Episode 118 Transcription

Welcome to episode 118 of Behind The Mission, a show that sparks conversations with PsychArmor’s trusted partners and educational experts. My name is Duane France and each week I'll be having conversations with podcast guests that will equip you with tools and resources to effectively engage with and support military service members, Veterans, and their families. You can find the show and all the podcast players, or by going to www.psycharmor.org/podcast. 

Thanks again for joining us in Behind The Mission. Our work and mission are supported by generous partnerships and sponsors who also believe that education changes lives. Our sponsor this week is PsychArmor, the premier education and learning ecosystem specializing in military culture content. PsychArmor offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations. 

On today's episode, I'm featuring a conversation with Dr. Georgine Nanos, a board certified family physician and the owner of kind health group concierge primary care at accelerated TMS practice in Encinitas, California. Dr. Nanos is passionate about the power of preventive health and has recently been recognized for her work with accelerated TMS, transcranial magnetic stimulation for the treatment of anxiety and depression.  Dr. Nanos is committed to promoting health and wellness and empowering everyone taking an active role in their own healthcare. You can find more about Dr. Nanos by checking out our bio in our show notes. So let's get into my conversation with her and come back afterward to talk about some of the key points. 

audioDuaneFrance,MA,M21092252752: Dr. Nanos, so grateful to be able to have you on the Behind the Mission Podcast to talk about the unique and innovative treatment for medication resistant mental health conditions, transcranial magnetic stimulation or tms. Before we talk about that, however, I'd like to provide you an opportunity to tell us about your background and how you got into this work.

audioDr.GeorgineNanos11092252752: Sure. Thank you for having me. First of all, I'm very excited to be here. I am a family medicine physician. I have been practicing family medicine in San Diego, California for the last 21 years. Can't believe it's been 21 years. And as the first 15 years of my career I was in a traditional family practice space with where I was seeing 25, 30 patients a day, 10 to 15minute visits, and was, we had 4,000 patients assigned to my panel and I was dealing with a lot of a wide variety of issues as we tend to see in family medicine. But didn't feel like I was spending enough time and taking good enough care of people. So I left that practice about, six years ago to start  a smaller concierge practice where I can spend more time with patients and develop deeper connections with them and really give them space to be heard and have essentially unlimited time with patients, which is a real luxury in medicine. But that really helps get to the root of a lot of problems and within the space of that practice, we also focus a lot on prevention and holistic care and really trying to treat the whole person, not just the physical aspect of medical care, but really the emotional wellbeing of people and individuals and patients we'd see. And so out of that and out of my 20 years o of practice, one of the big frustrations has always been the lack of ability to be able to give people with significant mental health issues, a real avenue to pursue better care for themselves that's not related to medication. Obviously, you know, I prefer everybody for therapy. I prescribe hundreds of thousands of, SSRIs and other, medications over the years. But it's not for everybody. And, not everybody gets, the effect that they need or as much of, what they need to lead better lives. So when I was introduced to tms, that was a real game changer for me and put me on this path now.

audioDuaneFrance,MA,M21092252752: That's amazing. And obviously, there's lots of different ways that medicine can be practiced. But you mentioned that you're practicing in San Diego, and listeners may be familiar is it's one of the nation's largest military towns. Again, here where I'm at in Colorado Springs, Colorado, it's an Army and Air Force town, San Diego like Norfolk, Virginia, is very much a Navy, a Marine Corps town. And so you likely have a lot of Veterans that you see in your practice. 

audioDr.GeorgineNanos11092252752: Absolutel, yes. And I am also a former Marine spouse, so I'm very familiar with the unique struggles of our military service members and Veterans.

audioDuaneFrance,MA,M21092252752: As we mentioned before we started talking, I'm familiar with TMS, in my previous clinical work and whenever I talk to Veterans that I work with as a therapist about TMS, I found it helpful to first describe what it was, why it was developed in a bit of how it works. Maybe we could start there.

audioDr.GeorgineNanos11092252752: Yes, absolutely. So TMS stands for Transcranial Magnetic Stimulation, and as soon as I say that, my next words are always, it's not electric shock therapy, because people often confuse the two and they are very different. So with TMS, there's no electric current going into the brain. And the beautiful thing about this treatment is that it has no long-term side effects, which is not something I can say about anything else in medicine.

Part of why I am so excited about this. TMS uses magnetic field energy, applied to the head and delivers, deep pulses into the brain to affect our salience network, where our depression and anxiety centers tend to live within our brain. So you can think of it as anytime any of us have any, stress or we're feeling anxious or depressed, we tend to form these loops in our brain and sometimes they can be deep negative loops and over time they become hard to get out of.

And so when anxiety and depression become pathologic is when you can't take your mindset out of those negative loops. And so what TMS does is actually stimulates the brain to create new neuronal connections, new synapses between the neurons to create new pathways, where you can create positive pathways and positive thoughts. So you can think of it as almost expanding your brain to create more space for a positive loop to form so that when we are challenged with issues, you don't automatically go to those negative loops. Now you have a positive pathway. So it helps gives us all better control of our emotions, better regulation of our thoughts and behaviors, and allows us to better function in the world.

audioDuaneFrance,MA,M21092252752: And really what it does, it harnesses the brain's natural tendency to adapt to the environment. And we call that neuroplasticity. And when I would have Veterans, they say, well, I don't want something messing with my brain. And I said, like, combat. Or like the, the things, I mean, these are the things that, as you, you talk about the adverse conditions that many service members and Veterans face, that is causing these neuronal changes in a negative way to their brain.

audioDr.GeorgineNanos11092252752: Absolutely. Absolutely. And that can have as we know, a lasting impact, and it can be very difficult to treat over time.

audioDuaneFrance,MA,M21092252752: One thing that I used to say, about it in, you recommend if this is a good analogy or not. But it's like a knotted muscle. And the TMS sort of helps within the brain. It helps relieve some of those knotted thinking, but some of that, so just like we would go to a massage, or get like one of the massage guns to relieve a charlie horse, so to speak. TMS does that in a non-invasive way to our brain. 

audioDr.GeorgineNanos11092252752: Exactly. And it's also strengthening those muscles within the brain as well. I also use the analogy of, before TMS, you can think of it as exercise, giving your brain more muscular strength. So then this works well, it's a good analogy for Veterans and first responders that we treat a lot.

So before tms, you can think of it as your brain only being able to lift like a 20, 25 pound weight. And then with tms, you feel a lot stronger and can maybe lift like a 250 pound weight. But sometimes life will throw a 500 pound weight at you where, it's not always, it's not a be all and end all. I like to describe it as a one very powerful tool in,the larger toolkit of mental health modalities that we have.

audioDuaneFrance,MA,M21092252752: and I think, you'd mentioned, again, electroconvulsive therapy, which many people are still surprised that actually does still happen. for very extreme cases of medication resistant depression, but as you mentioned, that has some severe side effects, whereas TMS doesn't have the severe side effects.

audioDr.GeorgineNanos11092252752: It works a little bit differently. Yes,  I guess the say the end goal is the same, is to get you to that state of remission and response, past the the severe symptoms and even mild symptoms of anxiety and depression. But it's a very different mechanism.

So I don't wanna really equate the two because they are very different. ECT electric convulsive therapy really has many side effects including significant impact on memory, which is probably the most intense one for a lot of people. And, so then, and it is a very effective treatment for some, but totally not the same.

audioDuaneFrance,MA,M21092252752: And that's the point that I wanted to bring up. And again, it was the same thing that a lot of people would bring up. when you think about, t m s, that was the same question that we always had. But t m s is again, non-invasive. It doesn't have the side effects and it's really, really beneficial. We've talked about what it is and maybe we can dig into it more, how it can support the recovery of military and Veteran population. TMS  is currently approved by the F D A to treat depression, obsessive compulsive disorders, some other conditions and Veteran seeking t m s in the US have to have a diagnosis for one of those conditions. but there has been some evidence that reduces the symptoms of other conditions like ptsd.

audioDr.GeorgineNanos11092252752: It does, help in, reducing the symptoms of PTSD as well as. Brain injury, post-concussive syndrome. t also helps with chronic migraines, tinnitus, which is a constant ringing in the ear. And, I dunno if you mentioned it,  anxiety disorder as well. So yes, it has a broad application for many, many issues.

audioDuaneFrance,MA,M21092252752: And so, I'd like to hear of the experiences that you've had in supporting, service members and veterans, or even as you mentioned, first responders in this treatment, what kind of things have you seen? I've seen some definite benefits. I've seen some veterans that I worked with for almost well over a year, that t m s almost, nearly overnight really, relieved them of a lot of their symptom.

audioDr.GeorgineNanos11092252752: Yeah. So I think, one point of clarification is, in the way that we deliver TMS in my clinic versus the way, it may be delivered in most parts of the country right now. And I'm hoping that is going to change. But the way when TMS was first approved, FDA approved back in 2008, it's been FDA approved for 15 years now.

It was approved in this very, prolonged protocol that, required 40 sessions. And so the t m s treatment itself only takes anywhere from four to 15 minutes, depending on what areas we're treating. So patients would have to come in once a day for 40 consecutive days, which is really hard to accomplish.

And I think that is why it hasn't really become mainstream. And then a few years ago at Stanford, they had a bunch of researchers come together to do a series of randomized controlled clinical trials to see if condensing that protocol to four or five days was as effective, and it was actually much more effective.

And that became known as the accelerated or Stanford or ST. Protocol. The same thing essentially. And that condenses the treatment into, instead of doing it over 40 days, you're doing it over four to five days and you're treating patients once an hour for eight to 10 hours a day. And that shows significant benefit.

The other thing that we do differently is that, include a lot of mental health support between those treatments, which is also a very unique model, which gives us much better results. So doing t m s alone usually yields something like anywhere from a 40 to. 55, 60% response rate, whereas we are getting over 85% response rate with the methodology and the protocol that we're using.

And so we are, have been treating members of the general community as well as veterans and first responders, and seeing really incredible results.

audioDuaneFrance,MA,M21092252752: And so it's interesting. You talk about using t m s in conjunction with other modalities. Right. You know, t m s can, as you said, it can help us regulate our emotions but it doesn't necessarily, maybe change behavior. Maybe using t m s in conjunction with, psychotherapy or psychoeducation or groups or things like that can also be beneficial. 

audioDr.GeorgineNanos11092252752: Exactly, and that's where we've seen the biggest impact. We have, a number of health coaches that work with our t m s patients in between sessions doing, cognitive reframing, positive affirmations, meditation, mindfulness, breath work, journaling, all of the things.

And we happen to also be located, two blocks from the beach here in San Diego. So there's a lot of, beach walking therapy that happens as well, which is always nice. And then we also, include long-term follow up for our patients. So not only are we really supporting them during their actual treatment time.

But then our health coaches continue to follow patients, weekly for the first four to six weeks after treatment and then monthly for the next year cuz our goal is to really get them to where they wanna be and make sure they're staying on the path that best suits them. So we find that, doing that also in conjunction with working with therapists is definitely augments that response. 

audioDuaneFrance,MA,M21092252752: Now you've mentioned, obviously with this accelerated protocol. But TMS is, again, I think really when it first began, it was for medication resistant,or when other types of treatment or other types of medications didn't work. And I've had clients, of mine who said that, they've tried everything. They've tried all of it, right? All of the modalities, all of the medications, and none of it seemed to work. and t m s seemed to be the one thing that helped.

audioDr.GeorgineNanos11092252752: Yes, we are very often the place of last resort. So we're used to that. But it is effective for,you know, a wide range of severity of symptoms. obviously in our Veteran and our, the first responder community, there is a lot of P T S D, a lot of trauma that they're coming in with.

But we also treat people with milder conditions. And, they see benefit as well. I do find though, that the more severe the symptoms are, they tend to see a probably a more significant response that we've been able to take people out of acute suicidality in a very short number of days.

I've had, a number of people come to me on a Monday telling me that if this doesn't work, they'll be killing themselves on Friday, which is absolutely horrifying. And we're able to take them out of that and keep them in remission with a lot of additional support. Again, I don't, I wanna reiterate, TMS does not exist in a vacuum, and I think that's really the key is that it is. t works best when you have a whole, multi, pronged, multidisciplinary approach to taking care of people.

audioDuaneFrance,MA,M21092252752: Yeah, I appreciate that. I mean, a lot of times, and again, Veterans will come in and say, just give me the one thing that will work, or the one thing that will fix. And there is not a one thing, it's usually a mix of all of them.

audioDr.GeorgineNanos11092252752: And that has been a little bit of a struggle with that community because it is something that, and not just the veteran community, everybody wants a quick fix. Everyone wants to have the thing, the magic cure, the miracle and just move on with their lives and it, and unfortunately it's not like that.

And this certainly accelerates the process and gets you on that path, but you still have to do the work. And that's sometimes hard for people to see. And those that are willing to see that and do that, do much, much better.

audioDuaneFrance,MA,M21092252752: And I think some of that has to do with the culture too. I, I have, veterans come in and say, just tell me what I need to do, just. My drill sergeant told me what to do. Then my squad leader told me what to do, and then my commander told me like I made a career out of doing what other people told me to do.

Or, there was this major transactional thing. And a lot of times, and especially if individuals may not be adapted to post-military life for whatever reason, then they just say, hey doc, just tell me what I need to do. And like you said, it's not that easy because their brain is in their head. Your brain is not in their head.

audioDr.GeorgineNanos11092252752: Exactly. I still tell 'em what to do though. I’m very bossy.

audioDuaneFrance,MA,M21092252752: I was gonna say, and sometimes you can leverage the culture a little bit to, to benefit what we need to do. I am an advocate for t m s. I've seen it literally work. and I don't use the word miracles, but I have seen it work for veterans who, like you said, really had, almost no other resort. So if people are more interested in learning about t m s, as you've mentioned, it's been around for a while. There are some barriers to it. It's not widely available everywhere, even in urban areas. Much less in, in some of our more rural communities where some of our veterans reside. So if people wanna find out more about T M S, how can they do that, do you think?

audioDr.GeorgineNanos11092252752: So the International Clinical TMS society is the body that, that a lot of t m s providers are a part of. And so finding t m s providers through that website is probably a good vehicle. And, on our website we have a number of studies as well that you can look at.

We do have people coming from all over the country to get treated at our clinic. One of the big issues is coverage for this procedure. So right now, one of the barriers is certainly, insurance coverage as we stand right now in, April of 2023 insurance will only cover that very long extended protocol. And even then, typically you need to have failed at least a significant trial of two antidepressants. The TRICARE and, the VA, or military, insurance plans tend to have the most favorable coverage of that extended protocol, but right now, unfortunately, nobody is covering the accelerated protocol.

So what we do in my practice right now is we typically treat a cohort of anywhere from three to five individuals at a time. And, we treat either a veteran or a first responder pro bono in that cohort. And, offset their costs with some of our paying clients and patients. But we are looking at, trying to connect with some of the larger military foundations to help fund that for more people. And that would be ideal cause it is a very in labor intensive endeavor, but the most rewarding thing I've ever done.

audioDuaneFrance,MA,M21092252752: And as you mentioned, yes, it's labor intensive for the providers, but it's also a significant commitment for the service members and veterans themselves. That's the piece like you were talking about, whether it is the. the prolonged protocol over 40 days, or it is even the accelerated protocol, but it's still a very intense four or five days, of long treatment.

audioDr.GeorgineNanos11092252752: Oh yeah, even more so. I think we're one of the few clinics that only does the accelerated protocol and we do it a lot. And so we have now have a lot of experience as to what that looks like. And it is extremely intense. There's a lot of emotional ups and downs. It's, throughout the week, where what happens to a lot of people is you're pulling out a lot of that past trauma that may not have been processed or usually has not been processed in a healthy way. And so they're readdressing a lot of that stuff and that can be really hard and really scary. So having that, that supportive network around patients when that is happening, I think is almost critical.

And my view, and obviously probably biased because of how we do it, but my view is to have t m s or especially accelerated t m s, without that support in the times that you're doing it, is can be potentially dangerous for people because there's so much happening. I think that's key if you're looking for t m s providers to make sure that you have a lot of that support around you because it is an intense experience.

audioDuaneFrance,MA,M21092252752: And I appreciate that you're being very clear and upfront. And I've had veterans be like, I'm not sure I want to go through that. I don't wanna, even regular therapy, they're like, I don't wanna dig all this stuff up because it's gonna make me feel bad. And I said, well, how things been for the past five years?

Has that been a cake walk? No, let's get through this. And there's, and so it's not that it's gonna be easy, but especially in and with, many of these modalities, it can be good and relief can come where for many veterans to hope wasn't there. So if people wanted to find out more about you, your work specifically, how can they do that?

audioDr.GeorgineNanos11092252752: They can check out our website, which is www.kindhealthgroup.com. on that you can just go to the t m s section and we have a number of patient testimonials. We have a really, easy to understand video that kind of illustrates exactly how it works.

And then we have a ton of articles and, research papers that you can dive down a deep rabbit hole of TMS research to look at all the studies that have been done. And there's so many of them. And I've been very fortunate to partner with one of the world's leading experts in tms, who's, Dr. Jonathan Downer. He's authored a lot of these studies and, he's our, our consulting psychiatrist. So it's a real privilege to be able to always have his expertise weighing in on everything we do and that's been amazing.

audioDuaneFrance,MA,M21092252752: That's great. I’ll make sure that those links are in the show notes for anybody that wants to access them. Thank you so much for coming on the show today.

audioDr.GeorgineNanos11092252752: Thank you so much, Duane. It was a pleasure to meet you.

Once again, we would like to thank this week sponsor PsychArmor. PsychArmor is the premier education learning ecosystem, specializing in military culture content. PsychArmor offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations. 

I appreciate you tuning in for this conversation between a medical professional and a clinical mental health professional. Hopefully, we were able to have a conversation about a subject that I frankly find complicated, even being familiar with it. But thought that it's a potentially valuable conversation to have. When we talk about mental health and diagnosed psychological conditions, we often forget that it's a function of our brain, which is a biological organ in our body. The same as our heart or our stomach or our liver. 

I once had a veteran come into therapy, frustrated, and he said, everyone's telling me that all of this stuff is just in my head. And I said to him, well, the right it's in your brain. We can obviously have discussions about the difference between mind and brain or the brain body connection or embedded consciousness in a physical organism. But the fact is that our brain is doing the work. As I'm speaking, as you're listening, whatever you're doing while you're listening, it's all a function of the brain. 

And the thing is as much as we use it, we know so little about it and figuring out more about it. We have to use our brains to learn more about our brains. It's like using a microscope to look at a microscope. So we live in this reciprocal relationship with our brains. We use our brains to have experiences and the experiences we have in life impacts our brains. Brains adapt to those experiences and are reinforced. This is where the brain's ability to adapt and rewire itself comes in. In the brain's ability to adapt is why humans can do so many amazing things like learning new things and achieving new results, making music and art that no one has ever heard before. 

Neuroplasticity the brain's ability to make new connections is how we achieve mastery in a subject or task. It's how we type without looking at our fingers or hit a 90 mile an hour fast ball with the bat. But like a computer, if it's garbage in, it can be garbage out. It's also how we get stuck in these negative thinking loops that Dr. Nanos was talking about. 

And it's how depression and anxiety and other psychological conditions can develop and worse in severity over time. Exposure to trauma, prolonged physical or psychological abuse. All of these things have an impact on the brain. And as basic as I'm attempting to keep it, it's so much more complicated. 

Chemicals and electrical impulses and hormones in different regions of the brain all play their part. How much sleep I had last night has an impact. And what I have to do later today has an impact. My brains interaction with other people's brains what we call relationships has a huge impact. So I said all that to say this, the brain is complicated, but it's also necessary. And when it's not working the way that it could, or it should. Transcranial magnetic stimulation or TMS is one thing that I've seen that could be beneficial. 

I'd also like to include a brief mention of one of the common objections I hear with TMS, which Dr. Nanos also mentioned. The commitment that it takes to go through the process. Our brains didn't get this way overnight. And while the TMS process is effective, it's not effective overnight. Using another analogy it's like mopping up a flood. 

The mop is not going to pick up all the water during the first pass. And so people that I saw would resist against coming to the office for the length of time that it takes. It's a, you want me to drive 30 minutes here for 15 minutes in the TMS chair and then drive 30 minutes back home. The answer is yes, actually. 

But it's about helping people understand that the time is truly well spent. So if this episode has made you curious about TMS and would like to learn more as Dr. Nano said, we have lots of links in the show notes. So I hope you appreciated my conversation with Dr. Nanos. If you did. we'd appreciate hearing from you. So if you do have some feedback, let us know, drop a review in your podcast player of choice, or send us an email at info@psycharmor.org. We're always glad to hear from listeners, both feedback on the show and suggestions for future guests. 

For this week, PsychArmor Resource of the Week, I'd like to share the course Invisible Wounds At Home. Understanding invisible wounds in this course, you'll learn about four of the unseen wounds of military service and be introduced to the PsychArmor series. That includes specific courses on myths and facts about PTSD, depression, TBI, and substance use disorder. You can find a link to the resource in the show notes.