NeuroScience & TMS Treatment Center

01/27/2023

A common question that comes up in consultation is, “What is Bipolar Disorder?”

There is a lot of confusion regarding this diagnosis because of the colloquial use of the term “bipolar.” This term is thrown around to describe instances of intense emotional outbursts, frequent mood swings, unpredictable behavior, or even an excuse for poor behavior: “sorry I went off on you, so bipolar of me.” Very different from the colloquial meaning, the medical meaning is a more defined psychiatric illness that can be controlled with appropriate treatment.

Most people are familiar with the diagnosis of depression and what that looks like. Bipolar Disorder consists of episodes of depression as well as episodes of mania or hypomania. These manic or hypomanic episodes with which most people are less familiar. Mania is a mood state that is defined as a period of abnormally and persistently elevated mood or irritability that is very different from someone’s normal personality lasting one (1) week or more. It is combined with at least 3 of the following symptoms: inflated self esteem, decreased need for sleep, excessive talking, racing thoughts, being more easily distracted, increased goal directed activity (work, cleaning, etc), and impulsive behavior out of the norm (spending sprees, sexual behavior, etc). Hypomania which are episodes which are lower manic symptoms (hypo) and only need to last four (4) consecutive days and are less severe in their presentation than mania. To be diagnosed with bipolar disorder, someone needs to meet criteria for having at least one manic or hypomanic episode and a depressive episode. Those people with depressive episodes and manic episodes are diagnosed with Bipolar I Disorder, and those with depressive episodes and hypomanic episodes are diagnosed with Bipolar II Disorder.

Both Major Depressive Disorder (MDD) and Bipolar Disorder (BD) fall under the category of mood disorders. Because the treatment of these brain illnesses is different, a clear and accurate diagnosis is important to make sure the right treatment is given. MDD is treated with antidepressants, psychotherapy, and specific neuromodulation treatments. BD is treated with mood stabilizers, other pharmacological agents, psychotherapy, and some neuromodulatory treatments (VNS and ECT), depending on which mood state the person is suffering (depression, mania, or hypomania). Treating someone with bipolar disorder with antidepressants, even when they have depressive symptoms, could make them feel worse. Getting an accurate diagnosis, though, can be difficult as some people have difficulty seeing the symptoms of hypomania and mania. Patients can be unaware of hypomanic episodes and therefore don’t report the symptoms to their physician making Bipolar II Disorder one of the hardest brain conditions to diagnose. In order to obtain an accurate diagnosis, find a clinician you trust and see them consistently for a period of time because getting to know someone in their different mood states can help clarify the diagnosis.

01/07/2023

Visit www.hopeforyourbrain.com to learn more...

01/04/2023

Medication Treatments for Depression - There are a number of helpful medications for depression. These medications are separated into different classes based on how they work in the brain to help alleviate the symptoms of depression. I will describe these classes below. The majority of them are very safe with few side effects. Choosing which one to start with involves a careful evaluation and weighing out the pros and cons to each one. All medications have about the same effectiveness for patients; all medications have the same likelihood of alleviating symptoms alone and with psychotherapy.

There are some claims that doing genetic testing can help to choose the right antidepressant for an individual patient but the evidence behind those claims has been modest. Pharmacogenetic testing can tell you what medications you might metabolize normally and which ones you may metabolize abnormally. This can give a prescribing clinician some insight into possible risks of side effects but little information about which medication will be best or what doctor’s call “most efficacious.”

As a psychiatrist, the most important piece of information I want to get out there is that while there is a large (almost overwhelming) number of medications, but there are only a handful of classes of medications. If you have tried and not responded to one, maybe two, medications in a particular class, there is no reason to continue to try other medications in that same class. I see too many patients that have been on 4 or 5 medications from the same class without any benefit. It is hard to get insurance to pay for something like esketamine or Transcranial Magnetic Stimulation (TMS). If only one class of medications has been tried.

These are the classes of antidepressants that are used for Depression:

Selective Serotonin Reuptake Inhibitors (SSRI): Zoloft (sertraline), Prozac (fluoxetine), Lexapro (escitalopram), Celexa (citalopram), Paxil (paroxetine), Luvox (fluvoxamine)
Serotonin/Norepinephrine Reuptake Inhibitors (SNRI): Effexor (venlafaxine), Cymbalta (duloxetine), Pristiq (desvenlafaxine), Fetzima (levomilnacipran)
Dopamine/Norepinephrine Reuptake Inhibitors (DNRI): Wellbutrin (bupropion)
Tricyclic Antidepressants (TCA): Pamelor (nortriptyline), Elavil (amitriptyline), Anafranil (clomipramine), Topramine (imipramine), Norpramin (desipramine)
Monoamine Oxidase Inhibitors (MAOI): Parnate (tranylcypromine), Nardil (phenelzine), Emsam (selegiline)
Other - these don’t fit into other classes: Remeron (mirtazapine), Viibryd (vilazodone), Trintellix (vortioxetine), Deseryl (trazodone)

In addition to classes of antidepressants, sometimes medications are added to antidepressants to make them work better; these drugs are called augmentation agents: Abilify (aripiprazole), Rexulti (brexpiprazole), Eskalith (lithium), Cyomel (liothyronine), Stimulants, Buspar (buspirone)

It is important to note that the TCA, MAOIs, and augmentation agents carry significantly more side effects and risks with them than the SSRIs, SNRIs, DNRI, and “other” classes of medications. The “other” class of medications all work through modulating serotonin and norepinephrine but in unique ways. There are also some medications not listed that are sometimes used as “off label” treatments.

A typical strategy is to start with SSRIs or bupropion then move on to SNRIs or the “other” class. TCA and MAOIs are often reserved for people who have not responded to the previously listed classes due to their side effect profile. Realistically, though, after failing to receive symptom benefits from two different class medications, it is time to consider something like TMS which has a higher probability of getting someone well.

At the NeuroScience & TMS Treatment Center, we have several treatment options we can use, beyond common medications and therapy, to aggressively treat you for brain diseases. Learn more about our treatments and services on our Comprehensive Behavioral Health Page.

Michelle Cochran, MD, DFAPA
Founder & Chief Medical Officer • Medical Director, Nashville Locations

Dr. Cochran has been living and working in the Nashville area for over 25 years. She supervises the skilled Nurse Practitioners who work in our clinics. She has been offering TMS services since 2011 and lectures and consults nationally and internationally about TMS. She is Board Certified and is a Distinguished Fellow of the American Psychiatric Association. Learn more about Dr. Cochran.

Jonathan Becker, DO
Medical Director, Brentwood Locations

Dr. Becker is a native of Tennessee, born in Memphis. He completed his undergraduate and master’s degrees in Developmental Psychology at Tulane University in New Orleans before attending Des Moines University for Medical School. He completed his psychiatry residency program at Vanderbilt University and served as a faculty member there for 7 years before transitioning to our office. While at Vanderbilt, Dr. Becker served as the medical director of the neuromodulation service from 2017-2020. Dr. Becker has also published many psychiatric articles. Learn more about Dr. Becker.

12/20/2022

Winter is Here!

The nights are longer and the days chillier

For many people, the holidays bring up a mix of emotions: joy, sadness, and anxiety to name a few.

In the midst of any activities, don’t forget to be 'present' for yourself this holiday season.

Here are a few ways to care for yourself this month.

Take a walk. Even short (10-15 minute) walks can boost our mood, improve attention & reduce anxiety. If you find yourself sitting inside most of the day, a quick walk around the block can help you stay alert and feel refreshed.

Drink water. It is easy to reach for more coffee, but our bodies need water. Try to keep a water bottle nearby and fill it 3-4 times a day outside of meals.

Prioritize sleep. Try turning off your electronics 30-60 minutes before you want to go to sleep. Scrolling on our phones in bed is hard to resist (Instagram reels). Unfortunately, this activity often keeps us up longer and makes falling asleep more difficult once we do turn off our phones. Try a book or magazine instead; it stimulates the brain less, and is easier to put down.

Fuel your spirit. We can’t pour from an empty cup, so make time to do something just for yourself this month that will “fill you up.” Perhaps that is an outing with a friend, reading a new book, taking a bubble bath, or attending a concert. Make out time for yourself this season and give yourself the gift of being 'present'.

12/02/2022

Whether it is due to grief for a departed loved one, family discord, isolation, loneliness, being "stuck inside", or any number of reasons, so many of us struggle through this time of year despite being told that it should be joyous and happy.

My wish is that those who are struggling will reach out for help...reach out to a trusted friend/family member, or to a mental health professional.

12/01/2022

Sean has been working with Neuroscience & TMS since May 2022 and is extremely passionate about being a resource for individuals along their mental health journeys. He graduated with honors from the University of Tennessee at Chattanooga, earning a Bachelor of Science in Psychology. He is currently a second-year graduate student at the University of Vanderbilt, working towards earning a Master’s in Clinical Mental Health Counseling. He plans to continue his education through earning a doctorate in clinical psychology.

11/25/2022

Year end staff workshop photo setup. Amazing group of young professionals, tecnicians and office managers that run our 4 offices. Many with clinical aspirations of their own, we thank Lauren and Brogan for the "vibe check" for all new hires!

Wishing you a safe and Happy Thanksgiving

11/23/2022

Psychedelics

Psychedelic medications are all over the current media. Not a week goes by where we are not asked a question from a current or an exciting patient. At the NeuroScience & TMS Treatment Center, we began offering the first legal psychedelic treatment in our clinical practice for Major Depressive Disorder and Suicidality almost two years ago.

What are psychedelics? The word "psychedelic" refers to the drugs and naturally occurring substances that can help treat brain disorders medically and psychologically. Psychedelics are NOT new. These substances have been used in most of the world for thousands of years, but they’ve been illegal in the United States since the mid-1960s because of perceived negative effects.

Some research suggests psychedelics can treat a range of brain disorders under expert medical supervision. Esketamine (Spravato) is the only current legal psychedelic medication, and it is covered by insurance. There are Phase 3 FDA trials that may bring M**A and psilocybin into the realm of FDA approved medications in the next few years.

What are the effects of psychedelic medications?
Psychedelics are substances that have dissociative or brain altering effects. The substances produce a feeling of relaxation, empathy, and sense of well-being or even a spiritual connectedness.
Sometimes, these substances have side effects, such as:
Uncomfortable reality distortions such dissociations or hallucinations
Overly intense emotions
Or even fearfulness or paranoia
How are psychedelic medications used?
In a therapeutic setting, a physician and a therapist or trained technician can help in treating depression and suicidality now per FDA approval; in the future, it is expected that post-traumatic stress disorder (PTSD), addiction, and other anxiety disorders will be approved indications.

What psychedelics can treat mental health disorders?
Esketamine (Spravato) is the only current legal psychedelic medication, and it is covered by insurance.

Other psychedelics could be effective in treating mental health conditions. There are Phase 3 FDA trials that may bring M**A and psilocybin into the realm of FDA approved medications in the next few years.

Some of the most well-known psychedelics are:
M**A, 3,4-methylenedioxy-methamphetamine, used illegally as "ecstasy", has Phase 3 trials underway for the treatment of PTSD;
Psilocybin could be useful for addiction, anxiety, and depression;
Ayahuasca is a South American tropical vine that might help treat addiction, depression, and anxiety; and
Lysergic acid diethylamide (L*D) which is presently an illegal drug, "acid", that alters mood, perception, and consciousness.

How are psychedelics administered?
Esketamine (Spravato) is the only current legal psychedelic medication, and it is covered by insurance. It is a nasally administered medication. The environment in which treatment is critical to its success. NeuroScience & TMS Treatment Center has currently developed two safe, comfortable environments for patients undergoing care with Esketamine. Following the treatment, we are developing integration therapy to help you process your experiences meaningfully.

Many of the other treatments are currently illegal, there are no standardized administration methods.

To find out more about our innovative, evidence-based treatments, call, email, or text the NeuroScience & TMS Treatment Center or request an appointment.

11/16/2022

Profile of our TMS Technician, Lillian Garrison

Lillian has been working with NeuroScience and TMS Treatment Centers since June. Prior to that, she attended Auburn University where she was awarded a Bachelor's degree in Psychology. During her time at Auburn University, she gained experience with DPICS (Dyadic Parent-Child Interaction Coding System) and PCIT (Parent-Child Interaction Therapy). Recently, she attended the PULSES course through the Clinical TMS Society. Lillian is planning to continue her education in psychology and begin a LCSW program next year.

11/04/2022

ECT is the oldest biologically based treatment in psychiatry. The first treatment was performed in 1938. The first ECT patient had a condition we now call catatonia. Catatonia, untreated, is nearly 100% fatal. This patient would have died in a state psychiatric hospital as many people at the time did due to untreated mental illness. Instead, he demonstrated full resolution of his symptoms and was discharged from the hospital. This was nothing short of a miracle at the time.

Many people have misconceptions and fears regarding ECT based on outdated media representations. The nuts and bolts of it is that the brain is an electrical organ like the heart. The electricity is used to generate a seizure (which is essentially generalized electrical activity in the brain). The brain responds by suppressing the seizure and reorganizing itself. We do not fully understand how this treats mental illness but we do know that people get better, there is normalized activity in the brain, and even increased volume of different brain regions that are abnormal in mental illness.

The problem with ECT is that it is time intensive and disruptive to a patient’s life. It requires general anesthesia three days a week and can cause temporary memory issues that result in the patient being unable to work or go to school until a few weeks after ECT is completed. Because of this, psychiatry is working to develop less invasive methods of using electrical stimulation to treat mental illness. This is where we hope advancements like TMS, Vagal Nerve Stimulation, and Deep Brain Stimulation can take us.

11/01/2022

Dr Becker spoke at the CTMSS PULSES conference in Sonoma, California.

10/28/2022

Obsessive Compulsive Disorder (OCD) may be the most misunderstood psychiatric illness. Most people have heard someone say, “well that’s my OCD” or “I’m OCD about cleaning my house.” OCD is not simply wanting things to be neat and orderly or having to do things a certain way. It is, at times, a debilitating brain illness characterized by having obsessions and compulsions. An obsession is a thought, urge or image which is often repeated and intrusive in nature. The thoughts, urges, or images can cause significant distress. A common symptom of OCD is a contamination obsession where a person repeatedly thinks that they or someone else will get sick by coming in contact with something specifically. Another common symptom is a fearful obsession whereby a person has mental images of assaulting or injuring others people. Still further indiduals with OCD can have obsessions that are intrusive taboo thoughts, like inappropriate sexual thoughts, or even magical thinking such as “if I don’t do this thing, my family will be in an accident.” There are many other examples and types of obsessive symptoms. A compulsion is a behavior driven by an urge to alleviate the anxiety or emotion caused by the obsession. This can include various rituals: counting, putting things in order, praying excessively, reassurance seeking from others, and similar.
OCD is treatable. Often patients are embarrassed by their obsessions or compulsive behavior and do not want to talk about them. OCD Treatments include medications (Serotonin Selective Reuptake Inhibitors, Clomipramine) and a type of talk therapy called Exposure Response Prevention (ERP). Transcranial Magnetic Stimulation (TMS) with ERP has been FDA cleared for the treatment of OCD since 2018 when medications do not work. Because we understand the neurocircuitry involved in OCD better than any other mental illness, there is a procedure called a cingulotomy which can be performed in the most severe cases that don’t respond to Meds, ERP, or TMS
Most of the time, OCD symptoms begin in childhood. Occasionally, the symptoms will go away as a child grows older, for others OCD becomes a lifelong condition that requires ongoing treatment to control symptoms.

10/21/2022

Ketamine & Esketamine: Busting the Myths

The drug, ketamine, comes in a variety of forms, potencies, and uses. For example, the medical community often uses it at high doses as an anesthetic and/or to help manage pain. Additionally, at lower, sub-anesthetic doses, clinicians may use ketamine to help treat depression. Nasal esketamine (Spravato®), which is the only FDA-approved ketamine-based treatment for depression, is an example of this. Unfortunately, however, people also commonly abuse ketamine for its hallucinogenic and dissociative effects.

With such a vast array of uses, forms, and potencies, it is no surprise that ketamine has become shrouded in myth and mystery. So, we are here to help separate fact from fiction and bust some of the most common myths about ketamine and esketamine. Read on to learn more.

Myth: Ketamine is a “cure” for depression.
This is not true. The benefits of ketamine (and esketamine) on depression typically wear off within a couple of weeks to a few months, at best. In nearly every study with these medications, patients needed to be on a maintenance treatment schedule to keep the antidepressant benefit of ketamine (or esketamine).

Myth: Ketamine is safe for everyone to use at home.
This is not true. There are online ketamine advertisements for at-home shipments of oral ketamine, ketamine suppositories, or compounded nasal ketamine to be administered in the home. There are two major concerns with at-home ketamine:
The amount of drug that is actually absorbed through these oral, suppository, or nasal ketamine formulations is POOR. The FDA has submitted adversaries about these formulations which were not FDA-approved.
Although rare, ketamine and esketamine can cause elevations in blood pressure which could cause a stroke or heart attack. Administration with esketamine must be done per a Risk Evaluation and Mitigation Program (REMS). Therefore, these medications should be given in a physician’s office where monitoring can occur.
For more information, reference the At-home Ketamine Warning posted by the FDA.

Myth: You can trust any clinic for ketamine treatment.
This is not true. Many ketamine doctors are not psychiatrists. They don’t have specialized training for treating depression and have not treated it throughout their entire medical career. Additionally, they are not specialists in treatment-resistant depression and are not able to truly discuss all treatment options available with a patient. Also, many of these non-psychiatrist clinics are CASH-PAY clinics, meaning the services they offer, including ketamine treatments, are not covered by insurance. So, treatments can be very expensive for patients. Unfortunately, these clinics often make false claims that the ketamine treatments will ‘cure’ a patient’s depression. However, we know from myth #1, that this is not true.

At NeuroScience & TMS Treatment Centers we are an in-network, specialized psychiatric clinic that evaluates patients thoroughly and assesses the risks and benefits of each type of treatment for each individual patient.
Myth: Esketamine treatments are too expensive for most patients.
This is not true. Though ketamine can be pricey, the ketamine-based treatment we offer, nasal esketamine (Spravato®), can be a very reasonably priced option. When choosing between ketamine and esketamine (Spravato), it is important to consider the costs. Both treatments will require maintenance sessions to maintain response. Esketamine (Spravato®) is the only FDA-approved ketamine-based treatment available and is covered by most insurance plans. This makes it affordable for most people. Ketamine is not covered by insurance. Additionally, those who begin ketamine treatments may be stuck paying thousands of dollars a year, out of pocket, for continued treatment in order to stay well.
Myth: Ketamine helps treat all sorts of psychiatric conditions.
There is not enough evidence to support this claim. However, we do know that ketamine and esketamine treatments have been scientifically studied and shown to help those patients who have failed to respond to multiple classes of antidepressants. In our office, we prefer to offer treatments with good response and remission data that have more durability before we offer Esketamine. Neurostimulation treatments, such as TMS (Transcranial Magnetic Stimulation), have an advantage over ketamine and esketamine. People who get better with TMS typically stay better without the need for any maintenance treatments.
Another group of people who ‘seem’ to particularly benefit from ketamine are people with a trauma history. This is not an FDA-approved treatment for PTSD, but there are many small studies that have shown that people who have experienced trauma are helped by ketamine and esketamine. Insurance covers esketamine for treatment-resistant depression (TRD) in adults and depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior.

10/19/2022

10/14/2022

TMS is a safe, non-drug, FDA-cleared treatment that uses gentle magnetic pulses to stimulate underactive areas of the brain, helping to better regulate mood in patients with depression. Often, TMS is even successful at helping treat depression in patients who have not been able to find relief through other methods, such as antidepressants and talk therapy. Read on to learn the answers to some of our patients’ most frequently asked questions about TMS.

What is TMS?
The acronym, TMS, stands for Transcranial Magnetic Stimulation. A TMS device uses an electromagnetic coil to generate a pulsed magnetic field. This pulsed magnetic field creates an electrical field in a small, superficial, part of the brain that has reduced activity in depression. The area of the brain that receives the electrical field propagates its activity in other deeper connected structures. Through repeated TMS treatments the brain learns (is trained) to continue the process, and recovers from depression, anxiety, and other mental health conditions.

Would TMS help me?
TMS is currently FDA approved for depression, depression with anxiety, OCD, smoking cessation, and migraine headaches. Depression is the most common reason someone might receive TMS treatments. TMS is helpful for people that have failed to respond to at least one antidepressant. Most of our patients experience significant improvement, if not, complete remission of their depressive symptoms.
Does Insurance pay for TMS?
Insurance will typically cover TMS treatment for depression, depression with comorbid anxiety, and sometimes OCD. Most insurance companies have developed their own criteria to assess whether a patient would qualify for the treatment. Most insurance requires an evaluation and prescription for the treatment with a psychiatrist. Some insurance required 2 or more antidepressant trials but other companies may require more antidepressant trials plus psychotherapy before agreeing to pay for TMS.

Are there side effects?

TMS is a very well-tolerated procedure. This is one of the major advantages of TMS over continuously trying new medications. The most common TMS side effect is experiencing a tapping sensation at the site on the head. Sometimes this sensation creates a headache during or following the TMS treatment. Typically, the side effects resolve within the first 3 – 4 days of care. There are very rare reports of TMS inducing a seizure. Most of these have occurred during treatment and were associated with excessive alcohol use, sleep deprivation (less than 4 hours/24rs), or with history of seizure disorder.
What is involved with TMS treatments?

TMS requires a time commitment as the brain needs time to be retrained out of the depression. TMS is generally administered 5 days a week for 4-9 weeks with approximately six tapering sessions over the last few weeks. Treatments typically last between 18 and 35 minutes a day depending on unique patient determinants. There are no restrictions following the treatments, which means you are able to drive, work, or go about your regular activities after a TMS session.

Are there any reasons I could not receive TMS?
There is only one contraindication: anyone with any implanted ferromagnetic metal objects in the brain cannot receive TMS. There are other considerations, which can be discussed with the physician in a TMS consultation.