Dr. Richard Bermudes (Part 2 of 3): Dr. Bermudes talks about the experience of TMS (including his own) as well as the future of neuromodulation as it transitions from research to practice. He is founder and medical director of TMS Health Solutions and founding member of the Clinical TMS Society. Part 1 can be found here: Transcranial Magnetic Stimulation: A Look Under the Hood.
David Carreon: Have you ever gone under the coil yourself?
Bermudes: Yes, I have. Several times. I think it's a procedure that is ... It's an interesting experience. Certainly I've sat through several treatments, in different systems, some of the coil types are different. I think it's a good thing to do. It's an interesting experience, and certainly, we all have our subjective sort of experience about what it felt like and what it did to our thinking, or mood, or whatnot.
David Carreon: No, I'm a big believer in that and especially done that myself within my own experience. It is really interesting, sort of the subjective effects and how it feels. What was your experience of, what does it feel like during the stimulation? What [crosstalk] the coil itself, when it goes off? What does it, what did you feel?
Bermudes: Yeah, you know, some of the descriptors that we use and that I would use, it's a tapping sensation. For me, underneath the coil, there's a lot of prickly, kind of pins and needles sort of sensation. I think at first, it's a bit like, oh, there is some sensitivity there. It's a sensation that seems to, at least my scalp, I was able to accommodate to pretty quickly. I was able to get up to a fairly high tolerance, even in the first couple of treatments that I did. There are times when we are on the sort of the trigeminal nerve, and there's sort of this optile [inaudible]. You can get some eye movement sometimes, some tearing. I experienced that as well during my couple sessions that I've sampled.
Jessi Gold: Is sampling just something that all people that do TMS do to themselves?
Bermudes: Yeah, I mean, I think experiencing that, sitting through actually complete treatment, I think is important. We actually have our doctors do it, unless there's of course, a medical contraindication. I think it's important the providers and the technicians ... We tend to have them do that.
Jessi Gold: Does it make you happier?
Bermudes: You know, for me, the way that my sort of subjective experience is ... I'm a big time trail runner, and I run basically every day about four to five miles. I get this sort of level of optimism after I run. Clarity of thinking, and I have a lot of ideas that I have during my runs. The four or five times that I've sat through a treatment, sort of randomly, they're not in a row, I have a similar sensation actually. Like I just went out for a nice four to five mile run, and sort of have this level of optimism about the day and clarity of thinking. That's been my experience. Not everybody has those sorts of immediate, sort of experiences with TMS. It can really vary.
David Carreon: I guess it depends on the day and the location. There's so many variables, and I think that the subjective effects of TMS are something that I think you need a lot more work. Because the standard story is, "No, you don't feel anything. It's just sort of the neuro-plastic effects over months," but I don't know. For some of my research subjects, and even myself and lab mates that have done it, there are some pretty significant subjective effects if you're at least either mindful enough or paying attention. It's pretty interesting. One of the times was this feeling of, for me it was more or less of a euphoria and more of a confidence, more of a mastery or control feeling.
Bermudes: Yeah, I would say it was that way for me as well. I tend to feel that way after I run. It's sometimes euphoric, but yeah, definitely a sense of here's what I'm going to do today and I can do it. Clarity of thinking.
Jessi Gold: Do you feel like if everybody felt like that, then they just wouldn't go for a run and would just put a magnet to their head?
David Carreon: What about recreational TMS?
Bermudes: I actually have thought about that. I'm kind of glad I get that, because it provides a lot of positive reinforcement for me to run. There are times when I start out in the day not wanting to, and I just sort of tap into that feeling. I'm getting this done, because I know I'm going to feel this way. Yeah, I'm glad there's not like a little device in my closet that I can kind of access, because I certainly know that I would slide on the exercise.
Jessi Gold: I think everybody would.
David Carreon: Any lab break-ins or clinic break-ins to TMS stimulation?
Bermudes: Not that I know of or will admit to.
David Carreon: This does raise the question of, I mean I know that with antidepressants, some of the probably more fringe opinions, but you know, everybody would be better if they were on an antidepressant. That antidepressants make anybody happier. Would you say something like that might be true of TMS, in a different world with different laws? What do you think it's doing to you or to me, to make us feel good, and is that a good idea?
Bermudes: I actually have some reservations about that, because I think that from a data point of view, we know that there are certain patients with clusters of symptoms. We can take patients with a certain score on the PHQ-9 or the [inaudible], and we know they have elevated depressive symptoms. We do a history, and we diagnose them with major depression. We know a certain part of them will have, basically network problems, so to speak. Broadly spoken, so there's sort of network disconnect. If we utilize TMS, we know that that network function improves, essentially. I'm trying to speak broadly, because without getting in to the specifics of the different networks that have been named and claimed, so to speak.
I don't know that if we modulate sort of, healthy networks, that are in a homeostatic balance and functioning the way they "should be," that that is necessarily a safe thing to do. I think it's one thing to sit through one or two random treatments, and it's another thing to get stimulated four to five days a week. I wouldn't put myself through that sort of protocol unless there was really clear evidence that I needed a particular network modulated. There was a point when people talked about how, what would the world be like if everyone were on Prozac. I think we're past that. In fact, I've even read some editorials about, is there an increased level of treatment resistance that we haven't seen before? Could the prolific use of antidepressants maybe contribute to that? I don't know. I don't know enough about antidepressants to be able to speculate on that, but-
Jessi Gold: Like antibiotic resistance somehow?
Bermudes: Maybe, I don't know. I know that sort of, there is an editorial by [Inaudible] recently in brain stimulation, where there's pretty clear evidence that the chronic resistant depression that we're seeing today is definitely less responsive to medication than what they were seeing in the late 90's, for example.
David Carreon: That brings up, I think this is also something that is a new idea for me at least of recent years in psychiatry, of sort of ... There's some sort of a story of psychiatry where we have these diseases, and they're fixed. The prevalence is fixed, and they're just sort of, you drew the unlucky genetic hand. Things don't really change, and there's no real cultural influences. It's just sort of this fixed lump of a field. We come up with treatments and the diseases don't move. You're sort of describing psychiatry almost like the world of infectious disease, where sometimes new things come up and resistances develop.
It's just sort of this, much more dynamic process, that brain stimulation now is a possible way to treat something that is now no longer responsive to antidepressants. I guess that's a different world than the sort of fixed universe that people maybe described before.
Bermudes: Yeah. I think we're all very, I think psychiatry, I hope is moving sort of ... I don't know what the word is. Kind of trans-diagnostically beyond the DSM-5. There's some usefulness to the DSM-5 or DSM-4, but I've started to think more in terms of network connectivity. I think that's what TMS has taught me, is that some of these older models. The serotonin, the [inaudible] hypothesis. I'm a cognitive therapist, so there's sort of this cognitive model of the mind. Before that, there was the more psycho-dynamic, sort of models. Those were useful at the time because they drove treatment at that time.
I think TMS and other modalities that involve neuromodulation, DBS, DNS, TDCS. It's really about the network, and can you associate a network or a dysfunctional network with dysfunctional behavior, emotions, [inaudible], et cetera? Can we then develop stimulation protocols, patterns, frequencies, that can sort of bring those networks more into balance? I think it is dynamic. I don't know if there's a cure out there. The brain is incredibly dynamic. We're in a dynamic environment, and one environment for one person can produce sort of illness, where another person can have the same environmental stressor and only take something like abuse, or divorce, or bankruptcy.
These are big environmental stressors that a lot of us will encounter at some point during our lives. They don't all produce the same problem with the brain. I think it is very dynamic, if you will.
Jessi Gold: Then if someone comes into your office, is there a depression space in the brain that you're just putting a magnet, or how does that work?
Bermudes: Yeah, so I'm talking about this new, sort of way to think of the brain, but in a way, I don't have biomarkers to tell me what's going with each person who comes into our office. We're sort of stuck with this diagnostics symptom-based, we measure very carefully the symptoms, and then we make assumptions of where on the cortex the magnet needs to be. What sort of modulatory pulse sequence needs to be prescribed. Then what we do, is we have people go through treatment, but there's no biomarker feedback with that. We do more measurement with symptoms, and then we make assumptions about what's going on in the brain based on that.
Transcranial magnetic stimulation: an exciting FDA approved technology in psychiatry. But exactly what is TMS, and why should psychiatrists—and perhaps even the general—public be aware of it?
That's the key question the hosts of this short podcast (the first in a series of three on the topic) put to Richard Bermudes, MD, founder and medical director of TMS Health Solutions and founding member of the clinical TMS society, Inc. Here, Dr. Bermudes talks about some basics: what these devices look like, how they work, and about the patient experience.
David Carreon: Welcome to Psyched, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. This is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: This is Psyched. We have with us today, Dr. Richard Bermudes, the founder and medical director of TMS Health Solutions. He earned his medical degree from the University of California San Diego in 1997. He served as chief resident for the family medicine and psychiatry combined program at the University of Cincinnati, then completed a fellowship at the Beck Institute for Cognitive Therapy and Research in Philadelphia. He's the founding member of a clinical TMS society, and he chaired the first annual meeting in 2013. Now was elected president of the society in 2015. Dr. Bermudes, thank you for joining us.
Bermudes: Thank you.
David Carreon: I wanted to talk to you a little bit about TMS. This is something that is a new and exciting technology in psychiatry, and just wanted to give you the chance to talk about ... What is TMS, and why should psychiatrists and maybe even the general public be aware of it?
Bermudes: That's a great question, and actually, it's a question I think about a lot. Probably too much. In its simplest form, TMS is transcranial magnetic stimulation. It's an FDA approved treatment for adult patients who have not responded to one or more anti-depressants, medications. In its basic form, we're using high powered magnetic coil to generate energy across the cortex. We're using that to modulate populations of neurons, so to speak.
David Carreon: You're taking this device, and walk us through, what does the device look like? If you're a patient walking into the office, what happens to you?
Bermudes: Well, the devices are pretty ... Each device essentially has a few components, but there's generally a stimulator with a bank of capacitors. This basically is a way for energy to store up and be discharged quite quickly, in milliseconds. This current then goes through a coil. There are various shapes of coils, the most common being, there's kind of two shapes that are pretty common. I won't digress yet, but basically, this current gets discharged into a coil, and then perpendicular to that coil, a fairly high powered magnetic field abruptly is on and then off.
This happens, it's a fluctuating current, which produces a fluctuating field. It's because it's not static, because it's fluctuating in milliseconds that it actually affects [inaudible] channels essentially. The discovery of this in the 80's by Mark George and others, that really kind of took our initial offering of, basically we've been waving magnets around the brain for quite a bit of time trying to change it. It's sort of this notion that it's a fluctuating current with a fluctuating magnetic field that makes it pretty powerful for the brain.
Patients would see, generally there's sort of a cart, or some sort of bank, or stimulator. Then there's some sort of arm that holds these coils. There's usually a user interface for the technician or physician to sort of navigate that coil around the person's head. There's generally some sort of medical looking chair to these systems as well.
Jessi Gold: I'd imagine patients don't get exposed to magnets in their brains very often. Probably the only thing they know from magnets would either be like, the little kid toys or maybe an MRI or something like that. Does that come up? Are people nervous about the idea of a magnet on their brain?
Bermudes: We get a lot of responses when we talk to patients about this procedure. I think it really depends on the patient, how they're conceptualizing their depression, or how they've been taught to think about their depression. Certainly, the experience of treatments and then, what treatments they're also being offered. For example, if I'm talking to a patient who's been on five, six, ten antidepressants and has suffered a lot of side effects, maybe have had an MRI in their life. The fact that it's a magnetic field, you know, they've had the MRI before, they know that's tolerable. Had side effects from the antidepressants, it's generally not a big deal to think about. Particularly for patients with moderate or moderately high or severe depression. They've been suffering for years.
It's not a first line of treatment. It's generally third, fourth, fifth line treatment. For the right patient population, it's actually pretty acceptable. Sometimes we have to clarify that it's not ECT. Patients will ask, "Are you going to shock my brain?" We're not generating a seizure. This is sub-seizure threshold. TMS actually introduced the idea that we could do neuro-modulation without generating a seizure and improve mood.
Jessi Gold: Since you brought up ECT, is there a reason why TMS doesn't get the reaction that ECT has? You know, right outside there were protestors. People tend to be pretty scared of ECT. The press has kind of destroyed it at one point and it's come back into fruition. They don't necessarily know it's better. Is there a reason TMS hasn't had that same reaction?
Bermudes: I'm a big believer in ECT. I used to do ECT. It's a very powerful treatment, very effective treatment. We don't have to overcome the kind of stigma that I used to have with patients who were getting consultated for ECT. I think some of the reasons, you know, not having to go under general anesthesia. It's a treatment that is accessible for patients who aren't as severely ill as those who are getting ECT. It's an outpatient setting. There's been no cognitive side effects associated with this procedure. All the modern day stimulation protocols for ECT, the cognitive side effects are pretty mild to non-existent.
You know, you started battling that legacy with ECT. I think people have been able to differentiate the two treatments.
David Carreon: You say it's not shocking the brain, but come on, it's a pretty powerful magnet you're putting out. 1.5 Teslas for a lot of these guys. That's a pretty hefty stimulation, isn't it?
Bermudes: Yeah, so it's kind of an interesting dynamic when we're demonstrating this with patients, because on the one hand, I'm saying, "Yeah, it's a fairly benign procedure. The seizure is rare. It's a benign procedure. The seizure is rare. It's not what we're trying to induce. Here I'm going to place this over your meta-cortex, and I'm going to get your thumb to move." That's a pretty powerful demonstration of how we can do non-invasive neuro-modulation at this point in time. It is powerful, but it doesn't have that stigma.