then the obvious sort of result would be that, if there are circumstances, legitimate circumstances in your life that are challenging, and it can induce sadness and make somebody feel down, would the TMS intervention help increase resilience to that?
JD Kalmenson: Wonderful question too. To answer that question best, maybe it's best to maybe get a baseline understanding of just a model of TMS, model of depression, and how the brain works, so we can look at those questions of resilience and anything. Long story short, when you look at any type of... let's just look at depression. For a good amount of people, major depressive disorder is just a single episode. It just happens and it goes away. For a lot of people, it's a recurrent disorder. Meaning you get a major depressive episode, you can do better, and it can recur. And there's all different types of parameters by which people recur more and more, depending on age of onset. And there's also people who have more vulnerability to going into a depressive episode based on circumstance.
At the end of the day, one of the best predictors of mental health is resilience and flexibility. When people feel like they can experience sadness related to an event, versus the medical illness of depression, those are 2 really different things. And so, but anytime we can recover from something, we feel like there's resilience. And so, but when we're looking at depression as a disorder, the way I look at it is we want to treat people to remission. We're not talking about kind of cure or those different types of things. And that when people say in sustained remission of any symptoms, as opposed to normal sadness, or whatever, then they're much better able to tolerate things, and they’re much better able to tolerate their lives.
And if they go into a major depressive episode based on circumstance or something that happens when they respond to the TMS, like I have a couple patients doing it right now, they get a 2-week booster, and it kind of brings them back to where they were before. So, responders to TMS when it comes to recurrences, tend to respond to a shorter session course overall, which is really amazing.
JD: Wow, just a slight tune up.
Dr. Sparago: [inaudible] kind of the biology.
JD: That's fascinating. So, if somebody is depressed (let's just shift gears for a moment) because of unresolved trauma, and they haven't resolved their underlying issues, would TMS treatment circumvent the need for additional treatment? Can TMS on its own be the answer, or is it most effective, or even in the most effective scenario, does it still necessitate and require some additional trauma care, trauma treatment, or other forms of talk therapy?
Dr. Sparago: Yeah. I mean, I think if someone were to say, “TMS wipes it all out and takes it away,” that's probably someone to run away from. I think the idea, more importantly, is when people are depressed, it impairs their ability to think. And in a trauma-based brain or a trauma-based model, you really have to be able to get in there and be able to think about things. And so, the less we're able to think, the more depressed we are, the more thought based we are, the more negative we are, and the less ability we have to process information.
So, sometimes it is really, really hard to get to the trauma when people are so incredibly depressed, and you just can't reach it in some way. But when you treat the depression and the depressive symptoms get better, some of the trauma gets alleviated anyway, but then it requires really looking at that trauma. Because at the end of the day, is we all have stuff underneath it. And whether it's stemmed from the most insidious or most awful traumas, just to the idea of life experience, being able to process it and think about it, well, that brings the resilience, and that feels like you can quote/unquote ‘master’ in some way.
JD Kalmenson: Wow. So, it's almost like a complementary asset and can even be a prerequisite to other interventions being effective. If we're trying to do with the trauma and we want to be able to have the true sort of wholesome participation of the patient, of the client, of the individual, having TMS there on the side will actually probably increase the efficacy (is what you're saying) of other trauma treatments and therapeutic interventions.
Dr. Sparago: Yeah. I mean, each treatment trauma, OCD, any different types of diagnostic paradigm can have their own treatments. But if you think about it this way, let's look at the lungs. The job of the lungs is to breathe. And if someone has... outside of what's happening with a pandemic, but if someone has a very severe pneumonia, and they're not able to breathe, then respiratory therapy, those things are important, even rehab to get somebody stronger in some way with their lungs is all necessary. But unless that pneumonia is cleared and they're able to breathe, nothing else can really happen. Right?
So, similarly, the job of the brain is to think. Right? And when people are depressed, they can't think. And when you can't think it's harder to work through things. And so, when that clears a little bit, like the pneumonia clears, it doesn't mean your lungs are in great shape. It doesn't mean that there's not underlying asthma or something underneath it. But there are skills, tools and things that can be done in order to make somebody feel better. And so, I think it becomes synergistic.
JD: Right, right. And then the words you used, you can think clearer. If you can think, you're intelligence is a crucial ingredient in any form of healing. And this just clears up that entire area. Amazing. I mean, you've been doing this for a number of years. Any personal stories or examples that you would be able to share with us?
Dr. Sparago: Yeah. I mean, well, just starting with the advent of TMS, one of my colleagues who I respect really who's a great doctor started to do TMS in his practice. And with the addition of women's mental health in some way, I was like, “Okay, I'll get the machine. I want to have somebody to have an option to do that. But frankly, I don't think it's going to work.” And the most personal story, it’s one of the best treatments for depression I've ever seen. It's absolutely amazing. Now, does it work for everybody? No. But when it works, it works. And does it tend to give relief in some ways, even if it doesn't fully reach remission? Yeah.
JD: Right, right.
Dr. Sparago: And so, my own story what it is, I mean, it's blown me away. It's incredible. And we can go back again if we have time and look at the biology of why I think it works to understand it.
Dr. Sparago: I can say this, when I first... I mean, I have tons of stories, but one that really sticks out the most is I had somebody who, when I first got the machine who was so incredibly depressed, and I ran out of options. And there was another person as well, and I said, “Well, I have TMS now, let's go ahead and do it.” And insurance didn't cover it or anything, and I said, “Doesn't matter. I will treat you. It's fine.” Changed his life.
JD: Wow, wow.
Dr. Sparago: I mean, he has never been that depressed again. And he was depressed for years and years and years and years. And I have another woman who experienced a ton of trauma who was on medications for, I mean, almost every medication known to man, and we took her off the medications... or man and woman, I guess, is a better way to say it, but... or human. But she's medication free right now. And she has remained in remission. And even women who felt like they couldn't get pregnant because they would get so depressed.
Dr. Sparago: I mean, there's just... I mean, I have these people in my mind, and, “I can't get pregnant again. I'll get so depressed. And I don't want to take medication,” I'm like, “There's something that we can do.”
Dr. Sparago: We treat them. And I've pretreated people and say they get sick at week 9, I've pretreated them at week 6, and then they're fine. I have people call me goes, “Now I have another kid, and the depression didn't stop me.” And those things are just... I mean, there's so many of them and they're inspiring.
JD: That's magnificent. That's truly magnificent. Is there anything in your experience, any patterns or trends unifying those that TMS does not work for? Have you seen any sort of parallels or similarities for what type of population it might not be effective for?
Dr. Sparago: Yeah. I mean in my private practice, I'm very selective in the people that I treat. I want to have as much of a pure major depressive disorder as there is. Even if there's a lot of anxiety and even if there's OCD in some way. Where it struggles in some ways, if someone in my practice just has a pure anxiety disorder without any concomitant depression, there are protocols where people can treat panic disorder, those things. But if there's no depression associated with it, that becomes a little tougher. And when there's a depression that's related to kind of a personality disorder, potentially borderline personality disorder, is people can get some relief of their depressive symptoms. But it doesn't stick the same type of way, because I think there is the true major depressive episode that can happen in those disorders where people can get a little better. But the chronic empty depression that is so persistent in some way tends not to respond as well to TMS, which is expected because it's a different type of pattern, a different type of paradigm.
JD: Right, right. But you're saying assuming a pure sort of depressive disorder syndrome, TMS will be effective.
Dr. Sparago: Yeah. I mean, in most instances.
Dr. Sparago: And then a lot of people who come to TMS come because they haven't responded to medication.
Dr. Sparago: So, it'll either turn people who are non-responders into responders then they stay on their medication. But even dysthymic patients can get better, but it's more the idea of that really profound personality disorder. Even though I want to be clear, it doesn't mean that they can't get help with their depressive symptoms. It's just a different phenomenon than with the older access 1 major depressive disorders.
JD: That's extraordinary. I mean, I understand that a lot of folks who come to TMS, having failed with medications, or simply not wanting to take that route on a long-term level. But let's just say somebody has these 2 options in front of them, and they're equally open to medication, psychiatric medication intervention, or TMS, would you say one is preferential over the other?
Dr. Sparago: I think that's where autonomy and feasibility comes in, the most important thing. All things being equal, TMS requires a big commitment.
Dr. Sparago: When people are coming in every day for 5 days a week for 6 weeks, and really 7 because it's 36 sessions, and then the taper, they're committing to something. In general, is it...? And some people just can't do it. Like, even in the postpartum, when I’m trying to treat women with postpartum depression, having somebody there at home every day or...
Dr. Sparago: So, sometimes it's a feasibility thing. All things being equal, if someone had failed several antidepressant medications and continued to fail them, and that's where the distinction would be made. I would be like, “Look...” and there's data from studies like the Star D trial and the Texas algorithm that show, after certain amount of antidepressants, it doesn't exclude antidepressants, but it's probably better to hedge our bets with something else.
JD: Right, right, and diversify.
Dr. Sparago: Exactly.
JD: My understanding is that there are actually different types of TMS treatments in their length and maybe in what they're accomplishing. Some take 20 to 30 minutes, whereas others take as little as 2 to 3 minutes. Is that accurate?
Dr. Sparago: Yes.
Dr. Sparago: And what would be the difference between them?
Dr. Sparago: Yeah. So, with regard to kind of treatment length and treatment time, just starting with the kind of the initial TMS machines, they're called rTMS. It’s the one that I have. It's ‘repetitive’ for the ‘r’, transcranial magnetic stimulation. Everything is, in some way, repetitive, versus there are continuous options as well.
Coils have developed and changed in terms of what they do and the kind of transcranial magnetic stimulation that they give. So, if you look at the idea of the first coil that was FDA approved, the NeuroStar coil, that one is 3000 pulses with a certain cool-off period. Because that's one of the rate-limiting steps is how much the machine can get without overheating. And that could be 20 to 30 minutes.
Now, there's coils where you can do it quicker, even with the repetitive TMS. And then there's other different models. There's deep-brain TMS. And there's something called theta burst. And theta burst is a different algorithm. And theta burst is an EEG wave. And the theta burst is what is present in the cortex in kind of a normal rhythm. It can, in some ways, disappear when people are depressed and you can institute that theta burst. But theta waves are present when you're really thinking, when you're mindful in an experiential way, in some way. And so, instead of rTMS, there's ‘I’ theta burst stimulation. And ITBS can be done in about 2 to 3 minutes. And so, the real trend of express TMS, they call it, is with a theta burst model.
JD: Is that anyhow, less effective?
Dr. Sparago: No. And there was a study in The Lancet, where they looked at kind of... it's part of what the company puts out as well. And so, but at the end of the day, no, theta burst treatment, and they're still markers that people are trying to look at, which is, how would someone respond to data burst? Are there predictors in everything? But no, there's really not.
JD: And they're all FDA approved?
Dr. Sparago: So, there's FDA approved and FDA cleared. Right? That's a little bit different in some way. And so, these machines, like for the NeuroStar machine is FDA approved, going back in 2009. And then they get FDA cleared, because they're a medical device. Then you have to have clearance and then approval. I don't know what all the approval status is for everything. But anything that's cleared, in my mind, and the technology has been there for so long, is study driven. Like, does it work? And how does it compare? And the answers is, it’s pretty amazing. It works.
JD: That is truly... it's not invasive, and yet, its impact obviously over a sustained time seems almost as organic as if you worked on it. I mean, it's not requiring the concept of dependency on a pill. So, it's extraordinary. And talking about the success of remission, have used had clients who never needed a tune up, have had TMS and have just been sort of good to go indefinitely?
Dr. Sparago: Yeah. I mean, I've had people who have TMS, who, I mean, I've treated I've never seen again. So, in some way, they went back to their primary practitioners somewhat that responded and they haven't come back. There's others that have. I mean, most people, again, require some type of maintenance treatment in some way, whether therapy or not.
Dr. Sparago: But certainly, like that very first person, when was that, 10 years ago? He's never done TMS again.
JD: Wow, wow. I'm going to ask you a...
Dr. Sparago: Maintained on his medication, but he lives a much better, happier life.
JD: That's so noble and beautiful that the effects are so long and enduring. I'm going to ask you...
Dr. Sparago: It’s really nice. I’ll just add one more thing.
Dr. Sparago: Even for people that recur and they get that 2-week booster, and they're like, “I already feel better,” I mean, it just gives the sense that there's something there that they can rely on and count on, where the this the illness of depression doesn't have to complicate as much the sadness or take away any of the joy of life.
JD: It's very true. I mean, just unpack what you're saying for a moment. If you're able to reduce, a tune up is able to accomplish the same effect in 2 weeks versus 6 weeks, then somebody who goes through this process, there's an investment here. You're building equity, as it were, that even, God forbid, if something comes up in the future, there's a trigger, there are certain circumstances that are debilitating that sort of push you right back into that place, you haven't lost it all. You can tap into this reservoir of work that you've done. And within 2 weeks, which is not 6 weeks, I mean, 2 weeks is much more surmountable.
Dr. Sparago: Right, exactly.
JD: You white-knuckle it.
Dr. Sparago: Yeah, no. And when people realize that, I mean, sometimes the effects aren't as profound as the beginning. But when they realize that the illness is unacceptable, that it is unacceptable to feel that way. And the quicker they're able to recognize what's happening, then that's part of the resilience.
Dr. Sparago: The idea of, “I can come in. I can do this. I can recognize what's illness versus wellness.”
Dr. Sparago: “It's not getting better. It's not where I want to be. I'm coming in.”
Dr. Sparago: And that's the wonderful thing.
JD: And then I'm sure, and you'll correct me if I'm wrong, I'm sure even when they do come in, because they are looking for a tune up, had they not had the TMS, the depressive disorder would be a lot more acute, almost like, yes, you might get COVID with the vaccine, but the symptoms are going to be a lot more mild.
Dr. Sparago: Yeah. I mean, I think that’s the issue. I mean, it's a good point. I mean, the vaccines (just because you brought it up), they don't prevent car accidents.
Dr. Sparago: Or seatbelts, you better have one on.
Dr. Sparago: And to what you're talking about, the better the baseline, the better the seat belt that you're in, the accident isn't as acute, and then you can work with it. And so, yes, And I think part of that is the idea because people recognize what it means to be well. And there's some people who have gone through this for so long, didn't even know it well was.
Dr. Sparago: And then they know what it is, and they’re like, “Oh, wait, I don't have to be in a car crash. I can wear my seatbelt. And if I'm struggling, I’ll just get a little tighter.
JD: Right, right. The following question I want to ask you, I might be coming from a supreme place of ignorance, but it's just something that intrigues my...
Dr. Sparago: [inaudible]
JD: It's intrigued me for the longest time. Using this sort of technology to outwardly magnetically stimulate parts of the brain, suppose that was directed at the prefrontal cortex, could that help inspire activity, thoughts about morality, existentialism, for somebody thinking about life not in those terms? Would this method potentially be able to help other sections of the brain become more active and more engaging? It's almost like, if that were the case, in 10 years is like, “You want to date my daughter, you got to do TMS for your prefrontal cortex for 36 sessions.”
Dr. Sparago: That’s really funny, “And you got to do it in my office. And you got to pay triple. And it's going to hurt.”
JD: So, what do you say to that sort of...?
Dr. Sparago: Now I already have a plan for threatening my daughter's would-be suitors? Well, so let's look at it this way. Let's just talk about wellness and illness in some way, and then we'll look at treatment, and then get to your question. One of the things that people are concerned about, “Well, if I do this, will it change my character? Will it change my personality? If I take a medication, will it do that?” And when I tell people is, “Treatment will only let you be who you are. Illness prevents you. It makes you what you're not in some way.” And so, with regard to...
JD: That's such a beautiful statement, just even to pause it and let that sink in, that wellness is really you amplifying all of that goodness that really is part of your integrity.
Dr. Sparago: Right.
JD: It creates more alignment. Illness is really taking you away from that who you are.
Dr. Sparago: Right. Exactly. And I think when I say to people, again, in the pneumonia analogy, if you had a cough and a cold and everything, and you went to the doctor, and they asked how you felt, you would say, “I feel bad.” You wouldn't say, “I am bad.” Where in depression, “I feel bad,” equals, “I am bad.” And so, the idea is that it makes you what you're not, and it's painful. And treatment just allows you to be who you are, to be able to, to live your life.
And so, as people become more of who they are in some way, as there's more wellness, I mean, cortical function and that executive function is the expensive part. And even if you look at like we talked about theta rhythms in some way, existentialism, all that other stuff can be coded in some way, and theta rhythms in the anterior cingulate cortex and other cortex. Giving TMS in some way, if you look at performance metrics, pre and post-performance TMS, TMS has a performance-enhancing effect on tasks, but that's because you're activating that cortical circuit. You're activating, it's like taking your Mac, and all of a sudden, upgrading it, like by adding in, like a ram in some way, but then...
Dr. Sparago: And then it performs at a higher level. But taking that and changing the process in which someone thinks, probably not, except that it would open the ability if you're not depressed to consider many other things. Right?
Dr. Sparago: But if the idea was the goal of spirituality, mindfulness, being able to be connected to a lot of kind of other spaces, that I think is a personal goal. But the more that you can do that in some way, that is a thinking model. And the more you can think, the less thoughts you have.
Dr. Sparago: And thoughts are important, but you can't say, “Let me thought about it,” you can say, “Let me think about it.” It's, “I think, therefore, I am,” not, “I have thoughts, therefore, I am.” I used to say, “I think, therefore, I'm leaving this class because it's boring.” But really what he was saying is thinking is what makes us individuals.
Dr. Sparago: Whereas other kind of reptiles or those things, they have thoughts, but hamsters don't think about the polystyrene component of their cage and wonder about climate change.
Dr. Sparago: They just have thoughts. So, thinking is the kind of gateway to everything you're talking about.
JD: Wow, that is interesting. Are there any downsides? Are there any risks associated with TMS?
Dr. Sparago: Yeah. I mean, everything has kind of risk associated. The first risk with TMS is making sure that no one has any metal implants in their head, because it is a magnet. And the magnet is an MRI-strength magnet. And just like if someone were to get an MRI, and you can't have any metal in that area. And then you look at kind of the other risks of TMS.
Now, I did TMS. I wanted to know what it was like. And you have to set up a motor threshold, which is how much stimulation areas. And, of course, my thick head, I was like off the charts. And so, and it feels like a woodpecker. It's very odd. It doesn't touch you, but it feels like this tapping sensation. And so, for some people, they can get a headache. And when they do, we can pretreat them. Now, it can also treat headaches and migraine disorders in some ways. So, it's not like it's creating a problem, but it's uncomfortable.
JD: How long after the treatment would there be an onset? And does that headache persist, or is it just more of a 1-time sort of effect?
Dr. Sparago: It's transient. I mean sometimes people get it just because it's uncomfortable. Sometimes the strength is pretty high. But at first, again, people accommodate to it. So, to your answer, they might get a headache at the beginning, and they're like, “I can't imagine doing this for all these sessions.” And then they come in, and they look forward to it, because they don't notice it anymore. They're watching TV and being stimulated by something else, then it pretty much goes away. I've never had anyone who had just persistent headaches in some way that warrant a continued treatment.
Dr. Sparago: So, it's transient and short-lived. And for the people that are worried about it, we can pretreat them with Motrin or Tylenol.
Dr. Sparago: And the only other major issue is a risk of seizure. Now, what does that mean? When we kind of look at and recognize where we need to treat people, we have to know how much motor stimulation they need, which is that their motor strip. Right. And so, that creates action. And so, seizures are usually either consciousness or motor disorders. Long story short, the incidence of seizure in TMS is probably the same or maybe even less than some antidepressants. It's one in about 3000 or 30,000 treatments. Now, I've done more. I've never seen a seizure. If it happens, it would happen in the chair, as opposed to like an antidepressant treatment. It doesn't require like paramedics or anything. It's a certain type of seizure in some way, and you just stop the treatment, and it goes away.
So, even if someone has a history of seizure disorders, which people have had, can you use TMS? Yes, you can. It just changes the paradigm a little bit, and you have to be more specific. But that's the risk that kind of scares people a little bit. But when you put it in context, it's minimal at best.
JD: Right, right. That's interesting. And are there any other disorders besides for depression that it is effective in treating?
Dr. Sparago: Yeah. I mean, so anything that depression is layered on, I look at it as kind of fertilizer for any other disorder. Right? So, if you have base OCD and depression, you're fertilizing that OCD and making it worse. And so, sometimes, when I've treated, treated people's depression, some of the other symptoms, like even generalized anxiety, obsessive compulsive disorder, those things have gotten better. Right?
Now, there's even bipolar depression. Now, there's, I think there might have been an indication now of treating bipolar depression, not just unipolar depression with TMS, like with ECT. I've had success with bulimia and eating disorders.
Dr. Sparago: Impulse-control disorders in treating, people have gotten better with their depression, and their bulimia has slowed down. So, just like antidepressants, can work for that.
JD: So, impulse-control disorders would really open up the doorway to almost like all of addiction.
Dr. Sparago: Yeah, exactly.
JD: If from a broader perspective.
Dr. Sparago: Yeah. And with regard to addiction, I don't know if there might be data. It's just not my specialty. But the idea of certain types of impulse control. And if you look at OCD has impulse control features.
Dr. Sparago: And there's successful paradigms and treatments. They’re a little bit better for OCD. And in general, anxiety disorders can respond too, generalized anxiety. So, it's not as narrow as major depressive disorder.
Dr. Sparago: But it certainly doesn't include everything. There’s even data in the past about hallucinations decreasing with TMS with schizophrenia.
JD: That's incredible. That's absolutely incredible. And then biologically speaking, I think was there some visuals?
Dr. Sparago: Yeah. Let me pull something up here. Maybe I can share my screen here.
JD: Yes. And if you can share with our listeners who are only plugged in on the audio.
Dr. Sparago: And I'll explain exactly.
Dr. Sparago: Okay. So, I'm showing people this slide here. And so, from one of the talks I do with TMS, the title of the slide is Depression, TMS and Rhythm. And I just want to go back and explain what I mean by that. All of life, a lot of life is about rhythm. Right? I mean, there's a rhythm for everything. There's a rhythm in our heart. There are rhythms in our brains. There are rhythms in day and night cycle. And so, when you look at your brain, you have your brain. And the thing about the brain is, in certain rhythms, you can use your mind. Try and use your mind when your brain is in a sleep rhythm. You can't because your mind isn't accessible. And so, in order to be able to use your mind, your brain has to be in a certain rhythm. Right? And arrhythmias don't feel good.
So, on the slide, what I have is an EKG. We've all seen the changing, but how many people have seen an EEG? We know they're there, but not many of... even in psychiatry, we don't see that many of them because they’re very complicated, and they look for specific things. But in this slide, you see a normal heart rhythm, which is what you see on that rhythm strip. And when someone's in a normal heart rhythm, they could feel okay.
When you're not in a normal heart rhythm, like atrial fibrillation, or your heart is beating irregularly, that is called an arrhythmia. And when someone is having an arrhythmia, their heart doesn't work in a way they would like it to. And so, you can be fatigued. You can be all different types of symptoms. And the entire goal, even if that rhythm is potentially fatal, is to put people back in rhythm in their heart.
Well, if you look at kind of the brain, the brain needs rhythm too. And that prefrontal cortex that we were talking about, that is the rhythm generator of the brain. And so, part of the ideas when another part of the slide here, so the brain and rhythm allows us to use our minds. And if there's an arrhythmia, it's very hard to look at it. And we can look at depression as just an arrhythmia.
And this other part of the slide is kind of what is a PET scan. And this PET scan is the scan that shows the non-depressed brain can depress brain. So, as you were talking about accessing thinking, accessing ideas, in a non-depressed brain, there is a lot of glucose being utilized. It lights up the yellow. In the depressed brain, it's lights out. And that's how people feel. “I have no energy. I have no desire. I have no mood.” It's because all those cortical circuits are gone.
And so, basically, if we look at depression as an arrhythmia of the brain which impairs function, and the way I explained to people, in TMS is a rhythm generator that we're seeing almost like a pacemaker and starts going on its own.
So, in this next slide that's here is, you can also think of your brain as a computer like a Mac. And a non-depressed brain is like this Mac right now functioning on all cylinders. It can do a million different things at once. It can function. Right? But if the operating system is overwhelmed, you get the circle of doom. So, when people are depressed, “I remit all the time. I can't stop thinking. I'm spinning, spinning, spinning, spinning,” it's because there's not enough of the operating system working to be able to think. And unlike our Linux, we can't force put our brains. We can't force put our thoughts. We can try and go to sleep.
And so, if we just go 1 more slide, when that operating system is cleared up, then the computer functions again, thinking thoughts like depression. So, this last slide that looks at TMS shows a brain which shows this prefrontal cortex, this area of stimulation, and that there's circuits that are involved in depression. And that the job of the thinking brain is to kind of suppress thoughts, fears, and everything, and feeds back to be able to work.
So, when people are depressed, like the Mac, the operating system isn't working. It's just spinning and spinning and spinning. And all these deeper structures, fear, anxiety, all that other stuff is taking over. Existentialism, all that other stuff gets impaired. Then we do the TMS, and we treat people, we get that rhythm generator going by that left prefrontal cortex. Then the deeper brain regions just quiet down like a parent taking care of a child and they function again. And then there's an intact operating system, a brain that's functioning in rhythm. And now we have that spinning going away. And we're back to being a human again.
Dr. Sparago: And that's kind of the way I look at it. And that was kind of a long explanation. But simply put, TMS is a rhythm generator. When we're in rhythm, we do well. Arrythmias are problematic in any function in our lives.
JD: Wow, wow. That is profound and so insightful. It's been such a pleasure having you here with us today. Thank you, Dr. Spargo for joining us on The Discover U podcast. We truly appreciate you taking the time.
Dr. Sparago: Appreciate it. Thank you so much.
JD: And thank you, audience, for joining us too. Hope you enjoy today's episode of Discover U. And at Montare, we want you to know that you're not alone on your journey. For inspiration, you can find us at montarebehavioralhealth.com, as well as on YouTube and all the other social media platforms. Wishing all of you a day full of vibrant health and joyful connections. See you next time.
Montare Media presents Season 2, episode 3 of the Discover U Podcast: TMS An Effective Tool for Treating Depression
Learn More about Montare Behavioral Health: https://montarebehavioralhealth.com/about/digital-library/