S1E15: Trans-cending Treatment-Resistant Depression with TMS (ft. Dr. Ted Williams, MD)

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Transcript S1E15

Hi! Welcome to It’s Like This podcast, your common sense, mental and spiritual talk show. My name is Dr. Uejin Kim, a dual board-certified psychiatrist from Texas. In this podcast I explain mental and spiritual concepts with fun analogies, real stories, and positive message. So you cannot just survive but thrive. My goal for you is to gain understanding, acceptance, and healing so that you can know your worth and live the life that you are meant to live. If you want that as much as I do, hit that subscribe button, and let's listen to today's episode.

In this episode, I'm working with Dr. Ted Williams. I met Dr. Williams during my training. And he became my mentor in psychiatry in so many ways, in private practice and incorporating faith with work. As I am “growing up as a baby attending psychiatrist.” He was amazing at being vulnerable and encouraging. At the same time, Dr. Ted Williams is the founder and board-certified child, adolescent and adult psychiatrist of Genesis Behavioral Health in San Antonio, Texas. He's an adjunct faculty at Department of Psychiatry and Law School of Medicine, UT Health Science Center Antonio and also at the University of Incarnate Word School of Osteopathic Medicine. In his previous career, he was board certified in family medicine, and practiced family and emergency medicine before later specializing in psychiatry. Guys! Just know that residency is horrible and it sucks. So the fact that this man went back to residency is an amazing commitment. He's an educator, proponent, and expert in TMS: a trans magnetic stimulation, a new technology used to promote the healing of the brain circuits involved in depression and other mental illnesses. In this episode, I'll be asking all the questions you wanted to ask about TMS. Does it hurt? How much does it cost? What are the side effects? And is it for me? I learned so much in this episode, and I'm excited that you will too. So let's get started. 

Dr. Uejin Kim: All right! Well, welcome to It’s like This podcast. I'm Dr. Uejin Kim, and we have a special guest today. And he is my first psychiatrist who is here as a guest. And a little bit about Dr. Ted Williams. I met him when I was training at UT Health San Antonio. And, you know, we maintain this kind of friendship and mentor-mentee relationship for a few years. So I'm so excited and honored to have Dr. Ted Williams. Welcome!

Dr. Ted Williams: Thank you, Dr. Kim. It's an honor. And it's really wonderful to see your professional career grow and blossom and, doing this podcast. The putting out great information and I am honored to be your guest.

Dr. Uejin Kim:    Thank you so much. And, you know, the reason why I reached out to Dr. Ted Williams is, he's kind of like a local expert in this therapeutic device called TMS. Can you just explain to us what TMS is?

Dr. Williams:      Yeah, TMS stands for transcranial magnetic stimulation. And so if you break the word down; transcranial, it’s magnetic stimulation, as opposed to electrical stimulation or some other kind. And transcranial means through the skull. So a magnetic coil is put outside the coil and the magnetic energy just flows right through skin and skull, as if it's not even there. Reaching the brain on the other side. And it's been shown that multiple pulses, like, 3-4000 pulses in a single treatment activates the network in the brain.

Dr. Uejin Kim:    So that's a lot of words. But just for our listeners. So, psychiatry treatments are evolving. You know, I think a few decades ago, only treatment options that we had was like AECT on which we'll have another episode and medications. But now there are so many exciting treatment options. And TMS is usually for treatment resistant depression. That's kind of how it started, but, you know, it’s evolving. So, I'm gonna ask Dr. Williams, you know, what is it? How can we use it? Who is it for? And all that information. So, Dr. Williams, let me get to know a little bit about you. You're a psychiatrist, but I know that it wasn't your first career path. So can you tell me like, how did psychiatry kind of fall into your life?

Dr. Williams:      Yes, actually I wanted to be a doctor since I was a kid. My father was a family physician. And that's all I ever wanted to be. I went to medical school with full intention of becoming a family doctor, which is exactly what I did. I did a family practice residency in my hometown, and opened up a family practice and emergency medicine practice, right there in Corpus Christi, Texas. And I did that for all total, with training and practice about 10 years. And then tragedy struck, my father died. And there were other things going on in my life that really caused me to pause and reflect what did I love the most about medicine? I love all of medicine. But what do I love the most? And what I love the most, is helping people who are hurting. And it's kind of funny, you know. Psychiatric issues, some doctors will turn and run away from it. I turn and run toward. I don't know why. It just is. So yes. I went back, I moved from Corpus Christi to Houston, and spent the next four and a half years getting doing my psychiatry residency and child adolescent fellowship. And with absolutely no regrets. I love psychiatry, and love what I do.

Dr. Uejin Kim:    Yeah. And that is very similar to mine. Like when I was attracted to psych patients, you know, that's when I knew that it was a calling, because not a lot of people can handle or understand psych patients. I was just like, ‘This must be a calling.’

Dr. Williams:      Yes.

Dr. Uejin Kim:    So do you think you know, with the background of family medicine and some emergency medicine, you know, from your practice, do you think that kind of makes you have different approach to psychiatry?

Dr. Williams:      It probably does. For one thing, medical issues don't scare me. I'm familiar with them. I sometimes might be listening differently to the patient's history and symptoms. I'll never forget, a woman who came for a consultation about getting TMS. And in during the consultation, she talked about some symptoms that in my mind did not add up as pure psychiatric symptoms. And I began to wonder about a brain tumor. And, lo and behold, that's exactly what she had. And so that's, I mean, sort of thing is really rare. But psychiatrists are first and foremost physicians. And I just had a little extra time doing general medical practice and getting that experience. And yeah, I think it did. The other thing I think it did is I think it made me more open to the idea of doing TMS. 

Dr. Uejin Kim:    Yeah.

Dr. Williams:      Because in psychiatry, we're generally trained to prescribe medications, have relationships with patients through psychotherapy. And so the idea of doing an intervention to someone can be a little daunting, a little scary. But if you're trying to do a spinal tap that's a lot scarier. 

Dr. Uejin Kim:    Yeah. I remember.

Dr. Williams:      Than putting a harmless magnetic coil on a person's head and treating with TMS. So I think probably it has made me more interventional and my thinking. And lastly, probably it has made me more holistic in my thinking. Because the science has just been pouring in over the last 15 years about the role of nutrition, inflammation, sleep, exercise, social connectedness, mindfulness and prayer. All these things have a really important impact on mental health. had the healing of mental health conditions.

Dr. Uejin Kim:    Yeah. And TMS is relatively new, because I just graduated a few years ago. And I don't think we had a like official rotation and TMS, you know, even a few years ago. So it's been here for quite a while, right? You said that it was like around 2012? 

Dr. Williams:      2012. Actually, TMS was FDA approved in 2008. But, it's not new anymore. Yeah, it didn't get to San Antonio until 2012, when I got a TMS machine and another clinic did and we collaborated some in those early years. But the problem with TMS is really still very few people even know about it. And physicians and psychiatrists know about it, but they are not familiar enough with it, to know when to recommend it. And so I think still, there's this tendency, that, for instance, with depression, you know, once a medication is failed, to try real hard. The psychiatrists to try hard to think about what next medication is most likely to be effective. But then, after a while, there's this law of diminishing returns. Where trying more and more medications is just simply not going to be effective, or the chances of it being effective are much reduced.

Dr. Uejin Kim:    So let's talk about that. Because most of our listeners, I think, tune in because I tried to explain mental health in a very easy to understand language. So some people might be like, not even aware that they have mental health issues or concerns, and they listen to this. And they're like, ‘oh, maybe I do.’ So some come from medication, very naive, you know, or even mental health concept naive. And some people maybe had multiple medication trial, like you're saying. So, we have like a pretty diverse, you know, awareness. And you just mentioned, first try the medications few times, you know, get help if you think you need help with medications. But for those who are discouraged, you know, by multiple trials on medication, you're saying that somewhere in between that TMS can be a solution.

Dr. Williams:      Absolutely can. Now, insurances will. So by the way, all major insurances cover, TMS, which most people don't even know that. So yeah, so cost is not the barrier that it was six or seven years ago. And insurances will cover it. Most insurances will cover it when patients have tried at least two medications. And they may have worked, but they didn't work well enough to completely relieve depression. Two medications and at least some sessions of talk therapy, psychotherapy, counseling. After failing two medications, the chances of the third medication, completely resolving depression is only about 15%. The fourth medication, it's only a 7% cent chance that medication is going to completely resolve depression. So that's why I say there's sort of a law of diminishing returns. And I've had patients, you know, that had tried 15 different medications, all in hopes of finding that silver bullet, you know, that will completely relieve the depression. But I think what we know now is that for some people, the networks of their brain are not working sufficiently well for medication, even to work.

Dr. Uejin Kim:    So two things. What do you mean by failed trial? Because some people will take a week and they're like, ‘Ah, I have loose stool. I don't want to take it right.’ Like, oh, they only tried it for a week. So can you explain to me what failed trial of one medication is?

Dr. Williams:      Yes, so a failed trial means one of two things. Either the medication didn't work well enough, or it caused side effects that the patient can't or doesn't want to live with. So a failure can be due to medication not working, but it could be due to side effects and medications frequently cause side effects. I mean, I think the most common side effects that are big turnoff are weight gain, sexual side effects, feeling emotionally numb from the medicine. People will say, ‘Oh, doctor, yeah, I feel less depressed. But sometimes I wonder if I feel anything, I was at a I was at a funeral the other day. And I couldn't even cry.’ So a side effect that's not tolerable is considered a failure. 

Dr. Uejin Kim:    And is there like a time duration?

Dr. Williams:      Two. A minimum of two weeks. In the first two weeks on antidepressant medication, majority of time will declare itself as to whether or not it's going to work. There are a few, there are some instances in which the onset of effectiveness of the medication is later, four weeks, six weeks, eight weeks. But by eight weeks, by a two month trial of medication, if the patient is not what we call in remission, we borrow that term from cancer. So if in cancer, if it's in remission, the patient may might have microscopic cancer, but cancer is not detectable in that patient. So with depression, remission is that, well, there may be, you know, a few little symptoms of depression with that. But really, depression is not detectable compared to a non-depressed person on a rating scale. So I would say, two months of medication, not completely resolving the depression is a failure of that medication.

Dr. Uejin Kim:    Right, right. And there's so just for the listeners, like, just one week of trial, and, you know, mild side effect, ‘I don't want to take it,’ that would not be a full course that Dr. Williams is talking about, is despite your effort to try it. It's not working, you know, for X amount of time, or severe symptom that are hindering you from continuing to take the medication that will be considered failure. So just to kind of recap, because we had this talk, you know, most, not most, but a good chunk of people might respond to first trial of medication. But then there's a portion of people who don't, and then they try the second medication, and there's some portion of people who get better, but there's big chunk that don't. So now we're talking about, let's say, third group of patients, you know, after they failed two trials, there, possibly a, I guess, target population for TMS, is that, right?

Dr. Williams       Yes. Failure of two medications, or maybe a third, and having therapy, and we could come back to why therapy is so important. But if those trials of medication either haven't been effective or have cause side effects, rather than trying more and more medications, TMS is statistically a lot. There's a lot higher chance of the depression resolving with TMS than with trying another medication. And the sad truth is that after trying to medications, about half the patients still, their depression is not resolved. It not even after trying, you know, three, four, five, six medications, there's still 1/3 of patients that do not reach remission, on medication. Yeah, that's a lot of patients.

Dr. Uejin Kim:    Yeah. And, you know, you mentioned brain network, I want to talk about, you know. I’m not like science-y, as much as you, you know, in regards to brain, and you mentioned network, and I'm thinking that that could be the explanation of why multiple trials and medication might not work for these people and why TMS might be a solution for them. So can you explain to us like the network deficiencies that you kind of talked about, you know, touch on that and why TMS could be a solution for that.

Dr. Williams:      Sure. So, you know, over my career, the brain is gone from being sort of a black box. And we had no idea what was going on inside to now. There's an understanding that the brain operates as a series of networks, anywhere from 7 networks to 17, depending on how you count. And what is a network, a network is as multiple areas of the brain, each with a specific task connected to one another, in order to carry out a brain function. So, it's multiple areas connected together, to carry out the brain's functions. That's a network. And, the in the brain is highly electrical. People don't really realize that it's bio electrical. There's some chemicals that help create the electric charge. But, the brain could communicate with itself through the little wires of the brain that operate in a network. I still remember in the 1990s, when functional MRIs came out. So a functional MRI is not just the brain structure. It has the ability to show how the different parts of the brain are connected to each other working together. And so they brought us into an auditorium, sat us down through a summation of seven patients who had been instructed to think sad thoughts. And they had their MRI scan while they were thinking sad thoughts. And in all the patients, the same area lit up. And I just thought, ‘Oh, my goodness.’ So, we've always known that the brain is the organ of the mind, but not how, you know. So we're finally beginning to barely get a peek as to how the brain is the organ of the mind.

Dr. Uejin Kim:    Yeah. And it's always changing. I love the unknown territory of psychiatry research, because sometimes we have these, you know, conceptual, very simplistic answers, like serotonin deficiency. Like we talked about, you know, before, and then it's like, gets debunked. So, you know, I know that we're just scratching the surface, and also, I think, before, they were like, ‘Oh, this area is in motion,’ you know. And like, but it's not as simple. You're saying, like, these are just groups, like, one factory can be part of multiple networks. And we won't get too nerdy and explain all the networks. But basically, there's a function of networks. And, you know, for the people who try multiple medications, and let's say we're talking about specific to depression. And they're not really getting better, which network is kind of needing that kind of stimulation?

Dr. Williams:      Well, the primary network that we're targeting with TMS is called the cognitive control network, or salience network, is sort of the official name. And this has to do with the ability to switch thoughts and in particular, not think about things that either are unhelpful or harmful. And we do it unconsciously. Negative thought comes in and a non-depressed person will just or something they can't do anything about a non-depressed person will just push it out of their minds. Not someone with depression. Someone with depression will think literally hundreds of negative thoughts in a single day. So decreasing the impact of those negative thoughts to be able to switch them off, blow off things that need to be blown off. It rather is than always seeing the glass is half empty, seeing everything is black or white. Seeing the things that all or nothing. Something positive happens, discounting it as not being relevant. Something negative happens, totally focusing on it as if it's everything.

Dr. Uejin Kim:    Right. Yeah. So this salience network. So something, if a person has a significant depression, their salience network is dysfunctional to the point that medication and therapy cannot improve. So how does, you mentioned trans magnetic stimulation, and you also mentioned that brain is like electrical, chemical, biochemical, you know, network. So how does that kind of come together? Like how does TMS machine like stimulate the salience network?

Dr. Williams:      Yes. It is fascinating, you know, from a scientific perspective. That is a law of physics. energy forms, can energy can take various forms. Magnetic energy, is easily translatable into electrical energy, and vice versa. So think about the hydroelectric dams in Tennessee. Really, these are giant magnetic rotors, that the water flows through and turns. And that's what creates electricity and powers the Tennessee Valley. So, that's going from magnetic to electricity. So in the case of TMS, the magnetic coil is put on the scalp, a pulse is given. The brain is just sitting waiting on the other side. It receives that magnetic energy and converts it into a tiny little current of electrical energy. So the brain cells themselves convert the magnetic energy into electrical energy at just the right power.

Dr. Uejin Kim:    So when it converted to electrical energy, does it grow or shrink or how does that change the brain?

Dr. Williams:      It excites an area of the brain a little over an inch in diameter, a little over an inch or inch and a half deep. It excites those nerve cells right under the magnetic coil. Those nerve cells and every other area of the brain that's connected to that area in a network all get charged up. And so you could think of TMS as taking a brain network to physical therapy. It gets its workout. And what does this workout do? Well, if the network has gone weak, it likely means that there are not enough connections in that network. And so stimulating the network grows connections. I don't think it's been proven yet. But there's scientific evidence to infer that literally certain areas of the brain would grow after seven weeks, a seven-week course of TMS. And why because the infrastructure of the brain itself is being rebuilt.

Dr. Uejin Kim:    So just to kind of recap, TMS is a magnetic stimulation brain converted to electrical energy, and certain targeted spots of a network will be targeted and stimulated. And eventually it will kind of grow and become more functional over time. Is that a good, accurate description?

Dr. Williams:      That's a great description of it. Perfect.

Dr. Uejin Kim:    But you know, I'm just kind of being a devil's advocate or, you know, a participant in the audience and be like, ‘well, then it just kind of sounds like, I don't need to take medications every day. That's a hassle. I don't want to do therapy, you know, that's too vulnerable. Now, I just want to zap my brain, you know, so that I won't be depressed.’ And to kind of argue against that you do something amazing in your clinic, you know, that is not just TMS and you want to bring the power of therapy. So can you explain to me like how that protocol has initiated in your clinic?

Dr. Williams:      Yes. So, we've been doing a TMS since 2012. And we know from many, many research studies done over decades, from various centers around the world, we know approximately how effective TMS is. A third of patients receiving TMS will reach remission, under the controlled conditions of science experiment. In real life or in practice, actually, the odds are usually better than that. I would say for many clinics, the remission rate is maybe in the in the 40s; 45-40%. Well, pretty early on it became clear to the scientists around the world that combining psychotherapy with TMS was going to produce a better outcome than just simply receiving TMS alone, like something being done to you. And that's it, it is not as effective as both receiving the treatment and being engaged in a therapeutic setting. So we really took this to heart. Everybody thinks it's a great idea to combine therapy with TMS, but it's not so easy to pull off. So we built a team of therapists so that instead of a medical technician being the one that you know, after I decide the treatment location on that first visit, how everything is supposed to be set up after that I'm not in the room. During the treatment, a technician is of some kind, someone who puts the coil in the right place and presses the right buttons and so forth. And that function is often served by a trained medical assistant. Well, we decided to make the treaters, people who are licensed therapists or therapy students, so that the patient is receiving therapy while they're getting TMS, which results in quite a bit of therapy because a course of TMS is about 30 or 45 minutes a day, five days a week for seven weeks. We haven't sort of as captive audience all the time. What about having a therapist there in the room, or as a part of their team with one with one goal in mind. And that is helping them get out of depression. Here's the thing about treatment resistant depression. If a patient has been depressed long enough to be getting TMS, for them, depression is not just the way they feel, it's become a way of life. They have let activities go. They've let relationships go. And why? Because, frankly, there’s just not the energy, hopes and dreams completely put on hold. So recovering from an extended period of depression is not just a matter of feeling better. Yes, feeling better is required. But it’s also a matter of re engaging with life to be the person that you would be if you weren’t depressed. And so we think, ‘well, who better than my therapist to link arms with you and help pull you out of this quicksand that you've been in? Who better than a therapist.’ And so we have a team of therapists. And generally the patient will have two or three therapists that they get to know on different days during those 36 treatments. And so, we had one of our one of our patients refer to them as is, you know that, you know, they're my homies. Or they're my team. These are the people who are helping me envision a different future. The walls have gradually closed in on me during depression. And I need to break through those walls in order to become me again. That's the role of a therapist. And that's why it's been so powerful. And since we have done, begin using a therapy team, with our team as patients, our results have gone through the roof. I want to tell a quick little scientific story that's illustrative of this. There was an experiment, you know, back in the 1970s. A fish, a walleye pike. And this northern fish aggressive anglers love to catch these fish because they fight so hard. Well, they put in a large aquarium, a walleye Pike, and some minnows. And in short order, the minnows were gone. They were food for the Walleye pike. Then they slipped a thick pane of glass in the middle of the aquarium, and the pike was on one side and the minnows were on the other. So the pike you know, then, you know, darts for the minnows, runs right into the pane of glass. Thinks whatever a Walleye Pike thinks when they're like, Wow. And then and then the second time, go again, but not with quite the same vigor than they would the first time. And then the 3-4th is less and less. And after a while the Walleye Pike gives up. We call this learned helplessness. Learned helplessness. Why? Because when you then pull the pane of glass out, the minnows will be swimming around the Walleye Pike. The Walleye Pike won't go after them. It has learned those minnows are off, they're out of my reach. I don't know why they're out of my reach. They're out of my reach. Learned helplessness. There's an extremely strong correlation with human beings and depression, and learned helplessness. Because if you banged your head up against the wall 100 times trying to beat back depression, but nothing is working, then there's a sort of a settling into a new normal, that excludes the person you really would be if you weren't depressed.

Dr. Uejin Kim:    I definitely heard that from my patient, because she was on partial remission from depression. And she asked me, ‘should I just accept this rest of my life?’ And she wanted me to say yes, because then now she can move on. Like, okay, you're telling me I can expect this rest of my life? So it was even almost painful to hope?

Dr. Williams:      Yes. It is. So

Dr Uejin Kim:     It is so sad.

Dr. Williams:      Oh, it is? Yes. And so being able to envision a future without depression, is really helpful. That's hope in action. It’s envisioning what life would be like without depression and beginning to act on that itself has a healing effect.

Dr. Uejin Kim:    Yeah. And it's almost like, you know, if you fail multiple trials or medications, you know, multiple trials of therapy, there's even an instead of opposite of placebo, there's no SIBO effect where you're like, well, let's see if this one works, you know. And there's that hopeless indifference, you know, to the treatment. And I liked that you're incorporating not only innovative treatment, interventional treatment, but also team that gives you so social support, and a community it feels like to really help the patient to have like a completely different approach.

Dr. Williams:      Yes, right. And we also, there is a weekly support group of all the patients who are currently receiving TMS. It's an education and support group of each week, we tackle a different topic of things that we believe are helpful in fighting depression. And so they  get sort of a sense of community with the therapist team. They get a sense of community with some of the other patients. And so yeah, I think and they drive hope from that. And because they are feeling better with the depression treatment, then they're actually able to act on it. And then engaging in life positively brings more positive engagement, which brings more positive engagement. And so things are things are finally headed in the right direction.

Dr. uejin Kim:     Yeah. And, you know, you mentioned like, when you're getting TMS and you get a therapist kind of talking to you and talking with a therapist. I'm imagining, I never got TMS myself. So I don't know. But does it hurt? Is there a pain that will distract from talking? Or how painful is that or not painful at all?

Dr. Williams:      It's not painful, we are not allowed to use that word in our clinic. It's not, it's not painful, and we have a lot of control over how it feels. Given the power level that's being used it most patients describe it as annoying. So it is annoying. We finally call it the electronic woodpecker. It feels like something's tapping you on the head. And, so it is annoying, but it's pretty easy to ignore. And, talk with the therapist during the treatment. Some people have gotten so used to it that a few patients want to sleep during the treatment, which we do not allow because the brain state changes when one is asleep. So, it TMS is tolerable enough to interact with the therapist.

Dr. Uejin Kim:    Yeah, or sleep or possibly sleep. So you mentioned it's not that painful, or it's not that terrible. Yeah, I cannot use the word painful. It’s every day for 30 to 45 minutes for about seven weeks. So that's kind of like one course.

Dr. Williams:      Five days a week. 

Dr. Uejin Kim:    Okay. And you mentioned that now you're incorporating psychiatry, you know, or sorry, psychotherapy. But can people be on medications when they're doing TMS too or is it like, one thing only?

Dr. Williams:      Great question. So most of our patients stay on their antidepressant medications. If they're on a medication that either has a lot of side effects, or maybe is not one of the safer medications. We encourage considering discontinuing those, but being on some sort of anti-depressant medication, it is more common than not being on one. There are a few people who, they're just done with medication. They have given many tries, had many side effects, and they are not on an on medication. TMS works for them as well.

Dr. Uejin Kim:    So just to kind of recap, TMS, it seems like you know, because we have a wide array of people who are medication naive and who has failed multiple medications. TMS is such a great tool, you know, because I think some people come with me, and they're medication naive, and they're like, ‘Oh, what if this medication doesn't work? But what if another one doesn't work?’ And I always remind them, I have other medication options, but it seems like TMS is a great tool in the toolbox. Even if medications fails. It's a very effective tool to treat, you know, treatment or medication resistant depression.

Dr. Williams:      It really is. So this year, we've had our best year ever in terms of treatment outcomes. So, this year, the first six months of this year, our remission rate was a whopping 64%. 

Dr. Uejin Kim:    Wow.

Dr. Williams:      So if you if you compare that fourth medication trial remission rate of 7% versus 33%, or 50%, or 64%. The odds of TMS working are so much higher than more and more medications, but it's time to switch gears.

Dr. uejin Kim:     Right. And just to put into perspective of percentages. What Dr. Williams is saying is in remission is like if you're in a fourth trial of medication, maybe one out of 10 people might feel better and the nine won't. But you're saying with TMS, six out of 10 people will feel better, and four won't. So that's why 1 to 10 for 6 to 10 ratio and that's huge. Yeah, that's five more people having hope in their life with five less people having hope in their life. That’s amazing. Now, I'm sure everybody like I am is very excited about this new tool, you know, and depending on clinic setting, you know, maybe I'll incorporate TMS into my own practice. But now before everybody signs up for TMS, is there any contraindication like reasons why you cannot get TMS?

Dr. Williams:      Yes. The primary reason for not being able to get TMS is having metal inside the head. How could that happen? Well, it hardly ever does happen. But it's possible that someone could have some magnetic type of metal from some sort of injury or whatever. Nowadays, even neurosurgery clips from neurosurgery are they're usually made of titanium, which is not magnetic. But having something magnetic inside the head. I'm not talking about dental or neck or anything. I'm talking about inside the head. That is, or cochlear implants. They are affected by the magnetic pulses. Those are contrary indications. Having Epilepsy is a relative contraindication in in that insurance companies will not cover TMS if a patient has a seizure disorder.

Dr. uejin Kim:     So can a pregnant patient get TMS?

Dr. Williams:      Absolutely, they can. Now it is not FDA approved. But there have been multiple research studies on pregnant patients. I have treated pregnant patients. And we don't have the level of scientific evidence that the FDA would require in order to give an indication for that. But the physics of it is that the baby is so far away from the coil, that the magnetic energy that they're experiencing is only at the level of the Earth's gravitational pull. The earth's magnetic energy. And plus it’s opposed to a medication and a depressant medication that a pregnant woman would take, then it goes around, goes through her whole body, including the baby, just to try to help the brain. The TMS is only affecting that area of the brain. Or that or that network of the brain. So in theory, maybe someday it will be the treatment of choice for depression, and even postpartum depression.

Dr. Uejin Kim:    And so, traditionally, pregnant women and children and adolescents are the hardest group to study with for medications or treatment because they're so fragile, right? So can children or adolescents get TMS? And can you update us on the research on that?

Dr. Williams:      Yes, so there's not an FDA indication for treating people under age 18. We came really close scientifically. There were a couple of large studies. One large study in particular that I'm thinking of that studied TMS for depression and teenagers down to age 13. And, and as expected, teenagers’ depression improved with TMS. However, this was a controlled study. And some patients got real TMS. Some patients got fake TMS, it was double blind, neither the patient or the researcher knew who was getting what. That's how we do our research studies. The problem was, is it the group that got fake TMS also improved? They improved so much, that statistically, there was not what's it called, a statistical significance that TMS outperformed fake TMS. And, you know, if you stop and think about it, it's not too surprising. This teenager is getting now daily attention. I'm not saying teenage depression is due to not having enough attention. But what I'm saying is that the attention that they receive daily helps their depression. We have plenty of evidence that TMS is safe and teenager. We don't have definitive evidence that it works in teenagers,

Dr. Uejin Kim:    Right? So it's like that research is not proving or disproving that TMS, or I guess I'm doing a double negative, it's not proving that TMS doesn't work. But I think it always is interesting with children, adolescents studies, because it's like, little attention they get, they get so much better. And it's just like, they can always use more love. They can always use more attention. And they're so delicate and sensitive, and it just kind of makes me smile, because, you know, having two little ones, it's just like, they can always use more love. So I think that's a research to prove that. So, you know, Dr. Williams, I am so excited about TMS. You know, like we talked about TMS all the time, every time we talk. And just more and more data is coming out and you're doing, you're using such an innovative and holistic approach, even with very innovative treatment tool. So that's very exciting. Do you have any like, take home message for our listeners, you know, who might be dealing with depression or even treatment resistant depression? Do you have any message for them?

Dr. Williams:      I do. And for psychiatrists, as well. For so many years, it was just me and my prescription pad. Old school. Now it's all electronic. This was me and my prescription pad. If the first medication didn't work, then I would just racking my brain to find out what the next one was that I needed to try. Because the patient was suffering, I would look under every rock if it needed the to help them come out of the depression. What I didn't appreciate is the sort of the law of diminishing returns. And, now we know approximately where to place TMS. And that is, you know, after the second or third, certainly by the fourth, any depressant medication. It's time to try something else. And I think for psychiatrists who know about TMS, but they're not super familiar with it, they're probably going to be racking their brain trying to think of what the next medication should be, rather than stepping back and saying, ‘Ah, we need a new strategy.’ And, actually, I probably get far more referrals from TMS, from the patients themselves who discovered online or heard about it from a friend, or maybe their therapist, then psychiatrists. Now certainly psychiatrists do refer for TMS. I'm not bashing them at all. But I am saying that there needs to be a change of mindset from trying more and more medications to switching strategies earlier in the process. And that's what I would say.

Dr. Uejin Kim:    Yeah, so it's like, medication is not a bad treatment option. It’s not all or nothing. Therapy's not a bad option. But at certain point, we kind of have-to-have a, you know, step out of that and be like, is there something else? And now there's, you know, safety, efficiency, and effectiveness proven with TMS. So let's bring the TMS into the toolbox for all psychiatrists to treat patients who are suffering and patients who need to stop suffering.

Dr. Williams:      Yes, absolutely.

Dr. Uejin Kim:    That's awesome. And, you know, we briefly talked about this, but I love when we went through the Depression talk that when you know, if anybody's listening, if depression kind of became the way of life for you, you know, and you're kind of suffering by yourself, and your hopeless. I think I wanted the listeners to know that there's hope, you know, and there's now going to be more and more tools in the psychiatrists toolbox. You're not alone. And there are great psychiatrists like Dr. Williams, who are, you know, giving 110% to, you know, make these innovative interventions possible. So I really appreciate your time here, Dr. Williams. And if anyone's listening, I know you're located in San Antonio, but how can people find you and get to know you and maybe sign up for TMS or just talk to you about their options?

Dr. Williams:      Well, our website is genesisbehavioralhealth.org. It is probably the best way to get in touch with us. And we have a lot of information about TMS on our website. So that can be helpful. Yeah. Or give us a call.

Dr. Uejin Kim:    Yeah. And I'll definitely put all that in the description box so that you can reach out to Dr. Williams. Dr. Williams, thank you so much for your time. I think every time we talk, I learned something new about TMS. And it's so good to have, you know, a passionate psychiatrists, that was my mentor. But now we're colleagues. I'm very excited about our collaborations.

Dr. Williams:      Thank you, Dr. Kim. Thank you so much for having me.

So in summary, it's like this, I just want you guys to know that there's no point in a sense of defeat when depression or mental illness is taking over your life. I think at each point, there are new, innovative technology treatment options coming up, and don't give up. Please reach out to help. Again, you're not alone. This is not too late. And it is always a good time to ask for help. So I hope that that was encouraging. And I really hope that you guys have a great day, and I'll see you in the next episode.