A Parent’s Guide to Treating Major Depressive Disorder and TMS

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In this episode, Rob Gent, Chief Clinical Officer of Embark Behavioral Health dives into treating Major Depressive Disorder (MDD) with Dr. Georgine Nanos, CEO of Kind Health Group. Rob and Dr. Nanos discuss how depression is diagnosed and what makes MDD different from other types of depression. Dr. Nanos explains many treatment options for MDD, including Transcranial Magnetic Stimulation (TMS).  

Related Blogs:

Treatment-Resistant Depression: What It Is and How To Address It  

What Parents Need To Know When Their Adolescent Has Depression 

Understanding Depression and Mood Disorders in Teens 

Smiling Depression: How Happy Faces Can Mask Depression 

TMS at Kind Health Group 

Related Videos:

The Science Behind Transcranial Magnetic Stimulation with Dr. Georgine Nanos | Embark Sessions 

Mental Health 101: Your Questions Answered | Roadmap to Joy 

How to Eat for Mental Health 

How to Improve Teen Mental Health 

Connect with Embark on Social Media:

Have a question for our experts? We want to hear from you! Submit your questions to: [email protected].

About Dr. Nanos 

Dr. Georgine Nanos, MD, MPH is a board-certified family physician and the owner of Kind Health Group, a concierge primary care and accelerated TMS practice in the setting of a luxury medspa in Encinitas, California. Dr. Nanos holds a Bachelor’s Degree from Colgate University, a Master’s Degree in Public Health from Boston University, and a Doctor of Medicine Degree from George Washington University School of Medicine. Dr. Nanos has been practicing medicine for over 20 years in San Diego and has expertise in treating a wide range of medical conditions in patients of all ages. She has been awarded and recognized by her peers as a Top Doctor of San Diego for over ten years. She also serves as the medical director of Rancho Valencia Resort & Spa and is a medical contributor to numerous local and national TV, radio, and print media outlets. 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 to take an active role in their own healthcare. 

About Rob 

Dr. Rob Gent, Ph.D., is the Chief Clinical Officer and one of the founding members of Embark Behavioral Health. Rob has been with the company for 15 years and has led the Embark organization in the clinical development and growth of numerous programs. He is the lead developer of the proprietary CASA Developmental Framework, which is pervasive throughout Embark’s programs. 

Through his dedication to advancing clinical development, practice, and research, he has become a nationally recognized expert in the field. His specialization in clinical development is enhanced by his therapeutic expertise and has yielded such accomplishments as the development of; The CASA Developmental Framework, Vive Family Intensive Program, Calo Preteens, Canine Attachment Therapy-Transferable Attachment Program, and other specialized programs. 

About Embark Behavioral Health

Embark has been helping people overcome behavioral health issues that may be affecting their everyday lives for over 25 years.   

Conditions We Treat Include:  

The Embark team has some of the most compassionate and educated professionals in the industry. Its core purpose is to create joy and heal generations. Embark’s big hairy audacious goal is to lead the way in driving teen and young adult anxiety, depression, and suicide from the all-time highs of today to all-time lows by 2028. Exceptional treatment options, like short-term residential care, makes Embark the world’s most respected family behavioral health provider.   

Check out our locations.

Transcript
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Welcome, everybody. I'm Dr. Rob gent, Chief Clinical Officer of

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Embark Behavioral Health feel very privileged to be doing a

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little bit rare thing for me to be doing the Roadmap to Joy

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podcast. But this is such an important topic that I wanted to

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be a part of this and so fortunate to be able to talk

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about major depressive disorder today. And our guest is Dr.

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Georgene. Nanos, from she is actually the CEO of the kind

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Health Group in San Diego, in particular Encinitas,

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California. And we're going to be talking about different types

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of interventions and things that she's seeing in her practice.

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And specifically, we're going to be discussing TMS, which is

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really exciting transcranial magnetic stimulation. It's a big

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word, but we're going to be talking about that. So let's

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just go ahead and jump in. Dr. Georgie Nanos. Welcome.

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Thank you, Rob. I'm so happy to be here.

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Well, it's so excited to have you and thank you for taking the

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time to us. And I know you've been so gracious. And you said

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to us, in particular, one of my big missions in life is to get

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out the word on TMS. Pretty important to you? Yes, it is.

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Yeah, super great. Well, if I can, before we jump into that,

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if I'm just a parent listening in for the first time, and you

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know, I sure you most of your day to day stuff is dealing with

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parents and I know, maybe talk a little bit, you're certainly are

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a board certified trained physician. And you see parents

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all the time, maybe give us a little context about Yeah, what

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is it that you do and the population you're seeing would

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be great? Sure, I'd

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love to. So I'm a family physician, I'm board certified

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in family medicine, I've been practicing medicine here in San

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Diego for over 20 years. And as a as a family doctor, I see all

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all ages of patients from infants to send to Janerio. And

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so I see the whole spectrum of life, which is a unique

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perspective to, to see in the course of one's medical career.

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So, and I also treat a lot of families as well. So I have

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often, you know, the parents, the or the children, the parents

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and even grandparents. So it's a real privilege to see the entire

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fabric of a fight family dynamic. And in doing so, I've

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got I've learned a lot about people and human behavior and

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the human condition. And what I, what I think some people don't

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readily realize is that family doctors and primary care

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providers are really the frontlines of mental health care

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in this country. And so when people are having issues with

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their mental health, they they're often will start by

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seeing their primary doctor, I think, as

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a therapist, we forget about this that the average person

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goes to see their primary care physician first.

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Absolutely, yes, it's very often forgotten. Much of my training

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and experience is in treating mental health as well as

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physical health issues. And they're really interrelated. So

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I treat a lot of adolescents, young adults, their parents,

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their grandparents. So I've seen the whole spectrum of patients,

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what

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can I ask that that seems in? Well, you tell me what you

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think. But in my experience, that seems to be the exception,

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rather than the rule. I mean, we talked about the medical model,

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so much of like, you know, it's seeing it medically, is it's

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kind of a linear approach. And you always specify a problem,

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rather than I think what you're talking about is, you see things

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more integrative ly or more functionally, with, with the

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person.

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Exactly. And that's how I approach medicine as well, I

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really like to look at the whole person and take into account

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their emotional and behavioral health as well as their physical

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health. And as I said, they are very interconnected. And I think

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when we don't recognize that how interconnected they are, that's

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where we can. That's where we have a hard time figuring out

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what's wrong with people. And it takes a lot of time to listen,

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and have people give people the space and time to tell their

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story.

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I would love to hear Dr. Nanos an example of I mean, I hear you

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say people come in, I would imagine that they don't know

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that they're have depression, I would imagine that it shows up

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in a ton of different ways. I mean, how do you kind of flush

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that out? I mean, we deal with teenagers all the time, who are

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like, I have a stomach ache, I have headaches, I have this and

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that and come to find out integratively it's a combination

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of a bunch of things.

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Exactly. That's very, very often the case but as as a family

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physician, our role is to rule out you know, every other

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possible etiology of a of any particular Symptoms before we

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say okay, this is anxiety or this is depression. What I tell

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people often is that when when we get to that point, and it's

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that anxiety or depression, causing these real physical

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symptoms, I don't want people to misunderstand that and think I'm

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saying it's in their head, it's not in their head. It's their,

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it's their brain screaming, it's their body screaming what their

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brain can't say. And so it is really a real, these are real,

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real physical symptoms of a of an underlying mental health

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disorder that are super common.

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Would you mind saying, like, just if I'm a parent, what are

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some of those things that you commonly see? Yeah, absolutely.

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So

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in terms of depression, the most common thing is a symptom called

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anhedonia, which means lack of interest in doing something that

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you used to enjoy. And if it lasts for more than two weeks,

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it's can be a sign of depression. Also persistent

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feelings of sadness, hopelessness, change, physical

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changes in in sleeping and eating, sleeping too much, not

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sleeping enough, eating too much or not eating enough. So those

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are some of the more common symptoms. And I think there's

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also, there's still, unfortunately, a big stigma in

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our society around depression. A lot of people think that in

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order to be depressed, or truly diagnosis depressed, you have to

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be suicidal. And that is most certainly not the case.

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Obviously, he's been having suicidal thinking is, is, is

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definitely a severe form of depression. But it's definitely

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not the norm. Most people who are depressed are never

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suicidal, but have these these other symptoms, which are super

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common, especially as I was saying, the most, the most

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common one is that feeling of just losing interest and not

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being motivated to do things that you used to enjoy doing,

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not wanting to get out of bed, that kind of thing.

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So that's super, super helpful. Because if I'm a parent, you're

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saying, don't, don't let suicidality be the barometer for

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this thing.

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If you got into suicidality, there's a, there's a much bigger

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problem, that's the extreme. So you don't have you don't want to

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wait till your, your your child or your loved one suicidal

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before you, you seek help.

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But if they're withdrawing, if they're no longer taking

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interest in the things that used to all of those things might be

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a good indicator of go see your primary care physician, go see

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somebody that can give you some perfect, professional

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recommendation.

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Exactly. And a lot of it, you know, there is a lot of it.

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That's normal, teenage, adolescent stuff. But I think

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seeing a professional and getting that teased out and

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figuring out what the nuances are, there are really important,

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because these kids today are very, very vulnerable. Social

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media is really just eating away at them in every possible way,

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especially for young girls. It's a very toxic environment out

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there for them. And a lot of parents aren't even aware of

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what's going on online.

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This brings up a really good point, because I would imagine

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it gets kind of confusing when we think of depression, is it.

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We talked about social media stuff, we talked about

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environmental factors, we talked about developmental factors. And

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there's also organic factors I'm sure you're looking at, but it's

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not just secluded to one of those factors, it can be a

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combination of everything.

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Absolutely. And it usually is and there's also family history.

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And there's also you know, particular stressors in in

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people's lives, if you know, their parents are going through

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a divorce. Or if there's some other major stress in the home,

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that's also can, can trigger it. So there are there are

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situations that can trigger a depressive episode. But the you

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know, the outcome is still the same. Someone is still depressed

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and needs to be treated, regardless of how you got there.

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This question comes to mind and I've been dying to ask you,

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you've been practicing, like you said, for 20 years. Have you

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seen an increase? Have you seen what types of increases or what

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type of trajectory Have you seen with the population presenting

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with depression?

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Well, you know, I'm gonna say that yes, I have. Yeah. So it's,

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it's, I feel like it's there's a doubling effect almost every

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year. And, and so it's wild to me every year. I'm like, How can

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this get worse? And it's, it's astounding, and COVID?

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Certainly, really, I mean, I think too. Just over over the

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edge, because we all you know, we all have trauma growing up.

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And throughout our lives, there's no there's no escaping

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that however big or small it is that that affects our world and

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how we interact with the world. And but then you throw on this

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collective trauma that we all had of going through COVID,

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which was very collective experiences, it was it was also

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very individual experience, and everyone reacted very

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differently to it. And none of it was good for, for any of us.

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And so we have that on top of all the other trauma that we've

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already accumulated in our lives. And it's caused a lot of

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profound isolation for people and really brought to light a

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lot of a lot of underlying mental health disorders that

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people were just kind of scraping by. With before now,

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it's, it's just much more difficult for people to cope.

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So you're saying we've seen it, I mean, doubling is just

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staggering. I know, that's true. It's just it's an epidemic at

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this point in time, and we're just see this exponential

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increase. Maybe talk a little bit about people's, how can we

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get a better understanding? Because we talk about this thing

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in the clinical world is major depressive disorder or treatment

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resistant? How do How can you help us to explain like, what is

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a maybe just an onset of mild depression versus more severe?

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How do you flush out with the differences?

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There's actually a questionnaire called the PHQ. Nine, which is a

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universally standard questionnaire used by by

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clinicians all over the world as a screening tool and a

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diagnostic tool for depression. And the questions there are

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actually nine questions and they encompass a lot of those

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symptoms we talked about earlier. Anhedonia lack of

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interest or motivation to do things that generally bring you

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joy, sadness, hopelessness, feelings of worthlessness and

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guilt, as well as changes in your, in your sleep or your

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eating habits. And then suicidality as well. So there is

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a score for that for those answers. And based on that

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score, we can kind of distinguish between a mild,

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moderate or severe case of depression. And that's what's

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most commonly used.

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Would you say, just as is it best practice to? If I go see,

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or I take my child to my physician in? Is it best

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practice to do a PHQ? Nine, or what would you say in the

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medical field is the best practice. So

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best practice really, is to screen everybody with with those

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questionnaires, which is what we do in my practice all the time.

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In addition to that PHQ nine, we also use something called the GA

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D seven, which is the general anxiety, disorder, scale,

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similar type of question, which assesses for symptoms and

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symptoms of anxiety as well. So those are standard

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questionnaires that we we screen everybody with in my practice

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these days, just because it is so prevalent. And oftentimes

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when people are coming in, for especially young adults, they

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don't come into the office that that frequently. So we want to

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capture them and make sure that that we can assess them and

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screen them for any of those disorders, if they're coming in

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for say, or a cold or a routine vaccination or something like

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that. So it is important that that we are screening as many

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people as possible because oftentimes these things go

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undetected.

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So let's just play this scenario. What happens if

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somebody does score pretty, pretty high on these measures?

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What do you guys do? Well,

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it depends. So if someone is suicidal, that's, that's an

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entirely different situation. Usually, that person may need a

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different level of support. If they're really acute, they may

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need inpatient hospitalization or something of that nature, if

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they can be managed as an outpatient, if it's, you know,

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not as severe of a case. Generally, we talk about the

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options with parents, which can include a variety of modalities.

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The first of which is is therapy, talk therapy, which is

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very effective for a lot of people. And then, medications

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most commonly SSRIs selective serotonin reuptake inhibitors,

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or SSRIs. Norepinephrine as well, are the most commonly

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prescribed medications for depression and anxiety and those

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are taken typically on a daily basis. One thing that we don't

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often talk about is exercise exercise is an excellent

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excellent treatment for depression. They've they've been

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a lot of head to head trials comparing Prozac and exercise

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and Has there been equal equal efficacy time so. So exercise is

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really important as well, I always emphasize that and

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limiting screen time and particularly for younger people,

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limiting limiting screen time and going on a social media

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diet, it's also very helpful for a lot of individuals, adults and

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children alike. So I think we can all benefit from a little

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more of that. And then some combination of all of those

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modalities is usually as a starting point, I usually tend

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to avoid medication unless there's a particular need for

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it. Right. But right off the bat, I think it's important to

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try to do everything you can before you go to medication, not

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that I'm opposed to it, I certainly prescribe a lot of

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medication, but I use it, you know, only when necessary. And

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and then if that's not working, then we usually talk about

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accelerated TMS, which is what we also offer at my clinic.

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So I'm hearing before you dip into the medications, maybe try

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let's talk therapy. Let's look at exercise, sleep, nutrition. I

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mean, there's a whole host of things. Oh, yeah, we can try to

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get back on track. That's great. Yes,

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we use. So we have a whole team of health coaches here at my

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practice. And we focus a lot on prevention, and health coaches,

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the role of the health coaches is really to give people that

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space and time to have someone to listen to them and kind of

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hear their story. And that's what everyone really that's what

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we all want, we want that human connection we want to be heard.

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We want to know that someone's listening to us and that, that

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goes so such a long way. And so that's what we try to provide

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for people so that they have someone to talk to particularly

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teens and young adults and their parents as well. It's just as

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difficult for them to watch your child suffer, and go through

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something really difficult that you can't always help with.

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So you're opening the door, I can't help but get a little bit

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excited. I just want to clarify because this is, you know,

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certainly from Embark This is our mission and our purpose, but

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what you're even articulating, as a physician, you're saying,

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listen, we're storied creatures, we want interpersonal

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connection, that the fact that we can be suffering, depression,

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feelings of anxiety, all of this stuff, we've actually know that

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parts of mitigating that is just simple empathy and human

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connection and being in safe relationship.

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Absolutely. 1,000% I can, I can't say that enough. And, and

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a lot, you know, when I talk about social media or screen

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time diet, that that's a big contributor to a lot of what

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we're seeing, unfortunately. And I mean, I'm just as guilty as an

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adult of being attached to my phone all the time. And it just,

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it takes away from that interpersonal human connection.

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And as you know, we move further away from it. That's exactly

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what we need more of, we need more of that human interpersonal

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relationships, to fill us up and to help us thrive and find joy.

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That is the Roadmap to Joy.

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Music to my ears, I get helpless. Wow, this is so

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terrific. So just kind of delving into this. So we get to

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cases. And then I love that you're saying when all of that

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the pieces are coming together and there's still some

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depressive stuff. And you mentioned accelerated TMS. So

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maybe talk a little bit about how, when do you approach a

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client a patient with this? When do you even offer it or

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suggested and then maybe talk about a little bit about how

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that unfolds a bit great. Sure.

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We have people come to me for accelerated TMS from a number of

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different avenues. We, so let me back it up a little bit by

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explaining what TMS is. Perfect. How about that? So TMS stands

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for transcranial magnetic stimulation. And as soon as I

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say that, my next words are always it's not electric shock

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therapy. It is entirely different. There's no electric

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current going into the brain. It's using magnetic field

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energy. So it uses deep magnetic pulses to penetrate into our

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areas of the brain called the salience network where our

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anxiety and depression centers live for all of us. And what can

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often happen is as we are going through life, we encounter

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negative experiences which are very common and typical and

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normal. But what will happen over time for some people is

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that you will get into these negative loops these negative

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thoughts letters, and they become these deeply worn grooves

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if you will, in our in our neural network and become really

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hard to get out of. And that's when it becomes problematic when

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you get stuck in these negative loops. And what TMS is doing is

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creating new positive pathways to get you out of those negative

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loops was actually creating new neural connections, new synaptic

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connections, so that when you are encountering a challenge, or

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stress or you know, a traumatic event, instead of going to that

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negative loop, you're going to a positive loop, it's almost

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expanding your brain in a way to give you more space and time to

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cope with what is happening. And it helps you to better regulate

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your emotions, your behaviors, and your thought patterns in a

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much more positive way. It's not invasive, it doesn't have any

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long term side effects, which is something I can't say about

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anything else in medicine. And it's a very exciting

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revolutionary treatment for anxiety, depression, and a whole

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host of other disorders as well.

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So one is there's research to prove its effectiveness. Yes,

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it's been

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FDA approved for over 15 years, it's actually been around for

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over 25 years. The reason you probably haven't heard about it

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very much, or most people have it is because when it was first

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approved back in 2008, it was approved in this very long

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protocol. The treatment itself only takes about anywhere from

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five to 15 minutes, it's painless, it's a metal cord at a

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coil placed on the forehead, it just feels like a little tapping

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sensation. And it's, it's a pretty quick treatment. But as

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it was first approved, it was administered once a day over 40

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to 50 days, and it takes at least 40 Sessions to get a

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therapeutic effect. So what you were seeing is people having to

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come into the office to a clinic once a day for 40 to 50

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consecutive days, which was really hard for people to do in

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in real life outside of research settings. It wasn't happening

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very often or, you know, people weren't seeing it through to

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completion. So we weren't seeing the effects that we were

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expecting. Then about three years ago at Stanford, a group

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of researchers came together to do a series of randomized

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controlled clinical trials, to see if perhaps condensing that

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protocol to four or five days would be as effective. And lo

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and behold, not only was it as effective, it was way more

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effective. And that became known as the accelerated or the

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Stanford protocol or the st. Protocol. They're all the same

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thing. And that administers the treatment eight times a day,

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eight to 10 times a day. So we're treating patients every

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hour and giving them a 15 minute rest in between. And this way,

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we're condensing that 4040 session treatment in four or

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five days. So it's very quick, but it's intense. And and that's

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the only protocol. That's the only TMS treatment that we do in

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my clinics. It's the it's the accelerated protocol, that it's

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pretty fast.

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It's so amazing to hear that we have effectiveness for this

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accelerated process and happens within a week. It's a very

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intense five days. But Dr. Nana's tell me you typically

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when you hear about TMS, you hear about a standard protocol

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taking weeks rather than the accelerated maybe taco. Why is

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that we don't hear so much about the accelerated

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it's relatively new. It was it was only started being used in

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practice about three years ago, it was FDA approved last year.

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And it's just there are not a lot of clinics that have

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experienced doing it. We are we've been very fortunate to

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have been doing this now for over a year with excellent

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results. It's the only type of TMS that we do. So we are quite

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seasoned in what to expect throughout the week. And it's

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we're learning we're still learning every week, we learned

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something new about this whole process. It's and it's it's just

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been an immense privilege and joy to be able to help so many

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people through such difficult times. So for me, it's changed

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my my life, my career path. It's something I want to make

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available to as many people as possible because it's such an

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important and incredible treatment.

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And I know that you've really taken the TMS and integrated, if

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you will all of this other holistic perspective.

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Right and that's exactly it. And that's where we're in a very

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unique position using our health coaching team myself or the rest

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of my team. We really when patients come to us we treat

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about anywhere from three to five patients at a time in the

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week and we We provide them with a really deep network of support

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throughout their, throughout their week of treatment. And

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then we continue to follow them up for a whole year after

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they've been treated so that they are getting follow up with

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our health coaches with myself, we have a consulting

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psychiatrist available for them as well. So it's really a

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multidisciplinary approach to making sure that people get what

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they need, and that we get them to where, where they want to be

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so they can live their best life. And I think, typically, in

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your average TMS clinic, patients will get treated, if

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they're even going to do the accelerated protocol that just

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get treated. And then they leave and do something for 15 minutes,

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they may sit in their car or watch TV or something. What we

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do here is that our health coaches are wanting to really

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engage our patients to give them tools, so that they can, so they

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can use what they've achieved through TMS and help them carry

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that into their life outside of that week of treatment. So

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people I want people to think of TMS is a very powerful tool in a

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larger mental health toolkit, so it doesn't stand on its own. The

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people that do best are the people who go through the

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treatment and are engaged. They have a therapist they have they

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have a social network, they have their you know, they're

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interacting and engaging with our, our health coaches. Those

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are the people who are going to have the best outcomes.

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So wonderfully described, and I think you're hitting on some key

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points that I want to make sure the listeners are listening to

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that. It takes us engagement, the best results we're getting

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at people who are fully participating in it. Let me ask

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you a little bit of a unique question. Do adolescents are we

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treating people younger? Should we be treating people younger

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than 18.

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So it's FDA approved for 18. And above, but typically, most

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clinics will treat patients as young as 12. We have treated

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younger than 18. But it's we require a parent or an adult to

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be there with them. And it's it is like I said it's an intense

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treatment, they have to be mature enough to be able to to

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be in a clinical setting for 40 consecutive hours, which is a

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lot for some for some kids. So it just it depends on the person

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and the circumstances. We we want to help as many people as

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possible. But it has to be something that's the right fit.

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Yeah, totally understand that. What kind of how long did the

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results last? What are you seeing?

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That's again, an interesting component of the level of

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engagement that we see from patients. So some people will go

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into a lasting remission. So my partner and consulting

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psychiatrist, Dr. Jonathan downer has been treating, he's

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treated over 5000 patients and has done as part as part of the

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trials that helped produce the Stanford protocol. And he will

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tell you that the the the remission rate, the length of

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remission really is highly variable, some people are in a

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permanent remission, some people will need an additional

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maintenance treatment after a year or two. Some people will

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need more after a few months. And it really depends on on.

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It's such an individual case by case basis. For example, I have

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a I have a patient that I'm training again next week who we

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treated about six or seven months ago, and she was severely

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depressed with anxiety and she had a great outcome from TMS She

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did really, really well. But then her husband was diagnosed

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with brain cancer and died a year a couple of months later.

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And, and so she's kind of gone, she's regressed a little bit and

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is going to be retreated again. And she's really the only person

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that we have retreated in the last year. But I use the analogy

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that TMS is like it's like weightlifting, you're you know,

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without TMS, maybe you can lift 10 or 15 pounds with TMS, maybe

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you can lift now 250 300 pounds, but then life throws you a 500

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pound weight. So only so much you can do there. So, so she got

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thrown a 500 pound weight, so we're gonna, we're gonna bulk

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her up again. So that's, that's the yet that's the idea.

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And I would venture to say that sometimes depression and anxiety

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sort of put these weird cloud Have the goggles in front of

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your eyes in the sense of part of the treatment is getting some

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relief from the symptoms actually gives you an increased

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clarity or even an awareness. So I imagine now she's probably

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like, wow, you know, depression, I always use analogies like

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you're the frog in the boiling water. Sometimes you don't

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realize the temperature is getting hotter. And you don't

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realize how bad it is until you take a step back.

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Oh, yeah. And she will tell you, we have actually our testimony

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on our website, she will tell you, she would have never been

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able to survive what she went through without the TMS it would

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have it would have killed her as well. So. So all in all, it was

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very positive. And it's just yeah, it's pretty incredible.

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So we've got this. Thank you so much. You've described it so

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well. So we've got transcranial magnetic stimulation. I would

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imagine you're recommending that before we get into more

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invasive, heavier type of medications to treat the

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depression. Look at it holistically, which is

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wonderfully. If I'm not near your clinic, I should be looking

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at somebody who does TMS. Let's say I'm a typical family is

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something that a standard practice TMS would be covered by

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insurance. How does that usually work?

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That's a great question. Well, first of all, we have people

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coming from all over the country to get treated here. So So

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we're, we're open.

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Don't let that stop you. Okay, so

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we are in beautiful Southern California. And it's not a bad

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place to be where a block from the beach. But anyway, they it's

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a great question about insurance. And this is a big

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problem, right? Now, insurance will sometimes cover the

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extended protocol. And in order to get that covered, you have to

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jump through a lot of hoops. Yet, depending on your

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insurance, you have to have failed at least a couple of

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medication trials for a series of of months. And then you may

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get it approved. But only the extended protocol is approved

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that 40 or 50. Or sorry, the 40 or 50 Day protocol is covered by

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insurance there, unfortunately, right now is no insurance

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company that's covering the accelerated protocol, which is a

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problem because it is a very time intensive and costly

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endeavor. So it's, it's something that we're working on

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making more available to more people. In my clinic, we also

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for all of our pain patients, we also have, we also treat a

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veteran and or veteran or first responder in every one of our

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cohorts so that you know, pro bono so that we can also, you

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know, engage that community as well and make give them some

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awareness and help them as much as we can.

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So a few things I'm hearing, if I'm apparent is that accelerated

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is a an amazing option. But at this point in time, not really

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covered by insurance. But if I have to have insurance coverage,

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it's the extended version. And to qualify for that, we're

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looking at need needing to qualify as treatment resistant,

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or, you know, we've tried other things, and it just hasn't

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worked a certain amount of medication. So those are

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something to consider if you're a parent. So let's say we're

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doing the TMS and I have a family member, I'm a parent,

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what is the best way that you recommend that family members

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support people who are doing TMS?

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Well, I think first, it's important for them to understand

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what it is and what it isn't. We've i It's not an instant fix.

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And so what will sometimes happen is patients will get

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treated, and then they'll, you know, go home and their partners

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or their family members will be like, is it working? Is it

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working? Is it working?

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Do you feel better? No, really

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like every day, 10 times a day, that's not helpful. So we see

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this a lot. So it's about managing expectations about how

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this works. It's not like I said, it's not an overnight,

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it's not an overnight thing. It's a cumulative effect. It's

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building over time. There. We do have cases and they're they're

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rare, where people have an immediate response within three

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or four days. And that's always wonderful to see. But that's not

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the norm. And it's usually after several weeks, even a few

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months, that you start to get the maximum benefit from it. And

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again, that is part of a bigger a bigger picture of multiple

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modalities of treatment, the therapy, the exercise, you know,

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eating right, all the other things that we talked about are

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equally as important. And so it's yeah That's, that's, that's

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something that is important for, for parents and partners to

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understand as people are going through this. It's not, it's not

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just a quick fix.

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Great. I always have to ask this because you know, if somebody

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says, Hey, Rob, I want to go see a therapist or take my family to

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a therapist, what are some things to look out for? I would

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ask the same thing of you like, Hey, if you're going to go look

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into the scene TMS? Are there any red flags that I should look

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out for somebody who's looking into doing this?

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I'm obviously very biased towards the accelerated

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protocol, because I think it just gives you the best results.

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But it's there's just not there are unfortunately, aren't enough

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people doing it right now. And we're fortunate to be one of one

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of the few clinics in the United States that's only doing this so

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we're, we've gotten to be very good at it. And I just wish we

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could treat more people and see, see better results for more

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people across the country.

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So if I'm interested, can I go to your website? Yeah, no matter

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where I'm at in the country, and I want to learn more about this,

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no matter where I'm at, where do I go to look at this to talking

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about,

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you can go to our website, which is www.com Health group.com. We

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also that will also link you to our YouTube channel where we

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have a lot of videos that explain what TMS is, we have a

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number of patient testimonials there, we have a huge 24 page

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document with all of the research studies, not all of

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them, but a select number of research studies that are the

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most relevant for people to review and, and look at and you

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can certainly call me text me email me I'm always available

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for questions. Careful what

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you asked for, but yeah, I know, I know. Well, one of my one of

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my last questions is just what is the number one takeaway if

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you're a parent, given this whole conversation, what would

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you say the number one takeaway is? For a parent?

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Less talking more listening?

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Less talking more listening? Put down your phone and listen? Yes.

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Listen to your kid.

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Yes, listening. It's hard. It's hard for us to do you know, I

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have two teenage sons, and I'm constantly peppering them with

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questions trying to extract information out of them. And I

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find if you just sit in the quiet for a minute, they'll

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start telling you everything. So especially when you're driving,

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that's the best when they can't make eye contact, and you can

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get all all the goods.

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Well, Dr. Nanos, I can't tell you how much I appreciate. I

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know this. This is our second conversation, we did a podcast

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called Sessions where I was so grateful I, what I appreciate so

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much is your this professional physician and have this amazing

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practice, but you're also a person and a human. And I'm

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certainly hearing that interpersonal relationship and

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all of this is really at the heart of what you're doing.

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It is it is and it's, it gives me it gives. It's my Roadmap to

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Joy, it really fills me up and it just, it brings me great joy

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to have the privilege of practicing medicine and being

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able to help so many people it really is my it's my why.

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Well, you certainly contributed that today on our podcast and

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just so appreciate so if you're a parent out there hopefully

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you've you've listened get get on our website or access Dr.

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Nanos website and learn about all of these interesting,

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effective treatments to help out with depression and anxiety. So

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if you can subscribe to wherever you find podcasts, and we look

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forward to you joining us.