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Transcranial Magnetic Stimulation (TMS)

In this presentation, you’ll learn how transcranial magnetic stimulation can help treat mental health conditions like PTSD and depression.

Transcranial Magnetic Stimulation (TMS)

Estimated watch time: 36 mins 

Available credits: none

Presentation Materials:

Dr. Charles Weber is currently the medical director and CEO of the Family Care Center, a comprehensive outpatient mental health/addiction treatment in Colorado Springs, now with 4 locations. He is married to Dr. Rae Ann Weber, FP, who is a full-time opioid addiction treatment provider.

He is a prior-enlisted infantryman and graduated from the United States Military Academy (USMA) at West Point in 1995. He attended Touro University College of Osteopathic Medicine and received a Doctor of Osteopathic Medicine in 2002. His transitional internship was at Walter Reed Army Medical Center, and board-certified Psychiatrist. LTC(R) Charles Weber was the Chief of the Department of Behavioral Health at Ft. Carson, CO, and retired in 2016 after 27 years in uniform. He is also Addiction Medicine Board certified.

Dr. Chuck is extremely passionate about Veteran and DoD mental health and this community.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Michael:
Good afternoon. My name is Michael Crisanto. I am a clinical outreach specialist with Advanced Recovery Systems. We operate multiple dual diagnosis treatment facilities throughout the country. We treat substance use disorders and mental health as well as eating disorders, and today, we’re really excited to be able to have Dr. Charles Weber here. Dr. Weber is currently the medical director and CEO of the Family Care Center, a comprehensive outpatient mental health and addiction treatment center in Colorado Springs, now with four locations. He’s married to Dr. Renee Anne Weber, who was a full-time opioid addiction treatment provider.

He’s a prior-enlisted infantryman and graduated from the United States Military Academy at West Point in 1995. He also attended Touro University College of Osteopathic Medicine and received the doctor of osteopathic medicine in 2002. His transitional internship was at Walter Reed Army Medical Center and a board-certified psychiatrist. Lieutenant Colonel Charles Weber was the chief of the department of behavioral health at Fort Carson, Colorado, and retired in 2016 after 27 years in uniform. He also is addiction medicine board-certified. Dr. Chuck is extremely passionate about veterans and the Department of Defense, mental health and this community. So thank you, Dr. Weber, and I’ll turn it over to you.

Dr. Weber:
Thanks. And I didn’t ask in the beginning, but also, my audience is a mix of clinicians, administrative as well, maybe some physicians as well — yes, no?

Yeah. Ask them in the chat. Most of the time, we can get a variety of those, so it’s a combination of all.

No problem, no problem. So, if I’m getting too technical, I’m trying to make it kind of, like, more of my vanilla kind of aspect. So, thank you for that introduction. I really appreciate everybody. My name is Chuck Weber, and as you said, you already gave me a great intro, so we don’t have to go through that. I’m not going to go through all of history; I did start off enlisted infantry, and so I do, like, kind of the history and how the migration — initially, I was a flight surgeon and then found my way to psychiatry because flight surgery is fun, but I don’t really want to do FAA physicals for the rest of my life. Plus, there’s such a huge need in both addiction and mental illness that it’s really kind of driven an aspect of that dynamic approach.

So, depending, a lot of people have different likes and everything; to me, diabetes, attention, low back pain — it was rote to me. But a psychiatrist and a mental illness — so dynamic. There are so many things. And I love that we have to have so many vocations. Social workers, LMFTs, addiction, CACs, psychiatrists, psychologists — I mean, the whole gambit. Social work. And also, just that structure on how we’re going to get somebody to that better place. But these are the things we’re going to cover just in kind of brief on. A little bit about Family Care Center, but really, spending the bulk of the time on TMS — transcranial magnetic stimulation.

This is our mission and vision. I mean, we primarily started this with just my wife and I and a handful of people. My wife’s a veteran too, and then she went to GS, which is government service. Our primary mission was always the Department of Defense family members because it was definitely a hole that we had in the military — a hole that we have in all of the military medicine, truly. You just cannot get the services that they really require. And then, of course, our veterans. You know, the VA gets some great people in it, some great — a lot of resources, a lot of technicality kind of things, but the bureaucracy is very, very hard, especially when you’re dealing with people that have a lot of frustration tolerance, right? So, that has been taxed by PTSD or MDD that’s not been treated. So, that’s what we focused on, really, for the first few years, and then we kind of branched out these next two-and-a-half to other insurances to take care of our whole community. Because this is where we laid down roots. I moved my wife nine times, and our deal was she gets to pick the last spot, so here it is in the Springs.

Kind of mentioned this just a little bit, and also, the better-looking Dr. Weber — that’s her. This was one of our — I had my prescribers and my leaders out. We had a team-building. This is the last time I’m going to go take them on a class 5 rafting trip; I almost lost three of them.
So, that was not good. Note to self, right?

Family Care Center. At Family Care Center, we do have child psychiatry. We have addiction with the FP. I think there’s about — with my nurse practitioners, together, there are about 13 prescribers. At least half of us all have our X designator, so we can take care of the opioids.
You know, I have not even maxed mine out, or my PAs. It’s not really the bulk of our services, but we definitely, definitely want to take care of it. I do have one doctoral level of CRNA that is doing our ketamine infusions. That is actually in a separate business because there’s not insurance with it. And then you can see the whole gambit. I really do believe in that holistic approach, and I think that it takes all of us to get somebody to that better place and to kind of reduce that suffering. But pretty, pretty blessed, more than I deserve. So, we have almost about 100 staff at this point in four locations.

We are pretty large, with probably the biggest one that has — especially for inpatient. I know there’s a couple, like AspenPointe — they got some tele-people — but pretty much everybody here is local. Seventy percent of my staff is veterans, and we do have five TMS machines. This is the most in Colorado, and we’ve been very blessed to be rated in a lot of things. So, just serving a lot of great people, and we’re taking care of the best patients in the world. And then we just have people that care, and it’s just amazing to see this movement. So, there are our four locations right there. I have a little bit, kind of around — of course, it’s doing the military thing. Strategic. I’m not trying to ambush anybody, but trying to make sure we cover Colorado Springs.

So, we’re going to go just very basic and stuff. We’re not going to go back to the old science, but I definitely want to kind of mention that and kind of throw that up there. Thank God we don’t do the lobotomies anymore, but can you imagine when we had this as prevailing wisdom, right? That — how are we going to treat? And we’ve done a lot of things. We have a sword history in psychiatry; you know, we’ve been leveraged and used by religion or the governments, and definitely, we’ve come a long way. I tell people now, as we’re trying to open up to insurances — and I think the parody kind of aspect has been great because, really, we’ve been the red-headed stepchild for 200 years, right? And this has been amazing, as we’re kind of seeing the science and we’re seeing more and more.

If somebody doesn’t know — just a little quick little history too — can you imagine a child, an adolescent that has presented, and he or she is drinking a lot of water, very fatigued, very slow to respond, very lethargic, one might say. Maybe even a little cachectic and getting not very much appetite, other than drinking copious amounts of water. So, back in the olden times, this used to be called lazy or just, “There’s something wrong with that person.” Well, that’s the beginning of — if somebody doesn’t know those kinds of a constellation of symptoms, it’s diabetes. Especially when somebody is about to head into diabetic ketoacidosis and they start really kind of being very, very lethargic and are almost going into encephalopathy. So, they even thought that diabetes at one point might have been a mental disorder. So, I think that as we learn and as we kind of peel the onion back, we’re going to find more and more out.

Alright, not going to do a big thing. We’re dealing with a whole bunch of people and we’re all in addiction and psychiatry, but just to kind of really point out that this is still — you know, up until the ages, it’s really either the No. 1, No. 2, and it definitely takes all ages, and it’s No. 8 of the chances of death to suicide. And most of the major depressive disorder is not treated, and if it is treated, it is treated by our primary care brothers, sisters, and there’s a lot of people that are at risk. So, you see not only that — that huge 18- to 24-year-olds. And yes, accidents are No. 1, but if you think about all of the different medical kind of aspects of psychiatry, suicide is No. 2 in that 18- to 24-year-olds. Of course, we have that biphasic aspect of the over 65. And then depending on your race, depending on the sexual orientation as well — I mean, these risk factors are huge. We really need a lot of resources, I think, specifically for these particular at-risk groups. But in general, this is a huge drain on our resources, a huge drain on our suffering that we’re kind of doing.

And I think that it really has a huge amount of impairment, and we really haven’t touched on what we can do with MDD yet. So, just kind of mentioned this, the health care providers — and most of them are not actually psychiatry or nurse practitioners. I mean, we really don’t do that much medication; if you really think about it, it’s pretty interesting. And I’m glad that we can use other modalities, right? And these are really just evidence-based; we haven’t even touched the surface of doing some of the things that are not necessarily evidence-based but are more holistic in general. A little caveat on this is — it’s been cited numerous times, and I tell this especially when I go to my family practice or teach in medical school or a nurse practitioner program — before somebody makes a decision before a completed suicide, they have, usually, about 80% have made some contact with a health care professional within the 30 days of that completed suicide. So, I let people know — yes, there’s a huge checkup block, and we’re trying to get through. Especially if you’re primary care, it’s really rough — my wife, a patient every five to 10 minutes. It’s just ungodly, but that brief second that you can take to ask about a safety concern, you know? And I know we do the PHQ-2 in the military, but just to have the people — that sometimes, that open-ended question can really lead and possibly get them to get help.

Alright, so let’s move on a little bit onto this. This is on a SPECT scan, so this is how we’re kind of using positron emission tomography. On what that SPECT scan is doing, what it’s really looking at is irradiate glucose and also the blood flow that’s going on; it’s putting those things together. So, when we look at controls — you know, I don’t know about “not depressed,” I just say “controls.” The controls on this — everything’s lighting up. I know that the movies and Hollywood like to say, “Oh, you’re only using 10% of your brain.” No, we’re using 100%. Maybe some are not using that many, but then they get into politics — I’m just joking. So, then the depressed — I mean, we’re really seeing that hypoactivity.

The glucose is not going up, and by the way, the way that these shots are — I don’t know if you can see my mouse, but this is on the left side. So, we’re still seeing some activity on the right but not on the left. It’s because of the SPECT scan, how the cuts are — that’s why this is left and right. So, that irradiated glucose is not being uptaked, we’re not getting a neurochemical activity, we’re a neurochemical sponge. So, we definitely see that there is a problem here when they look at the controls and the depressed. Unfortunately, these SPECT scans right now are not great — they’re all for evaluations in the sense of academic. We really haven’t found as much in the clinical correlations, but we know consistently this has been presented when they look at depressed and not depressed. And I think that that was male.

So, a little bit — not going to go over to the whole endocrine system, but we’re all interconnected. Especially at Family Care Center, and I hope a lot of docs are doing it too, psychiatrists sometimes forget about some of the endocrine system. And we kind of do the gambit. We send them back to primary care, we’re trying to get them some specialty care, they’re going down that road, but we really do want to take a look at that whole picture. If anybody remembers the STAR*D study, you know we added some armor — some Synthroid — in, depending on what the take was, as an augmentation if they failed an SSRI or two. So, back to the cortical limbic system. These are some of the areas that we’re kind of talking about, and this is the dorsal prefrontal cortex.

If everybody remembers the executive functioning, the front is kind of what makes us human, right? This is what — you know, how we can make a plan for suicide? We can make a plan for anxiety; we’re not turning off the amygdala. We’re not turning off our alarm system. It’s connected to something in the hippocampus that is saying, “Hey, this is a danger.” And when we’re going through or trying to make our decision-making, all of those things — if they’re hypoactive and they’re not functioning in some manner with serotonin, dopamine, norepinephrine, even GABA, glutamate, all those things are out of sync — we’re not going to be able to make very good decisions. We’re not going to have the executive functioning. And this is some of the aspects, I think, that’s really going to be taking off in psychiatry in general as we start to try to affect these areas.

This is kind of how we treat it, right? All of these different modalities in combination, and there’s a lot of other homeopathic kind of aspects, and you can take a look at this. The pathways are very, very important because they’re still going through those other sections, right? So, even as we’re going through the dorsal prefrontal cortex and trying to get some executive functioning, we’re going through the orbital frontal cortex. So, this bottom portion of the orbital frontal cortex, still all of the executive functioning — this is really how we process the environment. This is where OCD kind of comes on if we kind of get hooked on one particular thing and we’re not processing, or it connects back. We can stay on the hamster wheel for a long time, especially if we misinterpret, and then it comes back to the amygdala — quote unquote, “the alarm system.” And everybody’s favorite: the nucleus accumbens and the reward pathway. Everybody likes dopamine and I let them know, like, chocolate, cocaine, sex — and don’t do cocaine. That will work for 30 minutes. Don’t do that.

Now, I always kind of add this in here because it kind of goes along with some of the executive functioning and seems like I cannot — I have not been into a lecture yet that I’ve not been asked about marijuana. So, you guys are in an addiction place, and I’m not sure if even insurance is covering this — I really hope they are now. Lots of comorbidities. These are just some of the effects. Another big study came out, actually, from Pueblo. It was not only looking at the hyperemesis — so, just the violent and kind of consistent throwing up, vomiting that occurs, especially with edibles — but also all of the second- and third-order effects because when it was on the black market, per se, we were talking about 3% to 6% THC.

I mean, there are some, some aspects that it’s 40% to 50%, and then we’ve even had some different modalities. They are really making it on a potent level of sometimes up to 80%. So, we are in a new world on the things that THC is affecting. So, I’ll go through just a little bit because this has been reproduced so many times — like, it first occurred in JAMA. Did you use before the age of 24, especially the daily use — you can actually see this is a normal activity of the brain on how much that he’s actually kind of eroded, or those are kind of necrotic spots. And I don’t mean necrotic in the sense of a loss of vasculature, but they’re not being used anymore. They are so hypoactive and those receptors in those areas of the brain are so burnt out, it can affect all those other aspects we’re talking about from this last side — the executive functioning, either paranoia, anxiety. I don’t know if that was a question. Sorry if I’m not — even with all this stuff, we’ve got 36% telemedicine in my practice, but I still don’t know all this stuff because all of our stuff is going through HR, and they like encrypting stuff. So, I don’t know Zoom as well.

Regardless, marijuana definitely has affected — especially if you use it before the age of 24. And then, of course, here are the studies with it. The psychosis — these are two big studies. One was 45,000 and on the other end was a thousand — just some of those higher levels of schizophrenia, and these were kind of cited in the JAMA articles as well. If everybody just remembers, usually, schizophrenia is about 1% of the population, and that’s any industrialized society when they kind of look at those slices. And we can see about 18% is the ones that use before they turn 24 for daily use. I mean, that’s a world away. And then, of course, our suicide rates. Colorado has one of the highest, and El Paso County, in general — my place — with as many of the veterans that are here, we have one of the highest in Colorado.

For veterans, I believe, one of my staff members is on the governor’s kind of suicide prevention task force. And despite us having — I forget what the percentage of the population is; I think it might be 25%, 30% of the population in El Paso County — we’re about 44% of all of these suicides. So, even though Paso County is just incredibly huge, the number of suicides when marijuana was present has gone up dramatically. I think these are the things, whenever we have this legalized marijuana, we just have to watch out when it’s being made by a true botanist or a chemist that can really eke out THC to get the biggest bang for their buck. And unfortunately, it’s having an effect, especially on those lessons.

Now, another treatment modality. By the way, any questions? You guys can stop me any time. I’m not seeing any chat things, unless I’m missing something. Savannah was supposed to help me with that, so you guys can stop me anytime. You can question.

So, I got trained on ECT. It works. I think it’s wonderful. Unfortunately, it does have its downsides, right? And some of those downsides are not that great. And this, this is a treatment modality for so many things and even for pregnancy. And we’ve seen it for MDD, with psychosis and schizophrenia, schizoaffective, even bipolar. I mean, there’s a lot of indications that we have for ECT. And what are we doing with this, really? What we’re doing is, in general, we’re taking an electrical activity and we are putting it through usually one hemisphere of the brain — we’ve kind of moved away from the bilateral, although we still do it to the unilateral. And that unilateral is kind of the best approach to try to preserve memory, because despite inducing that seizure, that memory problems — sometimes, some studies show a 30% — but when you do bilateral for ECT, yes, the rates go up and the response rates go up with ECT, and it can still be out of the TMS admission rates.

But when you do bilateral, that could be 50%, and some studies have shown that there has been some short-term memory loss. Tell people, “You’re not gonna lose your childhood, but remembering where your keys are in the morning, that might be a little more difficult.” And it’s pretty pronounced when you actually see it in some patients, but I still think it has a place in medicine, and really, this ECT is the basis on what — as we kind of move, and we’re going to shift over to the TMS. Because if you can think of — sorry to use a military term — if you can think of ECT as calling for fire and artillery on one part of the hemisphere of your brain, or I’m taking out half of the country, And now, we’re going to talk about TMS, which is going to be kind of like a surgical precision or a sniper, per se.

A little bit of intro: We have actually been doing this for a while. A lot of trials were started in the ‘90s, and it’s been FDA-approved since ‘08. Now, a lot of insurances didn’t really pick it up until 2013. And a very interesting story about some of the histories on this is, you know, the blood-brain barrier is very strong. Pharmacologically, it is the Great Wall of China, right? So, we have to find things that kind of cross that. Well, it’s very hard to kind of cross that at times, except for, like, caffeine, drugs of abuse, nicotine — those things get through just fine. Those are the ninjas, right? So, they started using magnets in chemotherapy patients to try to get the chemotherapy through the blood-brain barrier because it might not have been so lipophilic. Because it can actually decrease a little bit of the blood-brain barrier and we have a little bit of profusion that increases. So, not only are there electrical activity increases, but there’s a little bit of blood flow that increases as well. And they found that people that had depression — clinical depression, as well as getting the chemotherapy and some kind of brain cancer — they improved. And they started to kind of look at this a little bit more and more. I put my ideal candidate down there. Now, the FDA is only one failed med, but insurance is — military never taught me about this, so it’s all over the place. It’s like they use a dartboard for their indications. And then, of course, we have the recent indication for OCD.

Right now, the two indications are MDD. A little bit — not to get too geeked out on you, but these two dead, white guys named Maxwell and Farady. Magnetic current creates an electric charge. And all this is in Teslas like that of our great Tesla, and no, you don’t get a Tesla from Elon Musk. It’s just how we measure the strength. Very interesting is that it is about the same Tesla level as an MRI. However, an MRI might have 10 to 100 pulses per second, and a TMS for that same Tesla will have 2000. Then, of course, we can change it depending on the frequency. So, we’re taking advantage of science as we’re kind of marrying up, evolving, going away from that lobotomy, and hopefully, maybe we can even make ECT a thing of the past if we get these very localized or kind of surgical aspects of treating pretty much a lot of indications.

And since we’ve been treating since ‘08, there are a lot of non-FDA approaches and a lot of studies out there. I belong to a TMS clinical society, and lots of studies are going on. I don’t necessarily do studies, but we definitely do collect data, the PHQ-9 and GAD-7. And we can talk about that in a second. Now with data versus just the higher frequency and changing that frequency — I’ll get into that in a couple of slides — it can make a world of difference.

So, what does it gotta be? Gotta be repetitive. So, just how these are showing different coils — if you can kind of think of the earth and the poles of the earth and magnetic pulses that are going through, when you have two of them, it creates this central kind of focus that really acts more like a cone. So, the studies have been deep and repetitive is what’s important. A personal patient brought to me something from Amazon, I think. They’re like, “Hey, look, if you buy a TMS machine at $600,” and it’s like, no, that will massage your scalp. That is not the Teslas of an MRI. A TMS machine is not gonna have their own electrical outlet — the electrical panel, actually, that’s actually a huge part of the cost. But this is kind of in the sense of how they work the magnetic pulses, and there’s a lot of different configurations. I’ve used, also, the brain’s way, which is H coil. They’re experimenting along with this as well.

The waveforms — not going up through EEGs. That’s almost like — I just hated histology, so it’s histology and the EEG. But our brain talks to itself and the other parts of the brain in a certain hertz, and that certain hertz is going to be somewhere between three and eight, in general. What they’re really looking at is using the EEG to find that specific one, and then we will make the TMS machine — instead of being a consistent, you know, 18 hertz, 12 hertz, there’s 10 hertz, there’s a lot of different protocols — the theta bursts on the outside would be a 50 hertz, and that’s the theta burst for TMS. But if we can mirror that same wavelength, which is how your brain is actually talking to itself, we’ve seen about a 5%to 10% increase on that remission rate.

So, these studies are getting better and better, and how we kind of use this — that’s not really mainstream right now, but this is kind of our next step where big TMS is going. We’re going to see a lot more of those different indications, almost like if you could think of some of the genetic aspects of pharmacology. So, we know your gene structure. We know your people, the 50 system, the gene test, which kind of can tell you how you will process things fast, metabolize it, but we made it specifically for you and your people 50 system, and how you metabolize. We’re going to get a lot less side effects and a lot better advocacy, and I can kind of see this going through TMS as well.

So what do we do? So, if anybody can remember from school, this is homunculus; homunculus is Latin for “the little man.” And everything’s pretty mapped out — this is kind of Frankenstein kind of time, right? You kind of figured out with electrodes, right? So, if anybody did a frog lab and stuff, you can kind of induce on the motor cortex, where a certain electrical input is put in there and you can induce a response. Okay, like depolarization is kind of what it’s called. You make a neuron excitable. So, by using the motor cortex here, and around the finger and thumb area — this area right here — I send a magnetic pulse there, and I use the least amount possible to see this twitch. And that twitch is going to tell me both an indication of the placement and the motor threshold. I want to use the least amount of the magnet to create neural excitability. When I do this, about five to six centimeters going forward is the dorsal prefrontal cortex, where I’m actually going to deliver all of this. And we know we can do other areas as well.

So, a neurochemical machine, trying to find these specific areas, and what we are actually doing with it? What we’re doing with it is instead of me giving you Prozac or Zoloft — pretty much all serotonin, just a very smattering of opinion, other dopamine, epinephrine, things like that, or Wellbutrin, which is pretty much just dopamine and more epi, right? I’m using combo meds and I’m trying to hit all these things, or we go back to the old school, right? TCAs, tricyclics, so now I’m getting all three receptors, but those are dirty. They have a lot of drug interactions, and of course, you can die with TCAs. So, what if I could say with the TMS, I’m going to create neuronal excitability in that area — the dorsal prefrontal cortex that is not working, that is not firing, is not excitable, shown by SPECT scans and other aspects. And now, I’m going to excite them. I’m going to turn them on again. And what we’re going to do with that is I’m going to hit all those receptors in that area. It, in a sense, rebalances that whole aspect of serotonin, GABA, glutamate, norepi, dopamine, all those aspects are going to be rebalanced.
And what they’ve kind of shown is that after doing these sessions, we have a response rate and we start the snowball effect.

So, a little bit of logistics, we’ll talk about some of the response rates. Good thing is, ECT, you’re bored. I need a nurse, I need an anesthesiologist, I need OR. This, you’re awake, it’s non-invasive, you get the treatment, you take off, you can drive, everything’s fine. The duration is 20 to 26 minutes, you know, with checking in, but we really try to have a good system for about 30 minutes. The bad is the five days a week for about six to eight weeks is usually what we look for. And then, of course, we have the MRI. This is the back venture. This is the one I have, and it’s used in the clinical studies because, if you can look at the arm — some of the things are like helmets or like NeuroStars, like a certain area. It’s very hard to be non-FDA things, but this is used in the clinical studies because now, I can go to both bilateral and I can utilize what somebody smarter than me has already done. So, I don’t have to experiment on my people, but we can do some augmentations with things, especially if they’re a little bit even resistant to TMS.

So, this is kind of what it is. You can look at the drug therapy, and everybody who is taking care of patients with a spin on any of our psych meds — we got some side effects, right?
Well, the only ones here are just a little bit of discomfort. Initially, just kind of feeling a little bit weird, but usually what I tell people it feels like — it should be weird and annoying, but not painful. And then, of course, there is a very rare seizure threshold, and that seizure lane was 0.1% to 0.3%. The most recent study that I read was one in 30,000, so it’s very, very rare. And it goes without saying: contraindication. It’s a magnet. It can’t have metal in your head. So, this does disclude some veterans if they have any shrapnel, and of course, all of the non-ferrous dental work — that is usually good to go.

I do tell a couple of stories when I was beginning, where two prior service people, male and female, and what we call is — they got the lowest bidder filling. So, when I had turned on the machine, it definitely was inducing some pain in their teeth because they had, like, a ferrous metal. They had a metal that could be affected by a magnet, and it was like almost pulling their teeth out in a sense. That feeling — it didn’t really pull their teeth out. So, the male never came back, the female actually got a real filling put in by a non-military dentist and came back and did great with the therapy. You do have to watch out every so often, but, definitely deep brain stimulators — it’s a no go. And they say pacemaker, but I will tell you that most of the studies, when you look at the one going back, how far it goes. I mean, there really is no magnetic force that’s really going below the neck, but it still is a concern, right? I don’t want to stop somebody’s heart.

Also, just to tell you, it’s not indicated in pregnancy. I’ve done it in some pregnant people; they sign a waiver. ‘Cause ECT isn’t actually even approved in pregnancy with MDD, so this just doesn’t have that indication yet. There’s a lot to go through with the FDA. Nobody knows.

So, here are some of what the response rates are. This is not shocking. It should not be painful. It’s not going to do “One Flew Over the Cuckoo’s Nest.” It’s a really good movie, but it really messed us over for ECT. It’s not what we’re doing — we’re not torturing somebody. But we see that there are both response rates and then the remission rate. There are over 200 studies right now. Lots of meta-analyses, definitely beats placebo. You can look at — remember, the big studies with psychotherapy and medication together, response rates are around 55%. So, this is pretty amazing. I still believe, in the biopsychosocial kind of model, I think that if I can reduce some of the symptoms, then they can probably get those gains in therapy that they never could get as well, to have that longevity. I always thought that psychiatry always has dark humor, right? Food is looking back at you, you should take your meds.

So, just in conclusion, what I really wanted to kind of cover today was just a little bit of an overview of TMS. Give you just a little bit of where the science is going, especially for MDD right now. I’ve just had some really good responses — ours are around 78%. So, I can beat that one out just a little bit, but I do take a different approach, and I like using both the normal and the theta burst together. The FDA — now, the theta burst has the same amount as Tesla, but it’s only three minutes. And there are some people or some practices that will only do the theta because it is FDA-approved. But your remission rates really go down. And not judging them, but I think that just doing that treatment every three minutes — it might be profitable, but it’s not efficacious. The best evidence has been to use both the normal version of theta together. So, I want to give you a little bit about TMS, a little bit about Family Care Center. We’re dedicated here to our military DOD and our vets, and then, of course, our community. Really, we’re kind of here to stay for Colorado Springs, and maybe I’ll venture out a little bit as we start kind of growing a little bit. But I wanted to give you just a little overview, and I really appreciate the invitation to talk to you all.

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

Transcranial magnetic stimulation (TMS) is the next step in electroconvulsive therapy treatment (ECT). In this presentation, Dr. Charles Weber explains the history of these forms of treatment and how they work to treat mental health conditions like post-traumatic stress disorder and major depressive disorder.

After watching this presentation, the viewer will:

  • Understand the unique strengths of TMS treatment and how it compares to ECT
  • Know the truth behind several prevalent myths involving ECT
  • Be aware of the research and statistics that support TMS as an effective form of treatment

Presentation Materials:

Dr. Charles Weber is currently the medical director and CEO of the Family Care Center, a comprehensive outpatient mental health/addiction treatment in Colorado Springs, now with 4 locations. He is married to Dr. Rae Ann Weber, FP, who is a full-time opioid addiction treatment provider.

He is a prior-enlisted infantryman and graduated from the United States Military Academy (USMA) at West Point in 1995. He attended Touro University College of Osteopathic Medicine and received a Doctor of Osteopathic Medicine in 2002. His transitional internship was at Walter Reed Army Medical Center, and board-certified Psychiatrist. LTC(R) Charles Weber was the Chief of the Department of Behavioral Health at Ft. Carson, CO, and retired in 2016 after 27 years in uniform. He is also Addiction Medicine Board certified.

Dr. Chuck is extremely passionate about Veteran and DoD mental health and this community.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Michael:
Good afternoon. My name is Michael Crisanto. I am a clinical outreach specialist with Advanced Recovery Systems. We operate multiple dual diagnosis treatment facilities throughout the country. We treat substance use disorders and mental health as well as eating disorders, and today, we’re really excited to be able to have Dr. Charles Weber here. Dr. Weber is currently the medical director and CEO of the Family Care Center, a comprehensive outpatient mental health and addiction treatment center in Colorado Springs, now with four locations. He’s married to Dr. Renee Anne Weber, who was a full-time opioid addiction treatment provider.

He’s a prior-enlisted infantryman and graduated from the United States Military Academy at West Point in 1995. He also attended Touro University College of Osteopathic Medicine and received the doctor of osteopathic medicine in 2002. His transitional internship was at Walter Reed Army Medical Center and a board-certified psychiatrist. Lieutenant Colonel Charles Weber was the chief of the department of behavioral health at Fort Carson, Colorado, and retired in 2016 after 27 years in uniform. He also is addiction medicine board-certified. Dr. Chuck is extremely passionate about veterans and the Department of Defense, mental health and this community. So thank you, Dr. Weber, and I’ll turn it over to you.

Dr. Weber:
Thanks. And I didn’t ask in the beginning, but also, my audience is a mix of clinicians, administrative as well, maybe some physicians as well — yes, no?

Yeah. Ask them in the chat. Most of the time, we can get a variety of those, so it’s a combination of all.

No problem, no problem. So, if I’m getting too technical, I’m trying to make it kind of, like, more of my vanilla kind of aspect. So, thank you for that introduction. I really appreciate everybody. My name is Chuck Weber, and as you said, you already gave me a great intro, so we don’t have to go through that. I’m not going to go through all of history; I did start off enlisted infantry, and so I do, like, kind of the history and how the migration — initially, I was a flight surgeon and then found my way to psychiatry because flight surgery is fun, but I don’t really want to do FAA physicals for the rest of my life. Plus, there’s such a huge need in both addiction and mental illness that it’s really kind of driven an aspect of that dynamic approach.

So, depending, a lot of people have different likes and everything; to me, diabetes, attention, low back pain — it was rote to me. But a psychiatrist and a mental illness — so dynamic. There are so many things. And I love that we have to have so many vocations. Social workers, LMFTs, addiction, CACs, psychiatrists, psychologists — I mean, the whole gambit. Social work. And also, just that structure on how we’re going to get somebody to that better place. But these are the things we’re going to cover just in kind of brief on. A little bit about Family Care Center, but really, spending the bulk of the time on TMS — transcranial magnetic stimulation.

This is our mission and vision. I mean, we primarily started this with just my wife and I and a handful of people. My wife’s a veteran too, and then she went to GS, which is government service. Our primary mission was always the Department of Defense family members because it was definitely a hole that we had in the military — a hole that we have in all of the military medicine, truly. You just cannot get the services that they really require. And then, of course, our veterans. You know, the VA gets some great people in it, some great — a lot of resources, a lot of technicality kind of things, but the bureaucracy is very, very hard, especially when you’re dealing with people that have a lot of frustration tolerance, right? So, that has been taxed by PTSD or MDD that’s not been treated. So, that’s what we focused on, really, for the first few years, and then we kind of branched out these next two-and-a-half to other insurances to take care of our whole community. Because this is where we laid down roots. I moved my wife nine times, and our deal was she gets to pick the last spot, so here it is in the Springs.

Kind of mentioned this just a little bit, and also, the better-looking Dr. Weber — that’s her. This was one of our — I had my prescribers and my leaders out. We had a team-building. This is the last time I’m going to go take them on a class 5 rafting trip; I almost lost three of them.
So, that was not good. Note to self, right?

Family Care Center. At Family Care Center, we do have child psychiatry. We have addiction with the FP. I think there’s about — with my nurse practitioners, together, there are about 13 prescribers. At least half of us all have our X designator, so we can take care of the opioids.
You know, I have not even maxed mine out, or my PAs. It’s not really the bulk of our services, but we definitely, definitely want to take care of it. I do have one doctoral level of CRNA that is doing our ketamine infusions. That is actually in a separate business because there’s not insurance with it. And then you can see the whole gambit. I really do believe in that holistic approach, and I think that it takes all of us to get somebody to that better place and to kind of reduce that suffering. But pretty, pretty blessed, more than I deserve. So, we have almost about 100 staff at this point in four locations.

We are pretty large, with probably the biggest one that has — especially for inpatient. I know there’s a couple, like AspenPointe — they got some tele-people — but pretty much everybody here is local. Seventy percent of my staff is veterans, and we do have five TMS machines. This is the most in Colorado, and we’ve been very blessed to be rated in a lot of things. So, just serving a lot of great people, and we’re taking care of the best patients in the world. And then we just have people that care, and it’s just amazing to see this movement. So, there are our four locations right there. I have a little bit, kind of around — of course, it’s doing the military thing. Strategic. I’m not trying to ambush anybody, but trying to make sure we cover Colorado Springs.

So, we’re going to go just very basic and stuff. We’re not going to go back to the old science, but I definitely want to kind of mention that and kind of throw that up there. Thank God we don’t do the lobotomies anymore, but can you imagine when we had this as prevailing wisdom, right? That — how are we going to treat? And we’ve done a lot of things. We have a sword history in psychiatry; you know, we’ve been leveraged and used by religion or the governments, and definitely, we’ve come a long way. I tell people now, as we’re trying to open up to insurances — and I think the parody kind of aspect has been great because, really, we’ve been the red-headed stepchild for 200 years, right? And this has been amazing, as we’re kind of seeing the science and we’re seeing more and more.

If somebody doesn’t know — just a little quick little history too — can you imagine a child, an adolescent that has presented, and he or she is drinking a lot of water, very fatigued, very slow to respond, very lethargic, one might say. Maybe even a little cachectic and getting not very much appetite, other than drinking copious amounts of water. So, back in the olden times, this used to be called lazy or just, “There’s something wrong with that person.” Well, that’s the beginning of — if somebody doesn’t know those kinds of a constellation of symptoms, it’s diabetes. Especially when somebody is about to head into diabetic ketoacidosis and they start really kind of being very, very lethargic and are almost going into encephalopathy. So, they even thought that diabetes at one point might have been a mental disorder. So, I think that as we learn and as we kind of peel the onion back, we’re going to find more and more out.

Alright, not going to do a big thing. We’re dealing with a whole bunch of people and we’re all in addiction and psychiatry, but just to kind of really point out that this is still — you know, up until the ages, it’s really either the No. 1, No. 2, and it definitely takes all ages, and it’s No. 8 of the chances of death to suicide. And most of the major depressive disorder is not treated, and if it is treated, it is treated by our primary care brothers, sisters, and there’s a lot of people that are at risk. So, you see not only that — that huge 18- to 24-year-olds. And yes, accidents are No. 1, but if you think about all of the different medical kind of aspects of psychiatry, suicide is No. 2 in that 18- to 24-year-olds. Of course, we have that biphasic aspect of the over 65. And then depending on your race, depending on the sexual orientation as well — I mean, these risk factors are huge. We really need a lot of resources, I think, specifically for these particular at-risk groups. But in general, this is a huge drain on our resources, a huge drain on our suffering that we’re kind of doing.

And I think that it really has a huge amount of impairment, and we really haven’t touched on what we can do with MDD yet. So, just kind of mentioned this, the health care providers — and most of them are not actually psychiatry or nurse practitioners. I mean, we really don’t do that much medication; if you really think about it, it’s pretty interesting. And I’m glad that we can use other modalities, right? And these are really just evidence-based; we haven’t even touched the surface of doing some of the things that are not necessarily evidence-based but are more holistic in general. A little caveat on this is — it’s been cited numerous times, and I tell this especially when I go to my family practice or teach in medical school or a nurse practitioner program — before somebody makes a decision before a completed suicide, they have, usually, about 80% have made some contact with a health care professional within the 30 days of that completed suicide. So, I let people know — yes, there’s a huge checkup block, and we’re trying to get through. Especially if you’re primary care, it’s really rough — my wife, a patient every five to 10 minutes. It’s just ungodly, but that brief second that you can take to ask about a safety concern, you know? And I know we do the PHQ-2 in the military, but just to have the people — that sometimes, that open-ended question can really lead and possibly get them to get help.

Alright, so let’s move on a little bit onto this. This is on a SPECT scan, so this is how we’re kind of using positron emission tomography. On what that SPECT scan is doing, what it’s really looking at is irradiate glucose and also the blood flow that’s going on; it’s putting those things together. So, when we look at controls — you know, I don’t know about “not depressed,” I just say “controls.” The controls on this — everything’s lighting up. I know that the movies and Hollywood like to say, “Oh, you’re only using 10% of your brain.” No, we’re using 100%. Maybe some are not using that many, but then they get into politics — I’m just joking. So, then the depressed — I mean, we’re really seeing that hypoactivity.

The glucose is not going up, and by the way, the way that these shots are — I don’t know if you can see my mouse, but this is on the left side. So, we’re still seeing some activity on the right but not on the left. It’s because of the SPECT scan, how the cuts are — that’s why this is left and right. So, that irradiated glucose is not being uptaked, we’re not getting a neurochemical activity, we’re a neurochemical sponge. So, we definitely see that there is a problem here when they look at the controls and the depressed. Unfortunately, these SPECT scans right now are not great — they’re all for evaluations in the sense of academic. We really haven’t found as much in the clinical correlations, but we know consistently this has been presented when they look at depressed and not depressed. And I think that that was male.

So, a little bit — not going to go over to the whole endocrine system, but we’re all interconnected. Especially at Family Care Center, and I hope a lot of docs are doing it too, psychiatrists sometimes forget about some of the endocrine system. And we kind of do the gambit. We send them back to primary care, we’re trying to get them some specialty care, they’re going down that road, but we really do want to take a look at that whole picture. If anybody remembers the STAR*D study, you know we added some armor — some Synthroid — in, depending on what the take was, as an augmentation if they failed an SSRI or two. So, back to the cortical limbic system. These are some of the areas that we’re kind of talking about, and this is the dorsal prefrontal cortex.

If everybody remembers the executive functioning, the front is kind of what makes us human, right? This is what — you know, how we can make a plan for suicide? We can make a plan for anxiety; we’re not turning off the amygdala. We’re not turning off our alarm system. It’s connected to something in the hippocampus that is saying, “Hey, this is a danger.” And when we’re going through or trying to make our decision-making, all of those things — if they’re hypoactive and they’re not functioning in some manner with serotonin, dopamine, norepinephrine, even GABA, glutamate, all those things are out of sync — we’re not going to be able to make very good decisions. We’re not going to have the executive functioning. And this is some of the aspects, I think, that’s really going to be taking off in psychiatry in general as we start to try to affect these areas.

This is kind of how we treat it, right? All of these different modalities in combination, and there’s a lot of other homeopathic kind of aspects, and you can take a look at this. The pathways are very, very important because they’re still going through those other sections, right? So, even as we’re going through the dorsal prefrontal cortex and trying to get some executive functioning, we’re going through the orbital frontal cortex. So, this bottom portion of the orbital frontal cortex, still all of the executive functioning — this is really how we process the environment. This is where OCD kind of comes on if we kind of get hooked on one particular thing and we’re not processing, or it connects back. We can stay on the hamster wheel for a long time, especially if we misinterpret, and then it comes back to the amygdala — quote unquote, “the alarm system.” And everybody’s favorite: the nucleus accumbens and the reward pathway. Everybody likes dopamine and I let them know, like, chocolate, cocaine, sex — and don’t do cocaine. That will work for 30 minutes. Don’t do that.

Now, I always kind of add this in here because it kind of goes along with some of the executive functioning and seems like I cannot — I have not been into a lecture yet that I’ve not been asked about marijuana. So, you guys are in an addiction place, and I’m not sure if even insurance is covering this — I really hope they are now. Lots of comorbidities. These are just some of the effects. Another big study came out, actually, from Pueblo. It was not only looking at the hyperemesis — so, just the violent and kind of consistent throwing up, vomiting that occurs, especially with edibles — but also all of the second- and third-order effects because when it was on the black market, per se, we were talking about 3% to 6% THC.

I mean, there are some, some aspects that it’s 40% to 50%, and then we’ve even had some different modalities. They are really making it on a potent level of sometimes up to 80%. So, we are in a new world on the things that THC is affecting. So, I’ll go through just a little bit because this has been reproduced so many times — like, it first occurred in JAMA. Did you use before the age of 24, especially the daily use — you can actually see this is a normal activity of the brain on how much that he’s actually kind of eroded, or those are kind of necrotic spots. And I don’t mean necrotic in the sense of a loss of vasculature, but they’re not being used anymore. They are so hypoactive and those receptors in those areas of the brain are so burnt out, it can affect all those other aspects we’re talking about from this last side — the executive functioning, either paranoia, anxiety. I don’t know if that was a question. Sorry if I’m not — even with all this stuff, we’ve got 36% telemedicine in my practice, but I still don’t know all this stuff because all of our stuff is going through HR, and they like encrypting stuff. So, I don’t know Zoom as well.

Regardless, marijuana definitely has affected — especially if you use it before the age of 24. And then, of course, here are the studies with it. The psychosis — these are two big studies. One was 45,000 and on the other end was a thousand — just some of those higher levels of schizophrenia, and these were kind of cited in the JAMA articles as well. If everybody just remembers, usually, schizophrenia is about 1% of the population, and that’s any industrialized society when they kind of look at those slices. And we can see about 18% is the ones that use before they turn 24 for daily use. I mean, that’s a world away. And then, of course, our suicide rates. Colorado has one of the highest, and El Paso County, in general — my place — with as many of the veterans that are here, we have one of the highest in Colorado.

For veterans, I believe, one of my staff members is on the governor’s kind of suicide prevention task force. And despite us having — I forget what the percentage of the population is; I think it might be 25%, 30% of the population in El Paso County — we’re about 44% of all of these suicides. So, even though Paso County is just incredibly huge, the number of suicides when marijuana was present has gone up dramatically. I think these are the things, whenever we have this legalized marijuana, we just have to watch out when it’s being made by a true botanist or a chemist that can really eke out THC to get the biggest bang for their buck. And unfortunately, it’s having an effect, especially on those lessons.

Now, another treatment modality. By the way, any questions? You guys can stop me any time. I’m not seeing any chat things, unless I’m missing something. Savannah was supposed to help me with that, so you guys can stop me anytime. You can question.

So, I got trained on ECT. It works. I think it’s wonderful. Unfortunately, it does have its downsides, right? And some of those downsides are not that great. And this, this is a treatment modality for so many things and even for pregnancy. And we’ve seen it for MDD, with psychosis and schizophrenia, schizoaffective, even bipolar. I mean, there’s a lot of indications that we have for ECT. And what are we doing with this, really? What we’re doing is, in general, we’re taking an electrical activity and we are putting it through usually one hemisphere of the brain — we’ve kind of moved away from the bilateral, although we still do it to the unilateral. And that unilateral is kind of the best approach to try to preserve memory, because despite inducing that seizure, that memory problems — sometimes, some studies show a 30% — but when you do bilateral for ECT, yes, the rates go up and the response rates go up with ECT, and it can still be out of the TMS admission rates.

But when you do bilateral, that could be 50%, and some studies have shown that there has been some short-term memory loss. Tell people, “You’re not gonna lose your childhood, but remembering where your keys are in the morning, that might be a little more difficult.” And it’s pretty pronounced when you actually see it in some patients, but I still think it has a place in medicine, and really, this ECT is the basis on what — as we kind of move, and we’re going to shift over to the TMS. Because if you can think of — sorry to use a military term — if you can think of ECT as calling for fire and artillery on one part of the hemisphere of your brain, or I’m taking out half of the country, And now, we’re going to talk about TMS, which is going to be kind of like a surgical precision or a sniper, per se.

A little bit of intro: We have actually been doing this for a while. A lot of trials were started in the ‘90s, and it’s been FDA-approved since ‘08. Now, a lot of insurances didn’t really pick it up until 2013. And a very interesting story about some of the histories on this is, you know, the blood-brain barrier is very strong. Pharmacologically, it is the Great Wall of China, right? So, we have to find things that kind of cross that. Well, it’s very hard to kind of cross that at times, except for, like, caffeine, drugs of abuse, nicotine — those things get through just fine. Those are the ninjas, right? So, they started using magnets in chemotherapy patients to try to get the chemotherapy through the blood-brain barrier because it might not have been so lipophilic. Because it can actually decrease a little bit of the blood-brain barrier and we have a little bit of profusion that increases. So, not only are there electrical activity increases, but there’s a little bit of blood flow that increases as well. And they found that people that had depression — clinical depression, as well as getting the chemotherapy and some kind of brain cancer — they improved. And they started to kind of look at this a little bit more and more. I put my ideal candidate down there. Now, the FDA is only one failed med, but insurance is — military never taught me about this, so it’s all over the place. It’s like they use a dartboard for their indications. And then, of course, we have the recent indication for OCD.

Right now, the two indications are MDD. A little bit — not to get too geeked out on you, but these two dead, white guys named Maxwell and Farady. Magnetic current creates an electric charge. And all this is in Teslas like that of our great Tesla, and no, you don’t get a Tesla from Elon Musk. It’s just how we measure the strength. Very interesting is that it is about the same Tesla level as an MRI. However, an MRI might have 10 to 100 pulses per second, and a TMS for that same Tesla will have 2000. Then, of course, we can change it depending on the frequency. So, we’re taking advantage of science as we’re kind of marrying up, evolving, going away from that lobotomy, and hopefully, maybe we can even make ECT a thing of the past if we get these very localized or kind of surgical aspects of treating pretty much a lot of indications.

And since we’ve been treating since ‘08, there are a lot of non-FDA approaches and a lot of studies out there. I belong to a TMS clinical society, and lots of studies are going on. I don’t necessarily do studies, but we definitely do collect data, the PHQ-9 and GAD-7. And we can talk about that in a second. Now with data versus just the higher frequency and changing that frequency — I’ll get into that in a couple of slides — it can make a world of difference.

So, what does it gotta be? Gotta be repetitive. So, just how these are showing different coils — if you can kind of think of the earth and the poles of the earth and magnetic pulses that are going through, when you have two of them, it creates this central kind of focus that really acts more like a cone. So, the studies have been deep and repetitive is what’s important. A personal patient brought to me something from Amazon, I think. They’re like, “Hey, look, if you buy a TMS machine at $600,” and it’s like, no, that will massage your scalp. That is not the Teslas of an MRI. A TMS machine is not gonna have their own electrical outlet — the electrical panel, actually, that’s actually a huge part of the cost. But this is kind of in the sense of how they work the magnetic pulses, and there’s a lot of different configurations. I’ve used, also, the brain’s way, which is H coil. They’re experimenting along with this as well.

The waveforms — not going up through EEGs. That’s almost like — I just hated histology, so it’s histology and the EEG. But our brain talks to itself and the other parts of the brain in a certain hertz, and that certain hertz is going to be somewhere between three and eight, in general. What they’re really looking at is using the EEG to find that specific one, and then we will make the TMS machine — instead of being a consistent, you know, 18 hertz, 12 hertz, there’s 10 hertz, there’s a lot of different protocols — the theta bursts on the outside would be a 50 hertz, and that’s the theta burst for TMS. But if we can mirror that same wavelength, which is how your brain is actually talking to itself, we’ve seen about a 5%to 10% increase on that remission rate.

So, these studies are getting better and better, and how we kind of use this — that’s not really mainstream right now, but this is kind of our next step where big TMS is going. We’re going to see a lot more of those different indications, almost like if you could think of some of the genetic aspects of pharmacology. So, we know your gene structure. We know your people, the 50 system, the gene test, which kind of can tell you how you will process things fast, metabolize it, but we made it specifically for you and your people 50 system, and how you metabolize. We’re going to get a lot less side effects and a lot better advocacy, and I can kind of see this going through TMS as well.

So what do we do? So, if anybody can remember from school, this is homunculus; homunculus is Latin for “the little man.” And everything’s pretty mapped out — this is kind of Frankenstein kind of time, right? You kind of figured out with electrodes, right? So, if anybody did a frog lab and stuff, you can kind of induce on the motor cortex, where a certain electrical input is put in there and you can induce a response. Okay, like depolarization is kind of what it’s called. You make a neuron excitable. So, by using the motor cortex here, and around the finger and thumb area — this area right here — I send a magnetic pulse there, and I use the least amount possible to see this twitch. And that twitch is going to tell me both an indication of the placement and the motor threshold. I want to use the least amount of the magnet to create neural excitability. When I do this, about five to six centimeters going forward is the dorsal prefrontal cortex, where I’m actually going to deliver all of this. And we know we can do other areas as well.

So, a neurochemical machine, trying to find these specific areas, and what we are actually doing with it? What we’re doing with it is instead of me giving you Prozac or Zoloft — pretty much all serotonin, just a very smattering of opinion, other dopamine, epinephrine, things like that, or Wellbutrin, which is pretty much just dopamine and more epi, right? I’m using combo meds and I’m trying to hit all these things, or we go back to the old school, right? TCAs, tricyclics, so now I’m getting all three receptors, but those are dirty. They have a lot of drug interactions, and of course, you can die with TCAs. So, what if I could say with the TMS, I’m going to create neuronal excitability in that area — the dorsal prefrontal cortex that is not working, that is not firing, is not excitable, shown by SPECT scans and other aspects. And now, I’m going to excite them. I’m going to turn them on again. And what we’re going to do with that is I’m going to hit all those receptors in that area. It, in a sense, rebalances that whole aspect of serotonin, GABA, glutamate, norepi, dopamine, all those aspects are going to be rebalanced.
And what they’ve kind of shown is that after doing these sessions, we have a response rate and we start the snowball effect.

So, a little bit of logistics, we’ll talk about some of the response rates. Good thing is, ECT, you’re bored. I need a nurse, I need an anesthesiologist, I need OR. This, you’re awake, it’s non-invasive, you get the treatment, you take off, you can drive, everything’s fine. The duration is 20 to 26 minutes, you know, with checking in, but we really try to have a good system for about 30 minutes. The bad is the five days a week for about six to eight weeks is usually what we look for. And then, of course, we have the MRI. This is the back venture. This is the one I have, and it’s used in the clinical studies because, if you can look at the arm — some of the things are like helmets or like NeuroStars, like a certain area. It’s very hard to be non-FDA things, but this is used in the clinical studies because now, I can go to both bilateral and I can utilize what somebody smarter than me has already done. So, I don’t have to experiment on my people, but we can do some augmentations with things, especially if they’re a little bit even resistant to TMS.

So, this is kind of what it is. You can look at the drug therapy, and everybody who is taking care of patients with a spin on any of our psych meds — we got some side effects, right?
Well, the only ones here are just a little bit of discomfort. Initially, just kind of feeling a little bit weird, but usually what I tell people it feels like — it should be weird and annoying, but not painful. And then, of course, there is a very rare seizure threshold, and that seizure lane was 0.1% to 0.3%. The most recent study that I read was one in 30,000, so it’s very, very rare. And it goes without saying: contraindication. It’s a magnet. It can’t have metal in your head. So, this does disclude some veterans if they have any shrapnel, and of course, all of the non-ferrous dental work — that is usually good to go.

I do tell a couple of stories when I was beginning, where two prior service people, male and female, and what we call is — they got the lowest bidder filling. So, when I had turned on the machine, it definitely was inducing some pain in their teeth because they had, like, a ferrous metal. They had a metal that could be affected by a magnet, and it was like almost pulling their teeth out in a sense. That feeling — it didn’t really pull their teeth out. So, the male never came back, the female actually got a real filling put in by a non-military dentist and came back and did great with the therapy. You do have to watch out every so often, but, definitely deep brain stimulators — it’s a no go. And they say pacemaker, but I will tell you that most of the studies, when you look at the one going back, how far it goes. I mean, there really is no magnetic force that’s really going below the neck, but it still is a concern, right? I don’t want to stop somebody’s heart.

Also, just to tell you, it’s not indicated in pregnancy. I’ve done it in some pregnant people; they sign a waiver. ‘Cause ECT isn’t actually even approved in pregnancy with MDD, so this just doesn’t have that indication yet. There’s a lot to go through with the FDA. Nobody knows.

So, here are some of what the response rates are. This is not shocking. It should not be painful. It’s not going to do “One Flew Over the Cuckoo’s Nest.” It’s a really good movie, but it really messed us over for ECT. It’s not what we’re doing — we’re not torturing somebody. But we see that there are both response rates and then the remission rate. There are over 200 studies right now. Lots of meta-analyses, definitely beats placebo. You can look at — remember, the big studies with psychotherapy and medication together, response rates are around 55%. So, this is pretty amazing. I still believe, in the biopsychosocial kind of model, I think that if I can reduce some of the symptoms, then they can probably get those gains in therapy that they never could get as well, to have that longevity. I always thought that psychiatry always has dark humor, right? Food is looking back at you, you should take your meds.

So, just in conclusion, what I really wanted to kind of cover today was just a little bit of an overview of TMS. Give you just a little bit of where the science is going, especially for MDD right now. I’ve just had some really good responses — ours are around 78%. So, I can beat that one out just a little bit, but I do take a different approach, and I like using both the normal and the theta burst together. The FDA — now, the theta burst has the same amount as Tesla, but it’s only three minutes. And there are some people or some practices that will only do the theta because it is FDA-approved. But your remission rates really go down. And not judging them, but I think that just doing that treatment every three minutes — it might be profitable, but it’s not efficacious. The best evidence has been to use both the normal version of theta together. So, I want to give you a little bit about TMS, a little bit about Family Care Center. We’re dedicated here to our military DOD and our vets, and then, of course, our community. Really, we’re kind of here to stay for Colorado Springs, and maybe I’ll venture out a little bit as we start kind of growing a little bit. But I wanted to give you just a little overview, and I really appreciate the invitation to talk to you all.

Thank you for watching this video. We hope you enjoyed the presentation.

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