Steve Martorano 
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The Behavioral Corner
Hi, and welcome. I'm Steve Martorano, and this is the Behavioral Corner; you're invited to hang with us as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and well-being. So you're on the corner, the Behavioral Corner. Please hang around a while.

Steve Martorano 
Hi, everybody, welcome to the Behavioral Corner. It's me again. We're rolling through our new year, 2023. We can only hope. He said knocking on wood here on the corner, that '23 is better than what we've been experiencing lately. Anyway, what we do here on the Behavioral Corner is hang out and it's my good fortune, and the dint of hard work. We run into very interesting people, we think anyway. And we hope they're informing you on a broad array of topics. I mentioned that this podcast is essentially about everything. Because as far as I'm concerned, that's what affects our behavioral health, everything. So if you're just finding out about us, check us out wherever podcasts are our had. And if you'd like it, we have lots of shows up in the library. Subscribe, we would appreciate it. It's all made possible by our underwriting partners, Retreat Behavioral Health, they don't only provide us the financial means to do the podcast. But very, very often we reach out to their people to get some really expert information. That's what to look for today with our guest, Dr. Roger Ayres. This is his first this isn't the Behavioral Corner. So we appreciate his time. A very brief and condensed resume for Dr. Ayers. He's board certified in addiction medicine, as well as child, adolescent, and adult psychiatry. He is with us in his capacity as Retreat's Chief Medical Officer and he's here to talk about something called T-M-S. Dr. Ayers thanks for joining us on the Corner.

Dr. Roger Ayres 
Thanks for having me.

Steve Martorano 
So you and I have been talking about this for a day or two getting ready to do this. We have done a show or two about TMS treatment. I have some acquaintances near where I live psychiatrist who administer TMS. They're good guys. I spoke to them before I spoke to you. Interestingly enough, what he said to me was, he still finds that his client base is confused about what it is what TMS is, and what it's intended to do. So we thought we'd circle back and see if we can clear some of that up. First of all TMS. What's it stand for?

Dr. Roger Ayres 
It stands for deep trans magnetic stimulation. And it is a treatment that is currently being used for various different mental illnesses.

Steve Martorano 
Okay, I want to get into what it's used for in a bit. So this is electricity in your brain. When I talked about this in the past, I know they were not the same things. My first impression was, well, gee, this sounds like an electric shock and electric shock was really, it really not what we're talking about. But there's such a negative connotation about that treatment, primarily through the movie, One Flew Over the Cuckoo's Nest where Jack Nicholson has given that stuff. What is different about TMS and electric shock?

Dr. Roger Ayres 
Oh, by the way, just to back up the "T" is transcranial. I think I left up the cranial because that's important because that implies that it goes on the cranium, which is the brain. So it's transcranial magnetic stimulation. What is the difference between this and electroshock? So with this, what you're doing is you're putting kind of like what looks like a helmet on your cranium -- on your brain. And you're using electromagnetic magnetic fields to target certain areas of the brain, depending on what you're trading. And these electromagnetic fields are going to generate either excitation or inhibition of certain neurons deep inside the brain, which over time, then translate into, ideally, the amelioration of certain mental health conditions. ECT is different. ECT is more invasive. That's probably the first thing I would say. Meaning that you know, there's anastasia required it's done and usually, like a very controlled kind of a setting, and what you're sort of doing is inducing a seizure. It's a very controlled seizure. And that's kind of the spirit in which ECT is used to kind of, I don't want to say necessarily reset the brain but to impact the brain. But again, it's it is more invasive than something like a TMS.

Steve Martorano 
So who would be --- or what types of disorders or problems would TMS be suited to?

Dr. Roger Ayres 
So it's approved for four indications at this point, and those are major depressive disorder, anxious depression, obsessive-compulsive disorder, and smoking addiction. Should, those are the four indications that it's approved for. However, if you go on the website, or you kind of does a quick search, you'll see that it's sort of experimentally being used on a whole host of other conditions. However, I'm going to limit myself to just the approved conditions at this time.

Steve Martorano 
Yeah, we're gonna have you back at some point to talk about a lot of what I refer to as "the wild west in psychiatry," but that's for another day. So what...smoking? What is smoking have in common with anxiety, and depression, that TMS would have an impact on?

Dr. Roger Ayres 
it's all brain related. So you're just kind of just looking at different areas of the brain. And that's why actually each indication requires a different coil. The coil is kind of the, without getting too technical, it's the thing in the helmet that you put on your head that is going to generate these magnetic fields that are going to kind of be providing the treatment. So it's...think of it as a different part of the brain. So the common thread here between all of this is that it all appears in the brain.

Steve Martorano 
Well, smoking is one of the indications for TMS, so why not other substances, potentially addictive substances like opioids or cocaine or whatever?

Dr. Roger Ayres 
Yeah, good question. So that's sort of what I alluded to earlier when I said that it's being tried for a whole host of other conditions.

Steve Martorano 
So they are using it for...

Dr. Roger Ayres 
Experimentally and they are running trials, as we speak, on other substance use disorders.

Steve Martorano 
So I hate to use the term "garden variety problems," but of the more, I guess, prosaic things, depression and anxiety, for instance, is it true that TMS is most recommended for people who have been not having success with other means of treating those things?

Dr. Roger Ayres  
That's the way it usually winds up going. I know, something that you and I talked about is just how things are very insurance driven, and our field, I would argue most medical fields, but since we're talking more behavioral health, definitely in behavioral health. We have to follow the payers. If you look at a lot of the insurance companies, they will require some kind of failure of treatment before they even think of authorizing and paying for TMS. So the reality is, while it's you don't have to have done that, most people are going to have to show that they failed, and I think most insurance companies require two different antidepressant trials that you would have had to have failed. Plus, you have to have had a course of psychotherapy. If I've looked across all the different insurance companies, there are some minor nuances. I've seen some that require medication trials, but overall, that's kind of sort of the standard, you have to fail two medication trials and a round of psychotherapy, and then they will pay and consider payment for TMS and approve and authorize it.

Steve Martorano 
So someone who is struggling should be dissuaded. Right right now that you're going to be able to walk into a physician's place who offers TMS and just get it by asking for it. I guess unless you want private pay?

Dr. Roger Ayres 
If you want private pay. So if you self-pay and you want private pay, then you would still have to go through an evaluation and make sure that you're meeting one of these approved indications with the understanding that in a private physician's office, they could choose to use it for an off-label indication. But that would certainly be something not covered by insurance. But since we're talking about the idea of self-pay, that could open up a door there where you didn't have to fail a trial number one and then number two, that also opens the door potentially for an off-label indication if everyone involved is comfortable with that.

Steve Martorano 
Dr. Roger Ayers, Chief Medical Officer for Retreat Behavioral Health, is our guest. We're talking about TMS. But let's take one moment, can we take one moment and can you explain off-label for people? When...there are loads of examples of this. Some of them you probably aren't even aware of that there is a use that they are not, I guess, technically approved for but other uses that are okay. When we say label, does that mean they're under the table or dangerous? What does it mean?

Dr. Roger Ayres 
Yeah, I know it might sound a little...

Steve Martorano 
A little shady.

Dr. Roger Ayres 
Yeah. These are when I say off-label. What I'm technically referring to is that they're not officially approved by the FDA today. However, there's probably been either a paper or some study. Here's our individual use, or maybe a colleague has had success with it in some way, shape, or form. It's kind of known in the medical community that this has shown success, but it hasn't gotten the formal green light from the FDA and probably hasn't gone through that rigorous amount of testing. So it is, I wouldn't say you know that there are risks, there are probably more risks associated with that than something that is being tested, and tried. And trials and things of that nature. This would probably maybe increase the risk a little bit more. And that's why, you know, this would be a risk versus benefit conversation with a physician that is comfortable using an off-label indication.

Steve Martorano 
Well, let's talk a little bit about the side effects. Are there any side effects? And what are they to TMS?

Dr. Roger Ayres 
It is minimal, I think the ones the big ones are site pain. So site pain is the site at which we put the helmet on. Jaw pain and just discomfort around the area that we're trading, which is the helmet area. So think like headache type stuff, you know, all in all, it's a pretty safe treatment; there is a slight risk. And the makers, the company, want me to emphasize that it's an extremely small risk, but I think it's worth mentioning there is a risk of seizures. And you know, there are certain conditions with which you want to be just mindful before using TMS. There's only one absolute contraindication. And that's if you have any kind of mental...mental implantation in your brain of any kind, then you cannot get the TMS. But there are other conditions, pre-existing conditions, that certainly warrants a conversation before undergoing TMS because that would then include the risk.

Steve Martorano 
I'm guessing, then, that there's a certain amount of preparation that the patient needs to do.

Dr. Roger Ayres 
Absolutely.

Steve Martorano 
In order to be ready for this.

Dr. Roger Ayres  
Yeah, so it starts out with like an evaluation would be the first start. And that's why it's usually a psychiatrist that's approved to do this, although, you know, I'm told that other, you know, you need to be a physician, it gets a little bit confusing because certain insurance companies require psychiatrists to do it. Some are a little bit less stringent, and they allow a physician of a respective specialty, so something like internal medicine or family practice or something that nature, they would allow them to do it as well. And then once you get that evaluation, and it's determined that you meet one of these indications, the next step would be a brain mapping, where you map the area of the brain, what's called the more motor cortex, and where you're trying to find that area of the brain specific to the conditions so that you can do the treatment. And then after the mapping, then you start the formal treatment sessions. So that's the sort of what the steps would look like.

Steve Martorano 
So the mapping allows you to place the electrodes where they need to be isn't a technician or a physician, who then you know, performs the TMS on the patient?

Dr. Roger Ayres 
So it would be a physician that does the evaluation on the mapping, it would likely be a technician that does the actual treatment once we've determined where exactly in the proper positioning of the helmet and the coils, once we determined that it would likely be a technician. And then usually, you know, there should be a physician, some kind of nearby or accessible.

Steve Martorano 
Are they able to, during the session, increase or decrease or move around the electrical impulses during the session is that what's going on?

Dr. Roger Ayres 
Well, it's a set amount, it's like a, like a burst, there's so many, I forget what they call it, but you get so many in a certain amount of time. So the treatment lasts about 20 minutes, and then that 20 minutes, you're getting the electrical stimulation so many times, and so the area of the brain and the intensity is determined prior to the treatment. And sometimes, before you start the treatment, if something has changed, you may want to revisit and sort of do a quick REMAP to make sure that you're still going to use the same area and the same intensity. But for the most part, once you have the area of the brain and it's mapped and the intensity, that's sort of like a setting that you either put in the machine or your chart and it's already known, so you're not necessarily doing it every time. So this allows the technician to kind of just know and just continue with the treatment.

Steve Martorano 
Yeah, and have a baseline. What do we know what new patients tell us they're experiencing during the session 20 minutes with the helmet on? What are they...are they sleeping? Are they awake? Do they talk to them? What do they do?

Dr. Roger Ayres  
I don't think they sleep. You definitely know the machines there, you know, it makes a noise. Yeah, it can vary. I think there are some patients that find it not painful, I guess the word I would use is it can be a little bit uncomfortable, you know, and most patients haven't had something like this on their head, you know, with electromagnetic fields going through their brain. So I think it could take a little bit of getting used to. And maybe that's an important point for me to make that you don't go straight up to that intense level. You kind of work your way up, usually. And ideally, over the first three to five treatments, I believe, to get to that goal, that level of intensity. So that's just a long way to say that different people struggle with it differently. Some people have no problem, and then I can get to the intensity sooner rather than later. And for some people, I need a little bit more of a warm-up, if you will, before I can get to the intensity. (You're) supposed to get to 120% to provide the most effective treatment.

Steve Martorano 
Well, it already sounds much less traumatic than one's first MRI when they put you in the tube, and you're encased in this machine, which is very if you're claustrophobic, it can be difficult. And it's noisy, and it's long, and you must stay still. I've had one of those and don't wish to have another. This sounds like it's open. And it's in sort of a physician's chair. Not unlike a dentist's chair, and you're sitting in a room and in an office. So it's, it's in no way as potentially scary as going inside of the MRI machine. You use a good point to talk about the intersection of this technology and your specialty, which is psychotherapy. Where, and how do they come together? I mean, I don't want people to leave a discussion of TMS thinking, Oh, good, I don't have to worry about this or that or this. I'll just go into the machine, put it on, have eight sessions and be okay. What's the intersection between this technology and this treatment and psychiatry?

Dr. Roger Ayres 
Well, I mean, this is all part of psychiatry. But I think in the field of psychiatry, psychotherapy and medications have been kind of the mainstay for a long time. And I think that you know, for patients that get TMS, it's not uncommon to also be on medication simultaneously. In fact, the recommendation is to not make any changes, especially while you're going through the whole TMS treatment. Maybe this is a good time to explain how long the treatments are. So I've mentioned each treatment is 20 minutes, but the total length of treatment is. There are kind of two phases. There's an acute phase and a maintenance phase. The acute phase is for the first four weeks, and during those first four weeks, it's every day, so five times a week. And then, after that acute phase, it's what's called the maintenance phase. The maintenance phase is eight weeks after that can be a little bit longer depending on the person and the patient. And that maintenance is about two times a week. So when all of a sudden done, you're looking at about 12 weeks, and as I said, the first four weeks are probably a little bit more intensive, where it's five times a week. But on the flip side, a lot of the treatment usually takes in the first four weeks, meaning you're going to get the majority of your result in those four weeks, and the eight weeks are just maintenance. So it's not like you're waiting for all the way for 12 weeks to feel any results. It's not like that. Generally, what I'm told is that in the first four weeks, you get the majority of the improvement is seen. If you're...if you're going to respond to the TMS in the first place.

Steve Martorano 
Yeah. Yes, you prior to the treatments being administered or even recommended. Are there potential subjects who you would evaluate go? No, they're not good candidates. Can you jump before you go in whether some people are, are better candidates than others?

Dr. Roger Ayres 
You always want to be mindful for, you know, what I said earlier, where you know, the absolute contraindication being the metal implants. But then I think there are certain other conditions that you definitely want to be mindful of. Someone who's actively abusing drugs or alcohol is probably not a good candidate that could potentially increase the risk of seizures, and then, you know, obviously, it would affect the whole treatment. And overall, I think someone with a seizure history you have to be mindful. It's not approved during pregnancy. So if someone is thinking of maybe getting pregnant during the treatment or is already pregnant, I mean, these are all things that we would want to be mindful of. Those are things that are usually assessed in the evaluation and so, you know, those patients have a risk versus benefit conversation to see if the treatments are even appropriate for them.

Steve Martorano 
I guess as, as we sum up here about TMS, where do you think it sits on the continuum of care with regard to pure mental health disorders? And then Addiction Medicine? Which is it just coming up? Is it brand new? Where is it? Where do you think it's going?

Dr. Roger Ayres 
TMS, I think it's been around since, I believe, don't quote me, I think it's around 1985, something like that. And then that was sort of the first version of TMS it was...it was maybe not as effective, the treatments were longer. It wasn't probably the better mousetrap that we built now. I think in 2013. We came out with sort of the next phase of deep TMS treatment, which I think is much better than the original one. But that's normal in medicine. We, you know, we kind of revise, and we make improvements along the way, as we've done with the TMS. So, since 2013, I would say I think, you know, the treatments have much improved. And, you know, on the continuum, it's used for both mental health disorders, and it's while smoking being the first one, but I have to wonder if it will ultimately be approved after the clinical trials, you know, it passes muster with the clinical trials, that it might be approved for other Addiction Medicine and substance abuse disorders. So I think it probably would be used for both again, you know, I don't necessarily think we're going to abandon psychotherapy or medication-assisted treatment, or things of that nature, or psychotropic medication for mental health disorders. But I think it's an option. There are patients that might have failed medications or that don't want to try medications. And I think that it serves as another option to get help.

Steve Martorano 
Yeah, I mentioned it here towards the end of the interview because, as you know, we live in an instant gratification culture, we're looking for something fast, and these new technologies and treatments are boring. We're being bombarded with information about them, some of it not so very good. Just want to leave you with this. I don't know if you have seen them. But I certainly have ads online. For the use of something like TMS. It looks like TMS in the ads -- you're at home, you got to things on your head, a dial in your hand, and it says from the comfort of your own home. What do you think about something like that?

Dr. Roger Ayres 
I think you got to be really careful. I think that a lot of things like that come to market online. I think in the medical community, we're very leery of that. At the end of the day, I really do think it's "buyer beware." And I say that because a lot of these kinds of medical devices that they sell online haven't been tested, you don't have the efficacy data, and you don't necessarily know the side effects. I think what's hyped up is just what it can do, and sort of how quickly it can do it, kind of what you alluded to before, which is the instant gratification, and that appeals. And that, you know, that's a hook for a lot of people. And then the problem with that is that you know, without, you know, kind of just taking the time to sort it all out, you sign up for something. It not only may not help, but it could potentially be harmful. So that's why I say, "buyer, beware."

Steve Martorano 
Yeah, we mentioned all of this because, well, everything I've read, experts like you have been on the program. In fact, we had the president of the company that built the technology that Retreat uses on the way back. It is getting better. We want to always make sure we're not telling people that this is the magic bullet. This is a this is this quick way in and out of a serious problem. Is it not that it is effective? Yes. It has been effective. It will be continued to be effective, we hope. Are you a candidate? As professionals, don't read ads to figure all that stuff out. Dr. Ayres, thanks so much for your time. I do want to put this in your ear because I'm going to reach out to you soon. Again. We talked about it off the air. We're at the dawn of this land rush, I call it psychedelics and psychiatry. I know that you're feeling...you have strong feelings about it. Can we get you back to talk about that down the road?

Dr. Roger Ayres 
Of course. I'd love that.

Steve Martorano 
Terrific. Dr. Roger Ayers, chief medical officer of Retreat Behavioral Health. Thanks, doc. I appreciate your time.

Dr. Roger Ayres 
Thank you.

Steve Martorano 
You guys as well. Thanks. Don't forget to push the subscription button. Appreciate it. See you next time on the Behavioral Corner.

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