Natural Ways to Treat Anxiety and Depression During the Fertility Journey

Dr. Amber Klimczak and Dr. Beverly Reed have psychiatrist Dr. Minwalla as a featured guest to discuss non medicated ways of treating depression and anxiety during the fertility journey. They specifically discuss transcranial MRI stimulation (TMS) and how it can help.

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Dr. Beverly Reed. And I'm Dr. Amber Klinczak. And we are Two Peaks in a Pod. Well, hi everybody. Welcome back. We are so excited today because we have a special guest appearance today. This is Dr. Minwala. Minwala. We are so happy to have you join us today. Welcome. Thank you. for having me guys. Um, will you tell us just a little bit about yourself, your specialty, and where patients can find you? Sure. So my name is Dr. Manwala, like they said. I practice at Salience Health here in Plano. It's in the Legacy West area. Patients can go to our website at saliencehealth. com. Look at all our, all our neat, uh, depression, anxiety, other mental health resources on there. But I am a board certified, um, adult psychiatrist. Do see patients aging, uh, from 15 and up. Okay, great. And actually, Dr. K today has a celebrity story for us to just kind of tell us about that is related to Dr. Manwala's visit today. Yes. So Dr. K, tell us about the celebrity. Okay, so I think a lot of our listeners will know him. Like I said to Dr. Reed. He's very good looking and I think there's, I think he has a brother maybe out there, but Chris Hemsworth reportedly, according to the internet, you know, you can find anything on the internet, allegedly, um, I guess has either suffered from depression, anxiety, or something where he was seeking treatment. And one of the forms of treatment that he did is transcranial magnetic stimulation. stimulation, sometimes called TMS. And, uh, this is a topic that we're very interested in for our patients and Dr. Emanuela is an expert on it. And so we have him on the show today to tell us all about it, as well as just, you know, other ideas and ways to help manage, um, anxiety and depression and some other disorders. I think too, it can be used for, um, knowing that he was coming on our show. I really paid attention the last two weeks. to my patients. And I will say almost 90 percent of my patients report a history of either anxiety or depression. And almost 60 percent of my patients are on an antidepressant or other anxiety, anxiolytic medication, which I feel like is really powerful information. Um, and I think Probably my patients when they come to see me think that that's just them, you know, but I'm telling you it's just very prevalent in our patient population of young healthy women, right? Um, and everything that they're going through. And so I think this is a really interesting topic for our patients and how they can manage this. Well, and I will say, too, I bet your patients have a lot of the same concerns that mine do, where maybe their anxiety and or depression have been really well treated with medication, but now they're wanting to get pregnant, and they worry, do these medications affect the pregnancy in any way? And we do feel like there are a lot of good solutions. safe ones. But even with that reassurance, sometimes they say, gosh, are there any other options that don't involve medication that I can consider? And so I think this is what we're going to get to hear all about today, right? No, absolutely. Okay, good. Okay. Well, can you explain to me, because I really don't know anything about it. What is TMS? Sure. So TMS stands for transcranial magnetic stimulation. It's a non invasive, in office, FDA approved treatment for major depressive disorder, as well as obsessive compulsive disorder, OCD. And it also has an indication to treat migraines, but, you know, we're probably going to be focusing more on the depression, OCD. We've also noticed that it's been extremely helpful in treating anxiety. When we've been treating patients with both depression and anxiety, we notice that their scores, their scales, uh, their symptoms improve almost identically for both depression and anxiety when we look at it on a graph. So it's been extremely helpful for, for that as well. Uh, what we do is we place a treatment coil on your scalp. That scalp produces a magnetic field that, um, stimulates and strengthens this network in the brain that's responsible for emotional regulation. works better than medications, safer than medications, which is why we're so excited about it. That's really interesting. Okay, so I did not know this about migraines, and I will say that is another condition that my patients report all the time, because again, Migraines really affect young women, oftentimes in their 30s and 40s. So I feel like that would be a huge benefit for my patients. So I have never seen this, right? So I'm imagining like a big like MRI machine, like what's around their head? What does this look like? So, you know, our treatment rooms are, are, um, there's like a, maybe walking into a dentist office. You notice that big recliner chair. We have one of those. We place the patient in this recliner. We get them all nice and comfy. I would recline their feet up, lay them back. We have this really cool pillow that goes around their head and their neck to give them some support. We vacuum the air out of this pillow, keep there to make the pillow firm, which gives them makes them feel really comfortable and snug. And what we do at the first session is actually we do something called a mapping. We determine the level of amplitude that we need to use for the treatment. So the treatment is very, very specific. It's not just You can go anywhere. Just someone puts something on your head and we're treating right, we're refining the specific prescription to that patient. So we place the, um, place them. Once we get them comfortable in the chair, we place, um, the coil on their head and we actually locate their motor strip on the left side and we go to the specific spot on their motor strip that actually controls motor movement in their hands. We use that to determine the motor threshold. We want about a 50 percent response there. And, um, once we find their motor threshold, we use a little bit of a math equation to figure out their, their amplitude that we need to treat for, for their depression, actually treat their depression in a different area of the brain. So, so the first session is mainly figuring out that amplitude. We give them a, um, a shorter course of treatment that first day. And then subsequent days we, uh, treat for the full amount of time. Okay. And so for our listeners, when they're doing this mapping, like their hand is moving, I think this is incredible. Like that you stimulate someone's brain and make them move their hand. Yeah. So we want to make sure that we're, um, reaching the correct depth. So that's why we know that they, uh, spot to stimulate the hand movement in the motor cortex. It's similar depth to where we need to treat the, um, other area of the brain, which is the, you know, dorsolateral prefrontal cortex, which is where we're targeting for the depression network. Very cool. I love that it's customized too, right? I mean, sometimes when you do think about medicine, it's like a lot of people just take the same medicine, the same dose, but it does seem that you're really customizing each patient. Our patients love that too. A lot of times that's why they come to us, they want custom fertility treatments, so this is nice that you can help. Yeah. Custom treatment for this as well. I think, um, one of the things that I've noticed too is, um, what do you see with your fertility patients? Sometimes the more depressed or anxious they are, I do think it can affect their treatment overall, right? Their fertility treatment. Absolutely. I mean, a big part of fertility treatment is being able to keep going, but if you're so depressed and anxious that it takes so much out of you to do a cycle, you may stop before you get to your goal. And so. In a way, I would almost consider this fertility treatment too. Absolutely. I explained this to my patients pretty much from the first time I see them. If they have anything in their history, I say to them, listen, mental health is extremely important to what I do. We have data that it affects our success rates too, right? So I need them to be on board, you know, with proceeding with treatment, right. And believing in yourself that you can do it. So it's very hard to do when you're not feeling yourself. And I think it even helps me as a doctor because they say anxiety is contagious, right? And I feel like sometimes maybe because of that, sometimes my patients, maybe I'm not always the best fit for a very anxious patient because they'll be like, well, Dr. Reed, I'm worried about this. And then I'm like, oh gosh, now I'm worried about that. And then they're like, well, now I'm even more worried. And then we just like feed off of each other. We really need you to bring that cycle for us. And maybe we'll just vote no. Okay. Um, okay, so, um, I know that you mentioned some of the approved official indications. Sure. If a patient wanted to come see you, do they need to have already been diagnosed with these conditions? Or do you, you know, how, how does that work? Could they just come book a session? Sure, yeah, so that's, that's Salient's where I work. I see patients, we treat the wide array of mental health issues. So we don't only do TMS or only treat really, you know, treatment resistant patients. We treat the full array. And if it's appropriate for the appropriate patient, we recommend this and we get people better with TMS. So yeah, we go through every patient comes through full evaluation, get a really good mental health history. I like to start by just getting to know them, what treatments have worked, what hasn't worked. Why things haven't worked? Have they had side effects to other treatments? Are we starting, you know, from scratch? What was their motivation to come in, get help? What are their priorities? What are their goals? And we customize a treatment plan. It's never one size fits all. And are there any people that just are not good candidates? I would feel really bad if I said something like, Go get TMS! And you're like, you're not a candidate for TMS. So, a couple of things that we don't want to treat patients that have certain things. One would be psychosis. So someone having hallucinations, auditory or visual hallucinations, paranoia, those would not be good candidates to put under, um, stimulation. Also, we don't want patients that, um, have, um, are currently in a manic episode of bipolar disorder. So if someone, someone is manic, not sleeping, uh, would not be, not be the best candidate for TMS. The other, the other patients that have epilepsy or an untreated seizure disorder, uh, would not be a candidates. And then anyone that has metal, that's not MRI safe, like shoulders and above would not be a, not be a candidate. So just like with MRI, same technology as an MRI. So if there's something is not MRI compatible, would not be able to go under the TMS. Go over pretty much really worried about metal shoulders and up because the oil doesn't, you know, Go through the whole body or anything like that. Is it around their whole head? Like, what about MRI people that don't, that feel claustrophobic? That was such a big thing. They don't feel claustrophobic in it? Nothing like that. Yeah, can you just lay on the chair? You don't even see the equipment. It's just an arm with a small coil that goes, like, Okay. Okay. Perfect. Um, so my understanding of TMS when I first heard about it is that it's not just a one time thing, right? So can you tell us more about the logistics? Cause I do think this is important for someone that's considering it because it is fairly involved and you have to commit to doing it. It definitely is a commitment. I like to explain it to people that it's kind of like going to the gym, but for your brain. We are strengthening something we're trying to add on to things. So it is a series of 36 treatments and each of those treatments going to build on each other and strengthen this network in the brain that's responsible for that emotional regulation. So we don't want to, we can't just do it one time and expect to have results just like you can't go to the gym. Expect to have, you know, significant results from the gym with just one or two days at the gym. We typically treat on different days. The main reason that the treatment is spread out over these 36 different days is because of insurance coverage. They cover one treatment per day. Someone wasn't going through insurance. We have these, um, really cool accelerated protocols where they've actually done studies, you know, very recently that they've done all the sessions in just like one or two or even three days. You still need those 36 sessions But the reason why they're done on different days right now, at least mainstream is because of the insurance company. So for using insurance benefits, people do treat different on different days. Each treatment though is 11 and a half minutes. So people come and treat before work after work during their lunch for open six to six and on Saturdays. So people, people can come yeah, before work, after work, Saturdays, they, they make it work. So nice because we have so many patients. It's so hard for them already to go to the fertility appointments. So that's really nice that you guys have such availability. Um, their treatments. And so you kind of mentioned insurance. So can you tell me more about insurance? Absolutely. So more recently, insurance has become better and better at covering TMS. Um, All major insurances cover TMS, and they cover it for patients that have a diagnosis of major depressive disorder that have failed two medications. Some insurances prefer those two medications to be in different families. And then Medicare covers TMS as well, and they actually only require one medication failure. A medication TMS. It's defined as like side effects to medication. So someone's having really bad nausea, sexual side effects, anything like that, that they don't want to take the medication because it's not a, if there's not a good fit for them, that's a failure or taking it for several weeks and not having a significant improvement or you're not in remission from depression. So you know, sometimes we hear this all the time, you know, I'm doing okay. You know, my depression is better. My anxiety is better. I feel functional. I'm doing okay. But you know, those patients are not in remission. If we took any other, you know, medical field, we wouldn't want to tell people that, hey, like, you know, we partially, you know, help treat this. We want, we want people in remission. We want people to feel well. We want people to have a good quality of life. Yeah. Yeah. Well, and you know, kind of my thought on this too is it almost seems backwards to me because it's like, okay, first you have to try these medications to try this more natural therapy. But I'm like, should it be like first you tried natural therapy and then you can take medication? Right. It's, it's interesting. It feels backwards to me. Right. The, the FDA, actually March of 2024, so last year they actually have approved TMS as a first line treatment option adolescents. So 15 to 21. The insurances, of course, are not fully on board with allowing us to treat it first line. They still want the medication failures. But I think as we learn more about TMS, as it becomes more widely accepted, I think that I think people will catch up, catch up, and insurance will catch up to the evidence. That's very interesting. So in your experience, when patients do this, usually they can come off meds All together? Is that what you're seeing? We, we typically don't pull people off the meds automatically. It's very personalized. So it depends on what the patient's goals were at the initial appointment. Mm-hmm. If patients tell me that, you know what? The medications work, work for this. Mm-hmm. Um, but I'm still struggling in these areas. We see what results we're getting with the TMS, and then we make a decision together after the treatment, whether we wanna scale back beyond less meds. Maybe someone's on two or three meds at the same time, they're on adjunctive therapy with. pretty nasty medications like maybe in the anti psychotic family to kind of boost the Antidepressant effect and that's causing them weight gain. It's causing them all these other side effects and we do TMS and they're significantly better than yeah We we want to scale off remove some of these medications that are causing problems Okay So insurance, and I would love if they covered it, but what if we have a patient and it doesn't cover it for them? Sure. I mean, I'm just gonna say it, it sounds really expensive, so I so give it to be straight expensive. So it, it's, it's more on the expensive side. Yeah. I will say that we have very good. Self pay cash pay raise. We have payment plans. We have, um, we reduce the cost for certain patients and We don't want money to be the reason why someone doesn't get TMS. We have a Highly trained group of people that really help with insurance companies So if we need to do like a peer to peer with the insurance company or get things approved We do get the majority of our cases, you know, paid for by insurance and with the insurance, the cost can vary widely as well. So even if you have a large out of pocket with the insurance, we're still there to help with payment plans, financial assistance, things like that. With the range of the cost can be an office visit, co pay all the way to having to meet your deductible or out of pocket maximum for the year. So sometimes with patients have met those things, met deductibles, met out of pocket max, they're doing TMS for no cost. Well, I would say. Our patients probably already met their needs. Yes, a lot of them have. Right, so it might be kind of a free print trip then for them. Um, okay, so question. When they're getting it done, does it hurt? That's a good question. Yeah, it feels like We worry about pain around here. Sure, sure. She and I are both wimps. We don't even like to get our blood drawn. Sure. So nothing's actually, the coil is resting on your scalp, but you do feel a sensation. You feel like someone is firmly tapping on your scalp really rapidly, or I like to describe it as a rubber band, like just snapping against your head. Um, someone, someone else that has gone through treatments says it feels exactly like a tens unit. So if you've ever used a tens unit on your muscles or, Having some some sort of pain feels like that like, you know stimulation on it on a part Okay, and you do feel it's safe during pregnancy Absolutely. I mean a lot of times you can be at higher risk of having postpartum depression if you have these issues So do you think it helps with that? Yeah, absolutely. So The, um, we know that TMS has been shown to have no adverse, um, outcomes on fertility for both men and women and no, um, not affecting the fetus at all. So there's no, no known risk to the fetus, no known risk to fertility and no known risks to breastfeeding moms and very helpful to help with postpartum depression, prevent postpartum depression. We know that women that struggle with depression and then go through pregnancy have a. much higher chance of having postpartum depression. I like to get ahead of those things and make sure patients stay well. And we also know that depression, anxiety, stress in general is not healthy for the baby. Healthier to treat the depression, treat the anxiety. Uh, keep mom, um, functional and well during pregnancy and after pregnancy. I feel like the magnitude of what you just said cannot be underestimated. I mean, that is really amazing to have a treatment that someone can have during the pregnancy and have no worries. I mean, we don't have. that. I mean we don't, you for such a common issue t dealing with. I mean that to be able to do. I don't have heard of T. M. S. Hon like it should be first l Yeah. Because even the ones that we consider to be very safe can still have risk for side effects. It's just kind of your way in the risk benefit ratio. Have you ever seen anything go wrong with it? I know you said there's some patients who shouldn't do it. But let's say they were a perfect candidate. Does it always go great? Yeah. As far as, um, effectiveness, very effective. We actually see a 63 to 70 percent remission rate from TMS. So patients that complete, um, The 36 sessions we're getting between 63 to 73 percent remission, meaning almost no depression at all. And we measure that, we do, we do a questionnaire of something called a PHQ 9, and less than five on the PHQ 9 is what we're seeing in 63 to 73 percent of our patients. 80 percent of our patients have at least a 50 percent improvement. So even the patients are not fully reaching the remission, the vast majority are, are going well, um, are having significant benefit. The same can't be said about medications, medications. Once you fail, once you're on like the fourth medication trial. The remission rate, the chance of depression going away with that med is less than 7%. And with each medication trial, the risk of the side effects increase. We just don't see, we don't see the level of side effects and we have this amazing remission rate with TMS. As far as things that may not go perfectly, Some side effects to look out for with TMS could be headaches and scalp irritation. Those are the two most common ones. Most, most of the time we don't even see those less than 1 percent of the patients actually choose to stop TMS due to a side effect, which is, which is very low and you know, not, you know, medications, people discontinue all the time because of side effects. Yeah. That is amazing. Cause you know, I think what I really just recognize in a lot of my patients is the suffering they're having. And sometimes they may not even recognize it. themselves. But, you know, you see them on this daily basis and you can just look at them and you can see, gosh, they don't feel good on the inside. And to just have a chance at being able to feel better, I think just sounds amazing. Yeah, definitely. I would say a very common theme for our patients is they come see us and they say, I've been on this SSRI, you know, Zoloft, Sertraline, something for a while. And they're like, Now that I want to get pregnant, I've stopped taking my medication, you know, or I'm planning to stop taking my medication when I get pregnant. And I think that they feel a certain like guilt and worry right about harming their baby and they want to come off of it. And I think for them to have another option where they don't have to feel even more guilt is really powerful. I think that's very interesting. Yes. Um, okay. Can you explain to me the difference between ECT and TMS. So I have learned, I think a long time ago about ECT. So at first when I was hearing about TMS, I thought this was the same thing, but it sounds like these are two different things. So can you explain that? Yeah, absolutely. That's a great question. So ECT is completely different from TMS. ECT stands for electroconvulsive. therapy. E. C. T. Is done under anesthesia. It is much more involved. So patients have to need a ride to get to the treatment facility because of the anesthesia. They get put to sleep and the electrode is placed on the head here. And what that does is it induces a seizure. The seizure is a generalized seizure. So what they have to do is give you muscle relaxers to relax the other muscles in your body. So it doesn't harm, you don't harm yourself with that. That seizure is thought to reset neurotransmitters in the brain. Um, and there's some of the side effects and concerns with ECT are that it can cause, they do does cause in the short term to memory, um, and cognition issues. Also because of the anesthesia, you can't, you know, work that day. You need transportation to go back home. Um, so it's a little bit more involved, um, is effective treatment for depression does work very well. Um, but just does come with some added risks of the anesthesia, the memory inducing that seizure. Um, the TMS, we're able to drive ourselves to and from the appointments ourselves. We don't need transportation. You're functional right after TMS. So that's why I was saying that people come during their lunch. You can still work that day. It's not a lost day. It's not lost time. Um, and then the, the safety aspect of it, we're not inducing that seizure. We're not, we're not causing anything like that, not affecting muscles, not affecting cognition. It's actually really interesting. They're actually doing studies now to see if TMS can be used in like post stroke patients to enhance cognition. And, uh, so if anything, TMS has been shown to be more cognitively enhancing than anything else. We're not worried about memory cognition loss with, with TMS. Interesting. And then let me ask you if you have any tips. So let's say we've got somebody listening right now, or maybe they live far away, so they can't come see you or maybe they're just not ready. Do you have any tips for them just at home if they're going through this fertility process. And, you know, I will say between depression, anxiety, I probably see way more anxiety. So, and I think it's so hard because they do sometimes look to me because they say, well, I'm afraid my treatment may not work. And the hard part is I don't know if it's going to work either. So in this case of the unknown, I mean, do you have any tips for us on how to cope with those feelings? Sure. I think that, um, anything time we're struggling with mental health concerns. I think having like a schedule at home and having routine is like, is the key. So, so two things I like to tell patients at home, I think schedule and then, um, and then having that routine. So I want people to kind of wake up at the same time every morning, shower at the same time, every morning, eat at the same time, go to the gym, exercise. People underestimate how, like cardiovascular exercise. And just exercise in general is natural anti anxiety. Anxiety tends to be fight or flight response. So if we can kind of, uh, expenditure energy with, with exercise, with running, we kind of help, help decrease some of that, um, that anxiety and then getting a good night's sleep. Sleep is the foundation of mental health. So prioritizing that exercise, that routine throughout the day, and then your sleep hygiene. So, you know, trying to avoid electronics at night. I think sometimes people get caught up in, um, the world is just so fast paced these days. You're getting notifications on your phone with your personal life, your work life, um, and you're just getting bombarded by all these, these intrusive notifications and then it causes all this, this anxiety that's pretty unnecessary. So kind of winding things down in the evening, again, part of that routine. Um, you know, silencing those notifications, limiting the screen time in the evening goes a long way. Amazing. Yeah. I have to say, I feel like tick tock. I love tick tock, but it keeps me up at night because I should be sleeping and instead of tick tock, but also I do think it contributes to a lot of anxiety for fertility patients. Cause although I think it can be a source of good education, a lot of times when people are trying to get views, they'll say something, you know, like Oh, did your doctor miss this? You know, Oh my gosh. Did, did Dr. Reed check that on me? And was I supposed to have it checked? And like, you know, and then they're calling the next day, you know? Um, so I think that's a good tip. Maybe to, you know, cut down on the electronics a little bit, especially when it's time to go to bed. Sure. Yeah, absolutely. Okay, so you mentioned something about the routine, and I think I remember you explaining to me also for TMS, um, maybe some of the benefits with having all the sessions is that the patients are actually forced to get into a routine of like getting out of the house, right? So do you think that is part of maybe the benefits? I do think and then like, you know, there are Coming and seeing the same treatment coordinator every day, and they're having that schedule, and I do think that definitely plays a role into it. They've also done studies that pair TMS with ongoing therapy or even trying to do therapy at every TMS appointment, and those patients tend to do better. So we know that, you know, it's not just one thing that's helping. We're strengthening that network in the brain that's responsible for that emotional regulation. But during the TMS treatment, it's important that we learn the coping skills, we use our therapy skills, and we engage those other things. Let's say somebody did their 36 treatments and they're great, but then how long is that going to last? That's an excellent question. That is a million dollar question. They've been trying to figure out what is a sweet spot for like retreatments or on things like that. And the evidence is kind of all over the place. I'll say that, um, in, in my practice, what I've noticed is most patients stay well for about a year. Some patients a little bit less, let's say nine months to a year. Okay. And then some patients are gone on two years, two and a half years, even three years. And they're, they're well, they're still in remission with that one TMS treatment. So there's absolutely no way for me to know which, which bucket those patients are going to fall into. But the good news is that if the TMS worked really well the first time, it continues to work just as well if we redid the 36 treatments. And insurance does cover re treatments if the depression does come back. Interesting. Okay, so I have a harder question. And you can say I don't know. It's too good at answering these questions. We have a staff here. I mean, I say I don't know to my patients all the time. Um, but, um. Like, is there any thought about the actual mechanism? Like you explained neurotransmitters. Is something similar happening with TMS when they're strengthening this? Or is it, what's really happening? We're not creating more neurotransmitters. I think we're, what's thought to be happening is the neurotransmitters are working more effectively. So we're, we are, um, we, people, people kind of explain TMS by it's like, Oh, there's a depression network. And I may have even misspoke earlier and used the word depression network. It's really not. what we're trying to do. It's not like, Oh, you have depression. We're going to stimulate this. Your depression is going to go away. When we strengthen that area, it's helping with like resiliency. So what was thought to happen is it's thought to help improve resiliency when negative things happen to people. So, you know, life's stressful. You can put two people in a stressful situation. Two people can be going through, say, fertility treatment, and they both, for some people, it can kind of beats them down and causes them a lot of anxiety, a lot of depression. You have this other patient that's going through the same stressors, but they're just more resilient to that. And so what's thought to happen is we're improving resiliency with the TMS. So it's not really targeting depression the same way as a medications or increasing the neurotransmitters. We're creating. What was thought to just be more resilience in that area. Okay, and tell our listeners what a neurotransmitter is. I realize we're using a really big word that probably people have never heard of. So, um, how do I describe neurotransmitters in, in, uh, so, They give signals, right? Sure. So the brain communicates with each other through different points. And to communicate with each other, they use these, these networks. And they send. Um, signals, like Dr. Eber was saying, through the neurotransmitter, through this pathway, and then that signal has to reach a receptor to do a certain job. So what we notice is that if we strengthen the connections between these points in the brain, it helps us communicate better. So when we're exposed to an environmental stressor or some sort of rhythm, Some sort of a cue in the environment we need to respond or act or react in a certain way. So sometimes those reactions are anxiety, worry, or they're maladaptive. They're not good to kind of what we need it to do. So we're just kind of trying to create more resiliency within those pathways. And to me it almost kind of reminds of like breaking a pattern too because I've always heard the brain loves to keep doing the same thing. So maybe the more anxious you are, the more anxious you're going to be until you break that pattern. So it sounds like this could be such a great way to break that. But, um, okay. And then a personal question you don't have to answer if you want, we can edit it out too. But have you ever tried? Like, I think if I were there, that's a really good question. I haven't done it personally, but I will say that quite a lot of people in my company at work. They're doing TMS. And it's really interesting. So we had someone come and speak to us during lunch one day that, um, he's this, you know, world's renowned TMS research guy. He's like, you know, I visit TMS clinics around, around the country, around the world. And this is the only medical specialty where you see like, you know, half or 90 percent of the office is doing TM, doing the treatment. He's like, you know, you go to like a ketamine clinic, you go to other places. You don't see the whole staff doing the treatment. You go to a TMS clinic and you're like, Whoa, 80 percent of the 80 percent of the people working here are doing TMS. Their whole family is doing TMS. Their cousins are doing TMS. And they were, he was like, you know, it's just really cool to see that it's like, you know, everyone in the company believes in this and we feel like it's safe enough to do our own, treat our own family. And he's like, we should treat our patients like we treat our family. And it got me thinking, you know, if it was my family member. I want them to do TMS, not medications. That's such an important point. This is what I say about the eye doctors. Why do they all wear glasses? It freaks me out! You're not wearing contacts. Something must be wrong. I mean, it's true. I've asked um, eye doctor friends about getting leaf sick. They don't get it! I know! So we are just so happy that you came to talk with us. I just feel like I learned so much. Awesome. I think you probably have helped a lot of people out there too. Awesome. Um, so tell us, just remind us again how patients can find you. Yeah. So once again, I'm Dr. Manwala. I work at Salience Health. It's off of communications here in the Legacy West area of Plano. Saliencehealth. com is the best way. There's like a contact us button on the website. There's a phone number and we'd be happy to Customize a treatment plan get you feeling better and there are lots of different options You know, it's like I said mental health treatment is not one size fits all. Some people fall into the therapy bucket. Some people fall in trying a medication out first. Some people, you know, qualify for TMS. That's the next best step. It's just everyone is different. The first step is to talk about it, talk about the goals and figure out what we need to do next. Dr. Mignola, are you on the gram? Okay. So do you wanna share your Instagram or is it's not personal? I don't, I don't have, don't have a professional, you gotta get a professional. I don't have a pro professional, do not have TikTok. Right. Um, which, okay. So on Instagram, I'm Dr. So you could be Dr. Happy Brain, we gotta help you start with, I do know, I think Salience Health does have a TikTok or Instagram or something like that. Okay. But, so you can, you could follow us on there. Yeah. Okay, good. All right. Well, we'll wrap it up for the week. Um, if you guys get a chance, we would love if you could leave us a review either on our peak fertility website, um, or on our podcast website or on YouTube. Um, any way you can help us out would be greatly appreciated and we will see you all next week. Have a good week. Bye. Bye.