Understanding the Science Behind Transcranial Magnetic Stimulation with Dr. Georgine Nanos

In this episode of “Embark Sessions”, Rob joins Dr. Georgine Nanos, CEO of the Kind Health group, to explore the benefits of transcranial magnetic stimulation, TMS. Dr. Nanos shares her journey to becoming a family physician, and why she chose to take a more holistic approach to medicine. Rob and Dr. Nanos also dive into Dr. Nanos’ personal experience using TMS to treat anxiety.

Resources:

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

Smiling Depression: How Happy Faces Can Mask Depression

High-Functioning Anxiety: How It Affects Teens and How To Help 

TMS at Kind Health Group

Related Videos:

Behind the Scenes at an Embark Outpatient Clinic

The Science of Stress with Dr. George Slavich

Personal Growth Through Social Support with Dr. Hansa Bhargava

Deliberate Practice with Scott D. Miller

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.

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Transcript
Georgine Nanos:

And so the pathology comes when you can't

Georgine Nanos:

get out of those negative pathways and find your way out

Georgine Nanos:

of that to a more positive space, and so, what the TMS is

Georgine Nanos:

actually doing is is physically creating new synaptical

Georgine Nanos:

connections and creating new neuronal pathways in the brain

Georgine Nanos:

to allow for these positive networks to form.

Rob Gent:

Welcome, everybody to another episode of Sessions.

Rob Gent:

Today, I couldn't be more excited to have just an amazing

Rob Gent:

guest on our podcast, her name is Dr. Georgene Nanos. Welcome,

Rob Gent:

Dr. Nanos, to the podcast.

Georgine Nanos:

Thank you so much, Rob. I'm so excited to be

Georgine Nanos:

here.

Rob Gent:

Oh, great. And I particularly lots of times we

Rob Gent:

have lots of PhD, mental health practitioners, that type of

Rob Gent:

thing. And so to have this really amazing cross section of

Rob Gent:

you being an MD, and then your experience, I can't just wait to

Rob Gent:

begin to talk to you and see how your views on mental health and

Rob Gent:

how you weave that in and what you're seeing these days, but

Rob Gent:

just to do an introduction for our listeners, Dr. Nanos is the

Rob Gent:

medical director and CEO of kind the Kind Health Group in San

Rob Gent:

Diego and specifically in Encinitas, but maybe if you

Rob Gent:

could, Dr. Nanos, give us give us a little bit of orientation

Rob Gent:

around your practice, and what you offer would be great.

Georgine Nanos:

Yeah, sure. So our practice is primarily

Georgine Nanos:

started as a concierge primary care practice, and now over the

Georgine Nanos:

last year or so, we are also offering accelerated TMS to a

Georgine Nanos:

number of patients in our community and from around the

Georgine Nanos:

country. We also have a med spa associated with the practice,

Georgine Nanos:

but my primary focus is on primary care and TMS treatments.

Rob Gent:

Wow, it's just amazing. If I can ask what

Rob Gent:

really gave you this, maybe the vision is, is a good word, to be

Rob Gent:

more inclusive and see this treatment in a different way?

Georgine Nanos:

Well, I would say so I have been practicing

Georgine Nanos:

family medicine for now over 20 years here in San Diego,

Georgine Nanos:

Encinitas is a northern suburb of San Diego County, and for the

Georgine Nanos:

first 15 years of my career, I was practicing in a traditional

Georgine Nanos:

primary care setting, I was a partner in a medium size group,

Georgine Nanos:

I was seeing 25 to 30 patients a day, which is a lot. I had 4000

Georgine Nanos:

patients assigned to my panel. I was very busy. I was charting,

Georgine Nanos:

you know, well past midnight and 1am many nights of the week, but

Georgine Nanos:

I loved, and I still love practicing medicine and wanted

Georgine Nanos:

to figure out a way that I could continue to do it for as long as

Georgine Nanos:

I could in my lifetime. And kind of seeing the writing on the

Georgine Nanos:

wall there that this was not a sustainable model for me or my

Georgine Nanos:

life. To deliver care the way I wanted to deliver it to

Georgine Nanos:

patients. I just didn't feel like I was taking good enough

Georgine Nanos:

care of people, and so I left that practice, which was a

Georgine Nanos:

wonderful training ground for, for family medicine and just

Georgine Nanos:

had, you know, the best colleagues and greatest patients

Georgine Nanos:

but wanted to find a way that I could better serve people and

Georgine Nanos:

myself in the way I provide care, and so I started this

Georgine Nanos:

concierge practice where we focus a lot more on prevention

Georgine Nanos:

and emotional and mental health in addition to physical health.

Georgine Nanos:

So we're looking at the whole patient, and not just their,

Georgine Nanos:

their their physical health. So it kind of originated from that

Georgine Nanos:

we use a lot of we use health coaches and partner with a lot

Georgine Nanos:

of therapists in the area to deliver emotional and, and

Georgine Nanos:

physical health and treat the whole person as best we can, and

Georgine Nanos:

then a couple years ago, I was introduced to TMS through a

Georgine Nanos:

through a colleague of mine and got to learn a lot more about

Georgine Nanos:

that, and over the last year, we have been delivering accelerated

Georgine Nanos:

TMS treatments with pretty incredible results, probably

Georgine Nanos:

better than a lot of clinics throughout the world is what I'm

Georgine Nanos:

told. I'm very proud of that.

Rob Gent:

As as you should be, yeah, and I'm, of course, I'm

Rob Gent:

just fascinated because we tend to, you know, here at Embark we

Rob Gent:

see a lot of the mental health but we're always seeing more and

Rob Gent:

more this principles of integrated health and, you know,

Rob Gent:

I'm talking to people about "oh my gut microbiome health is

Rob Gent:

nutrition, and medication and all this stuff." It really is

Rob Gent:

becoming more of an integrated, holistic approach and I love

Rob Gent:

that even in your own practice of saying "Hey, TMS, if it's

Rob Gent:

major depressive disorder or a whole host of things that we're

Rob Gent:

seeing real high effectiveness across the board."

Georgine Nanos:

My approach to medicine has always been to take

Georgine Nanos:

a more holistic approach, you know, I write, I can write

Georgine Nanos:

Lipitor prescriptions and Prozac prescriptions all day long,

Georgine Nanos:

that's not what I want to do if we can get people better with

Georgine Nanos:

lifestyle modification, and, you know, improving their mental

Georgine Nanos:

health in a more holistic way, that's, I think, always the

Georgine Nanos:

ideal. It's what everybody wants, just very hard to

Georgine Nanos:

achieve, and so being in primary care for so many years, one of

Georgine Nanos:

the biggest frustrations for me has been that there isn't, there

Georgine Nanos:

hasn't been a really good, holistic, safe solution for

Georgine Nanos:

mental health treatment until really until now, and being able

Georgine Nanos:

to provide that to people and giving them hope, without

Georgine Nanos:

medication, in a very safe with a very safe modality is been one

Georgine Nanos:

of the most inspirational things in my life, and has really

Georgine Nanos:

changed the direction of my career.

Rob Gent:

So amazing. Yeah, well, I gotta say, just, I, it's

Rob Gent:

easy for me to get sidetracked, but you've obviously, 20 plus

Rob Gent:

years, this is a very purpose driven, maybe I even use the

Rob Gent:

cliche term of mission for you, it feels like this principle of

Rob Gent:

healing and health seems very purposeful to you.

Georgine Nanos:

Very much so. It is kind of the, the fiber of my

Georgine Nanos:

being to, for better, for worse, kind of defines me, so that's

Georgine Nanos:

not always good; that I'm working all the time.

Rob Gent:

Given this is, you know, our audience tends to be,

Rob Gent:

you know, interested, curious people with critical thinking a

Rob Gent:

lot of practitioners, a lot of therapists and psychologists, if

Rob Gent:

we can just take this moment that were in your life, how did

Rob Gent:

that get developed, or you have this, you know, the purpose is

Rob Gent:

kind of the essence of who I am. I'm curious early on your life,

Rob Gent:

what shaped that for you or mind walking us through that?

Georgine Nanos:

So I was the firstborn child of Greek

Georgine Nanos:

immigrants that came here to the US to the east coast. I'm from

Georgine Nanos:

originally from Stamford, Connecticut, the suburb of New

Georgine Nanos:

York City, and if you've ever seen the movie, "My Big, Fat

Georgine Nanos:

Greek Wedding", that is the exact story of my life. I didn't

Georgine Nanos:

speak English until I went to kindergarten, and yeah, I had

Georgine Nanos:

like veal sandwiches for lunch, while everyone had peanut butter

Georgine Nanos:

and jelly, so it was a very different upbringing, and I went

Georgine Nanos:

to Greek school instead of doing sports in elementary

Georgine Nanos:

school. So that that was a my upbringing, but I think in terms

Georgine Nanos:

of coming from a healing, a healing perspective, I'd have to

Georgine Nanos:

say that would come from, from my dad, my dad, unfortunately,

Georgine Nanos:

had end stage kidney disease early in his life in his 40s,

Georgine Nanos:

and was on dialysis. for about 16 years, from the time I was

Georgine Nanos:

in, say, eighth grade, and we had an at the time, this is very

Georgine Nanos:

unusual. And it still is, we had the hemo dialysis machine in our

Georgine Nanos:

home, which was operating, you know, six, or six to eight hours

Georgine Nanos:

a day, every other day. And so my dad was receiving treatments

Georgine Nanos:

at home for for 16 years, which is highly unusual for anyone to

Georgine Nanos:

survive more than a couple of years on dialysis, let alone 16,

Georgine Nanos:

and my mom, who's had no health experience whatsoever, got

Georgine Nanos:

trained to administer the treatments for him, and, one of

Georgine Nanos:

the reasons that he lived so long was because he had this

Georgine Nanos:

environment of love and support, and, you know, it became the

Georgine Nanos:

norm. This was part of our lives and the set and setting in which

Georgine Nanos:

he received the care really changed the trajectory of his

Georgine Nanos:

disease and extended his life by an insane amount. I mean,

Georgine Nanos:

that's, I don't think, very often seen as so. So I think

Georgine Nanos:

that certainly was the impetus to get me into healthcare into

Georgine Nanos:

medicine, and then to provide that extra level of care to

Georgine Nanos:

people is what I'm most passionate about, because that

Georgine Nanos:

was kind of my origin story, if you will.

Rob Gent:

Well, what a great story. I mean, this is just this

Rob Gent:

is why I love doing this to find out about people, but what an

Rob Gent:

amazing story and I'm really highlighting that you're saying

Rob Gent:

it was of course it's the treatments and having in your

Rob Gent:

home but really the impetus or the catalyst for that longevity.

Rob Gent:

That is, really you said, the love and the nurturance in the

Rob Gent:

relationship.

Georgine Nanos:

Absolutely, and that's the foundation of what my

Georgine Nanos:

practice is about. It's called Kind Healthcare Hightide Health

Georgine Nanos:

Group for a reason, because I take the kindness part very,

Georgine Nanos:

very seriously. It's our core value, and my core mission is to

Georgine Nanos:

treat every, first of all ourselves with kindness, and

Georgine Nanos:

treat our patients with as much kindness and love as possible,

Georgine Nanos:

and then you know, each other, our community or our team, and

Georgine Nanos:

that is the true foundation, and so, I think, when you lead with

Georgine Nanos:

kindness and love, everything else kind of falls into place.

Georgine Nanos:

It's very idealistic, but that's, that's at least the

Georgine Nanos:

idea.

Rob Gent:

Well, I'll be transparent, part of the reason

Rob Gent:

that, yeah, I wanted you on this, in the podcast, is just it

Rob Gent:

so aligns with, you know, for my own, my own career has been

Rob Gent:

deemed an expert in understanding attachment and

Rob Gent:

nurturance, and all of this, but you know, our core values are

Rob Gent:

based so to have this complimentary to say, "No, it's,

Rob Gent:

it's about kindness and love," and those, really, I had even

Rob Gent:

the question down here, what is your philosophy of relationship

Rob Gent:

and health, and you're defining it very well, that it's well

Rob Gent:

proven, well proven that that's such an effective intervention,

Rob Gent:

if you will.

Georgine Nanos:

And, and that's, it also has such become the

Georgine Nanos:

foundation of the way we administer TMS, which is very

Georgine Nanos:

different from how it's being done, really anywhere else in

Georgine Nanos:

the country, and as I've been told, is anywhere else in the

Georgine Nanos:

world, and right at this moment in time, and hopefully, that'll

Georgine Nanos:

change and more people will be doing it in this way.

Rob Gent:

So if you go to medical school, and, you've kind

Rob Gent:

of portrayed this wonderful picture of, you know, going to

Rob Gent:

med school you get out, and, if I can rewind a little bit, did

Rob Gent:

you know what you wanted to focus on while you're in medical

Rob Gent:

school, or how did that transpire?

Georgine Nanos:

So I was one of those medical students that

Georgine Nanos:

loved every single rotation that I did. And so when I would do my

Georgine Nanos:

OB-, so in family, in medical school, you rotate through

Georgine Nanos:

everything, surgery, OBGYN, psychiatry, internal medicine,

Georgine Nanos:

and every, every time I go through a rotation, I'm like,

Georgine Nanos:

"Okay, I'm going to be a gynecologist, okay, I'm going to

Georgine Nanos:

be a surgeon, I'm going to be a psychiatrist," and then "This is

Georgine Nanos:

it! This is the one! I'm sure this is the one!" So at the end,

Georgine Nanos:

I love them all, and really, the solution is to go into family

Georgine Nanos:

medicine, which encompasses everything. So that's how I came

Georgine Nanos:

to that.

Rob Gent:

That's great. And so when you told us this wonderful

Rob Gent:

story, for how long were you focused in medical practice,

Rob Gent:

before you became aware of alternative, you know,

Rob Gent:

treatments?

Georgine Nanos:

So I was in a traditional practice for about

Georgine Nanos:

15 years and, and in the course of being a family doctor, we are

Georgine Nanos:

also very much the frontlines of being mental health care

Georgine Nanos:

providers as well, and especially, you know, now more

Georgine Nanos:

than ever, where there's such a scarcity of access to mental

Georgine Nanos:

health, I mean, there always has been, but it seems like now,

Georgine Nanos:

especially post COVID, everyone, all our mental health care

Georgine Nanos:

providers are difficult to access for a lot of people.It's

Georgine Nanos:

been even more so even more pronounced, but part of the part

Georgine Nanos:

of the state of California that I live in is there's lots of

Georgine Nanos:

alternative medicine approaches, so I've seen that throughout my

Georgine Nanos:

career where I have patients coming to me, who are seeing me

Georgine Nanos:

for, you know, say, their gynecologic visits or for

Georgine Nanos:

whatever conditions that they have, and then they're also

Georgine Nanos:

seeing alternative health care providers, and so I've always

Georgine Nanos:

been interested in those other approaches, and there's a lot of

Georgine Nanos:

stuff out there that is not always, you know, the most, not

Georgine Nanos:

always the safest approaches for patients, and so I want- but I'm

Georgine Nanos:

very open minded, and so I wanted to create a space for

Georgine Nanos:

people where patients come see me and we can kind of look at

Georgine Nanos:

all of the best practices of, of a naturopath, the of Chinese

Georgine Nanos:

medicine of alternative medicine, integrative medicine,

Georgine Nanos:

holistic medicine, functional medicine, in addition to this

Georgine Nanos:

traditional Western medical model because as and I think

Georgine Nanos:

this happens with a lot of MDS, you get very pigeonholed into

Georgine Nanos:

thinking, "Okay, Western medicine, allopathic medicine,

Georgine Nanos:

the people that go to medical school," to generalize a little

Georgine Nanos:

bit tend to kind of think in this one way and don't always

Georgine Nanos:

see outside of that box, and so, for me, that's how the world

Georgine Nanos:

live the world lives way outside of that box and so, so I want to

Georgine Nanos:

be in that space where we can look at everything critically

Georgine Nanos:

with a scientific approach. Look at the evidence and kind of look

Georgine Nanos:

at the best practices of all of these approaches, and figure out

Georgine Nanos:

what's best for each individual, and that's always different for

Georgine Nanos:

every person. So, I like to open it up myself up to all of it.

Georgine Nanos:

And then with patients, kind of go through and say, "Okay, this

Georgine Nanos:

makes sense, this doesn't make sense," and "This is safe, not

Georgine Nanos:

safe," and be that voice of reason. Very complicated. What

Georgine Nanos:

health and wellness space?

Rob Gent:

Yeah, that sounds like a bit of a test to balance out

Rob Gent:

what is the science? What is the research? I can't imagine even

Rob Gent:

how many, and we treat a lot of parents, you know, there's a

Rob Gent:

placebo effect that's actually totally valid too, and yet,

Rob Gent:

people get really their hopes up for these some of these things

Rob Gent:

that they are not be proven effective, and that's got to be

Rob Gent:

a tough balance for you.

Georgine Nanos:

Oh, yes, and then throw in a couple of Google

Georgine Nanos:

searches here and there and off to the races!

Rob Gent:

Yeah, well, that's a good point, yeah, a few videos.

Rob Gent:

So you have this where you're treating people, and I just have

Rob Gent:

to ask just because what we do, you're starting out and you're

Rob Gent:

seeing I'm sure, like, medical issues, but like you said it

Rob Gent:

best. Oftentimes, practitioners are the first line to see people

Rob Gent:

are struggling with mental illness or people are struggling

Rob Gent:

with it. How was it for your career? Were you, has it been

Rob Gent:

escalating? Have you noticed an increase? I'm curious.

Georgine Nanos:

Oh, absolutely. Every year, I feel like it, I

Georgine Nanos:

mean, for me, it almost feels like a doubling effect, but

Georgine Nanos:

it's, it's I started practicing it in 2002, and, I would say,

Georgine Nanos:

every year it is getting where our mental health crisis is

Georgine Nanos:

escalating yearly, and of course, after the last three

Georgine Nanos:

years, it's kind of, it's really out of control, especially for

Georgine Nanos:

our young population. So yes, in primary care, a lot of patients

Georgine Nanos:

don't necessarily even understand what defines a mental

Georgine Nanos:

health condition, and so when they're coming to see their

Georgine Nanos:

doctor for whatever routine issue they have, oftentimes, in,

Georgine Nanos:

you know, we, a lot of times screen people for these

Georgine Nanos:

conditions, but even in casual conversation, what we find is a

Georgine Nanos:

lot of coexisting mental health disorders, particularly anxiety

Georgine Nanos:

and depression being the most prevalent that either people

Georgine Nanos:

don't understand or don't, or don't understand how to quite

Georgine Nanos:

treat or even address in any way. So, family doctors, primary

Georgine Nanos:

care specialists, or primary care doctors tend to be the

Georgine Nanos:

frontline, for most, the access point for most mental health in

Georgine Nanos:

healthcare in the country.

Rob Gent:

Well, it's such a breath of fresh air, especially

Rob Gent:

from a behavioral health company like ours, that we get kids, and

Rob Gent:

adolescents, and even the parents with all these somatic

Rob Gent:

symptoms, and they're like, you know, "My stomach hurts," or "I

Rob Gent:

have headaches," and we have all this somatization of symptoms,

Rob Gent:

and we're like, kind of tracing that back. "Well, let me know a

Rob Gent:

little bit of your history? Oh, there's some severe trauma,

Rob Gent:

there's been excessive anxiety all this time," and I'm hearing

Rob Gent:

you say, you're stepping away from a traditional strict

Rob Gent:

medical model, to say "No no, let's view what's going on," and

Rob Gent:

maybe that's what led to- I'd be curious, how did that lead into

Rob Gent:

some TMS and maybe we can define that?

Georgine Nanos:

So the summarization is something, you

Georgine Nanos:

know, is, we see it a lot, and the nice thing about being in

Georgine Nanos:

family medicine is that you can kind of rule out all the true

Georgine Nanos:

somatic etiologies and then be able to show patients "Okay, you

Georgine Nanos:

know, we've looked at every single thing, this is probably

Georgine Nanos:

what it is," which is usually what I may have said from the

Georgine Nanos:

very beginning, but, you know, understandably, that's, you

Georgine Nanos:

know, the first rule of medicine, to do no harm, you

Georgine Nanos:

want to look at every possible cause, and especially the causes

Georgine Nanos:

that, you know, could potentially be harmful to

Georgine Nanos:

people. When you get to that point, I think it's really-

Georgine Nanos:

depending on where they are and their understanding and their

Georgine Nanos:

acceptance of mental health for themselves, or, you know, in

Georgine Nanos:

general. People sometimes hear you say that, and they think

Georgine Nanos:

that you're saying it's in their head, and that's so different

Georgine Nanos:

than what I'm actually saying. Right, and so it's really

Georgine Nanos:

important to explain to people "Okay, I it is very real. These

Georgine Nanos:

are very real somatic issues, that are a physical

Georgine Nanos:

manifestation of XYZ depression, anxiety, PTSD. This is your body

Georgine Nanos:

screaming what your brain is trying to say." So, so yeah, I

Georgine Nanos:

get to that point a lot with people. And so, as I was saying

Georgine Nanos:

earlier, having, you know, my first line has always been

Georgine Nanos:

therapy, and medication as needed for people, but

Georgine Nanos:

oftentimes, people are very resistant to that, there's still

Georgine Nanos:

a really big stigma around medication for mental health

Georgine Nanos:

disorders, and even therapy, and people find that, "Okay, I'm not

Georgine Nanos:

going to, I don't have time to do therapy, I can't afford to do

Georgine Nanos:

therapy, I don't have access to therapy, I don't want to be on

Georgine Nanos:

an antidepressant," that is, you know, something that people are

Georgine Nanos:

very reluctant to do as well, and then sometimes even when

Georgine Nanos:

they're doing both, they will have, you know, a lot of people

Georgine Nanos:

will have good outcomes, but there's a substantial part of

Georgine Nanos:

the population that doesn't get as much benefit as they want or

Georgine Nanos:

need, and so, that's been a big frustration for me over the last

Georgine Nanos:

couple of decades, and when I was introduced to TMS a couple

Georgine Nanos:

years ago, that really was an eye-opening experience to see

Georgine Nanos:

that there was something out there that I really feel is

Georgine Nanos:

going to be the next generation the next evolution in mental

Georgine Nanos:

health treatment, where we can really get to the deep areas of

Georgine Nanos:

the brain to really change those neural pathways and make a

Georgine Nanos:

difference for people in a longer term.

Rob Gent:

Dr. Nanos, thank you so much. I really appreciate

Rob Gent:

highlighting that there's this connectivity, right? We might

Rob Gent:

have some relational issues at home anxiety, depression,

Rob Gent:

whatever it is, it's manifesting in some sort of somatic or

Rob Gent:

physical way, and I'm hearing you say, "Yeah, my practice is

Rob Gent:

about really figuring that out, and not just putting an

Rob Gent:

immediate bandaid on things," because we've seen that

Rob Gent:

certainly in our practice. We get, people with these

Rob Gent:

underlying issues, but it's like, don't just do the

Rob Gent:

superficial. Don't just put the bandaid on the wound, we need to

Rob Gent:

get underneath there and figure out where's the infection

Rob Gent:

coming. If you wouldn't mind, we've used the term TMS multiple

Rob Gent:

times, I think, you know, we're kind of immersed in the language

Rob Gent:

of that means. If you wouldn't mind just where, you know, our

Rob Gent:

new listeners, even define what TMS is, just gives us an

Rob Gent:

overview and an orientation, and maybe what threw you over the

Rob Gent:

edge to actually explore this would be really great.

Georgine Nanos:

Yeah, absolutely. So TMS stands for

Georgine Nanos:

transcranial magnetic stimulation. And the second I

Georgine Nanos:

say those words, my next words are usually "It is not electric

Georgine Nanos:

shock therapy, and there's no electrical current going into

Georgine Nanos:

the brain," because the second you say that, that's what people

Georgine Nanos:

tend to think. So TMS uses magnetic field energy to deliver

Georgine Nanos:

pulses into deep areas of the brain called the salience

Georgine Nanos:

network, where our depression and anxiety centers tend to lie,

Georgine Nanos:

and so, and also it treats other other disorders as well, but the

Georgine Nanos:

primary focus tends to be on depression and anxiety. So what

Georgine Nanos:

a lot of people don't realize is that TMS has been around for

Georgine Nanos:

over 20-30 years now. It's been FDA approved for depression and

Georgine Nanos:

anxiety, specifically, since 2008. So it's been FDA approved

Georgine Nanos:

for fifteen years, and the reason it hasn't really taken

Georgine Nanos:

hold in the greater community is because the way the original

Georgine Nanos:

protocol was approved was a kind of onerous process, and so

Georgine Nanos:

initially, it was, and still without delivery in most parts

Georgine Nanos:

of the country in the world. You need 40 sessions to get a

Georgine Nanos:

therapeutic effect, at least 40 sessions, each session takes

Georgine Nanos:

about anywhere from four to 15 minutes, depending on on what

Georgine Nanos:

areas you're treating, and, typically, the original protocol

Georgine Nanos:

calls for going in every day for 40 consecutive days to get

Georgine Nanos:

treated. Now outside of research, institutions, that's

Georgine Nanos:

hard for people to do on a regular basis and see it through

Georgine Nanos:

to completion. Doing anything 40 days consecutively is a tough,

Georgine Nanos:

thing to do, and so what we were finding is people were kind of

Georgine Nanos:

falling off and not completing the treatments and not getting

Georgine Nanos:

the therapeutic effect back that they were expected to have. And

Georgine Nanos:

so that's why it hasn't been that popular until a few years

Georgine Nanos:

ago, at Stanford, a bunch of researchers got together to

Georgine Nanos:

conduct a number of randomized controlled clinical trials to

Georgine Nanos:

see if perhaps, condensing the protocol to a shorter timeframe

Georgine Nanos:

of four to five days, was as effective as doing the 40 to 50

Georgine Nanos:

day protocol. And lo and behold, not only was it as effective, it

Georgine Nanos:

was way more effective, and that became known as the "Accelerated

Georgine Nanos:

Stanford" or "SAINT" Protocol, which was FDA approved last year

Georgine Nanos:

for, administering TMS, and what that does is condenses the

Georgine Nanos:

treatment to during those five to fifteen minute sessions,

Georgine Nanos:

eight to ten times a day instead of daily, so this way you're

Georgine Nanos:

completing the treatment in four or five days, so you're being

Georgine Nanos:

treated over 40 hours in a week.

Rob Gent:

So I'm gonna interrupt you, because this is monumental.

Rob Gent:

I mean, this is huge. To go from five week protocol to say, and I

Rob Gent:

just want to highlight this, so everybody knows, the random

Rob Gent:

control trials is the highest form of research that we can get

Rob Gent:

validated all of that stuff, it really is, and so there's so

Rob Gent:

much validation and reliability behind these studies to be able

Rob Gent:

to show that, "Hey, we're moving away from actually more

Rob Gent:

effective this the equal or even more effectiveness than to doing

Rob Gent:

the standard protocol," which is phenomenal. Just on a personal

Rob Gent:

note, I got to ask you, I would imagine even saying that

Rob Gent:

probably ruffles some feathers in the TMS world.

Georgine Nanos:

Probably, but I think-

Rob Gent:

Not in a bad way, I'm just saying, I wonder-

Georgine Nanos:

I think it's a matter- so, it is a relatively

Georgine Nanos:

newer approach to doing something that we already know

Georgine Nanos:

works very well, but, like you said, it's been it's been

Georgine Nanos:

scientifically validated, there's a lot of evidence behind

Georgine Nanos:

it, it's FDA approved, already in the accelerated form, but it

Georgine Nanos:

is, frankly, hard to do, and hard to administer in practice.

Georgine Nanos:

So what we're finding is a lot of the TMS clinics around the

Georgine Nanos:

country are still doing the extended protocol and doing some

Georgine Nanos:

of the accelerated protocols as well. My understanding is we're

Georgine Nanos:

one of the few clinics that only does the accelerated protocol,

Georgine Nanos:

so that's the only kind of TMS protocol we offer, and we do it

Georgine Nanos:

over the course of four to five days here in our practice in

Georgine Nanos:

Encinitas. And the the, the other unique aspect to the way

Georgine Nanos:

we deliver TMS is that we also incorporate health coaching and,

Georgine Nanos:

and a lot of support around the treatments. So, typically, in

Georgine Nanos:

your standard TMS clinics, you'll get treated, you know, do

Georgine Nanos:

whatever you need to do for an hour come back. What we do in

Georgine Nanos:

that time in between TMS is our health coaches are working with

Georgine Nanos:

patients to give them tools that they can use beyond their TMS

Georgine Nanos:

experience to help them better get the most out of their TMS

Georgine Nanos:

treatments. So for example, that may be, you know, cognitive

Georgine Nanos:

reframing, positive, you know, positive affirmations,

Georgine Nanos:

meditation, mindfulness, breathwork, journaling, any

Georgine Nanos:

number of activities, and then we've also partnered with

Georgine Nanos:

therapists who will occasionally have- will have a whole TMS

Georgine Nanos:

cohort, that's the patients of a particular therapist, and that

Georgine Nanos:

therapist will come in and also work with those patients where

Georgine Nanos:

we've seen even more impressive results, and so what I what I

Georgine Nanos:

tell people is TMS is not the be all and end all it doesn't exist

Georgine Nanos:

in a vacuum. It really is one very powerful tool in a bigger

Georgine Nanos:

mental health toolkit and what we want to do is give you as

Georgine Nanos:

many of those tools for coping as we can so that when you come

Georgine Nanos:

out of it, you are able to sustain that. What TMS

Georgine Nanos:

essentially does is give you better emotional control and

Georgine Nanos:

better ability to regulate your thoughts and behavior patterns,

Georgine Nanos:

and that's what we want to do in the long term, and so we also

Georgine Nanos:

incorporate long term follow up with our TMS protocol. So our

Georgine Nanos:

health coaches are working with patients once a week for six

Georgine Nanos:

weeks after their treatment and then for an entire year monthly

Georgine Nanos:

after that to ensure that they're getting where they need

Georgine Nanos:

to be.

Rob Gent:

So it's tremendous follow up and I really want to

Rob Gent:

make sure that this is articulate, you did such a great

Rob Gent:

job to say, "We're coupling that. We're doing the TMS along

Rob Gent:

with bolstering. If we're seeing more regulatory ability with the

Rob Gent:

brain, it's, wow, we're doing psychotherapy, we're doing

Rob Gent:

mindfulness, we're doing all of these other things," and I

Rob Gent:

always call it, it gets the flywheel of health going, right?

Rob Gent:

I mean if you're more regulated then your relationships are

Rob Gent:

going to be better and then there's more nurturing and love,

Rob Gent:

and then, I mean, it really tends to get this- the flywheel

Rob Gent:

or the snowball going, and I'm sure you have a lot of, I'm

Rob Gent:

sure, amazing stories to say "Yes, this is actually, it's

Rob Gent:

working and that's why we're doing it."

Georgine Nanos:

Oh yeah, it has made all the difference

Georgine Nanos:

incorporating that health coaching component. We already

Georgine Nanos:

see- we've had a couple of unintended natural experiments

Georgine Nanos:

where we didn't have the health coaching. For example, there

Georgine Nanos:

were a couple, few months ago where one of our health coaches

Georgine Nanos:

was really sick and couldn't come in, and so we didn't, we

Georgine Nanos:

didn't have that, and those patients did great, but not as

Georgine Nanos:

well as, as the ones that were getting the regular home health

Georgine Nanos:

coaching on a consistent basis. So it's, it's been incredible to

Georgine Nanos:

see, I mean, and we've treated so many different kinds of

Georgine Nanos:

people with different experiences and different issues

Georgine Nanos:

that they're grappling with. We've treated moms with severe

Georgine Nanos:

postpartum depression who've been suicidal, we've treated,

Georgine Nanos:

you know, teenagers, adolescents, with severe anxiety

Georgine Nanos:

disorders. We've also had the privilege to take people out of

Georgine Nanos:

acute suicidality. I've had patients come to me, telling me

Georgine Nanos:

they're going to, you know, on a Monday, when we're starting

Georgine Nanos:

treatment, telling me that, if this doesn't work, they'll be

Georgine Nanos:

killing themselves on Friday, which is horrifying, and we've

Georgine Nanos:

been able to take them out of that condition and keep them in

Georgine Nanos:

remission. It takes a lot of work, and there's a lot of, you

Georgine Nanos:

know, there are a lot of elements that go into that I

Georgine Nanos:

don't want to mislead people to thinking it's just the TMS

Georgine Nanos:

there's, there's a whole network of support that we've built

Georgine Nanos:

around that, and like I said, the TMS is one very, very

Georgine Nanos:

powerful tool to help us get patients there, but it is

Georgine Nanos:

definitely it definitely takes a village.

Rob Gent:

And it's- what's so amazing talking about the, you

Rob Gent:

know, major depressive disorder, the high suicidality, we've

Rob Gent:

certainly seen that a lot, and I just want to ask, it's, what's

Rob Gent:

so fascinating to me is that TMS is it's non invasive, like we're

Rob Gent:

not hooking up to IV, we're not injecting you with anything,

Rob Gent:

because, you know, especially in this world with, we're seeing

Rob Gent:

this rates of adolescent suicidality, that, you know,

Rob Gent:

it's, we see a lot of recommendation from

Rob Gent:

psychiatrists, "Well, you might want to consider ketamine as a

Rob Gent:

way to get on this," and I just want maybe, maybe give us your

Rob Gent:

perspective on, you know, where does TMS fit with that?

Georgine Nanos:

Absolutely, and there's definitely a lot of

Georgine Nanos:

interest now in in ketamine, and also coming down the road,

Georgine Nanos:

psychedelics as well, which is fast becoming, you know, more

Georgine Nanos:

readily accepted in the in the wider community, and there's

Georgine Nanos:

definitely a role for those treatments, as well and those

Georgine Nanos:

modalities, so I don't want people to think I'm not against

Georgine Nanos:

any particular modality. I think it's a very individualized

Georgine Nanos:

decision that, you know, people have to explore with their, with

Georgine Nanos:

their own providers, but the amazing thing about TMS, for me,

Georgine Nanos:

is that it has no long term side effects, which is not something

Georgine Nanos:

I can say about anything else I do in medicine. Literally

Georgine Nanos:

nothing. So, for me, that's, that's huge, and to be able to

Georgine Nanos:

give people an extremely safe way to deal with really complex

Georgine Nanos:

problems is life changing. We've changed so many people's lives

Georgine Nanos:

and done in a really safe and effective way. So what- I didn't

Georgine Nanos:

get a chance to really explain how TMS actually works. So what

Georgine Nanos:

what is happening when we're doing those, those deep magnetic

Georgine Nanos:

pulses into the brain, we are looking at these areas in the

Georgine Nanos:

brain where our depression and anxiety centers live, and what

Georgine Nanos:

happens is we tend to, everybody has this, we have these negative

Georgine Nanos:

loops in our brain, where when we're stressed or have a, you

Georgine Nanos:

know, a triggering event or something that is uncomfortable

Georgine Nanos:

for us, we can often go to these negative loops that are very

Georgine Nanos:

well worn pathways of negativity, and so the pathology

Georgine Nanos:

comes when you can't get out of those negative pathways and find

Georgine Nanos:

your way out of that to a more positive space, and so what the

Georgine Nanos:

TMS is actually doing is, physically creating new synaptic

Georgine Nanos:

connections and creating new neuronal pathways in the brain

Georgine Nanos:

to allow for these positive networks to form, so that

Georgine Nanos:

instead, you can think of it as expanding your brain to create

Georgine Nanos:

more space for these positive networks so that when you are

Georgine Nanos:

encountering something that's upsetting or difficult or

Georgine Nanos:

challenging in any way, instead of going right into that

Georgine Nanos:

negative loop, you have a positive loop to go into

Georgine Nanos:

instead. And so that's really how it works, and it's, it's

Georgine Nanos:

pretty remarkable.

Rob Gent:

It's very remarkable! My gosh! And so, if I can ask

Rob Gent:

you some questions, I mean, so the pulsing, literally, is it

Rob Gent:

disrupting the existing neural synaptic connections, so it

Rob Gent:

allows- or how is that frequency changing or allowing for some

Rob Gent:

new neuro plasticity to take place will be helpful.

Georgine Nanos:

It's not disrupting existing connections,

Georgine Nanos:

it's actually creating new ones. So, for example, we know, in

Georgine Nanos:

cases with traumatic brain injury and post concussive

Georgine Nanos:

syndrome, a lot of those patients have damaged

Georgine Nanos:

connections, and so what it does is it can strengthen and create-

Georgine Nanos:

it can strengthen existing connections, so it's not

Georgine Nanos:

breaking things up, it's strengthening and building up,

Georgine Nanos:

so there isn't a disruption, it's more- you can think of it

Georgine Nanos:

more of as a, like a muscle workout. So I like to use the

Georgine Nanos:

analogy sometimes, like, what you're doing, you can think of

Georgine Nanos:

your brain as another muscle and you're strengthening that muscle

Georgine Nanos:

and giving it the ability to have resilience and, like we

Georgine Nanos:

said, neuroplasticity, and to be able to respond to these, you

Georgine Nanos:

know, events that happen through all of our lives that are that

Georgine Nanos:

are that are challenging.

Rob Gent:

So great, it's so great. If I were a new

Rob Gent:

clinician, where can I go to learn more about this? I mean,

Rob Gent:

it's like most of us just learning about this. Where would

Rob Gent:

you recommend as a first step, if you're a practitioner or a

Rob Gent:

parent, or you know, you're struggling with your own issues?

Georgine Nanos:

That's a great question. There isn't a great-

Georgine Nanos:

well, so I'd say the clinic- the International Clinical TMS

Georgine Nanos:

Society is one of the main bodies that kind of aggregates a

Georgine Nanos:

lot of the the TMS research. That would be a good starting

Georgine Nanos:

point. We have, on our website, a lot of the relevant journal

Georgine Nanos:

articles, you know, we have a long PDF that kind of condenses

Georgine Nanos:

all of it with all the relevant studies, and there's not, as you

Georgine Nanos:

know, there's not- really, my mission is education, because

Georgine Nanos:

there's not a lot of it out there right now. So I wish I

Georgine Nanos:

could give you-

Rob Gent:

Well, I'm gonna make a plug for your website, because

Rob Gent:

you sent that to me, and it was incredibly helpful. If you just

Rob Gent:

wouldn't mind, tell us what the website is, and for listeners to

Rob Gent:

access, that would be great.

Georgine Nanos:

Sure, it's www.kindhealthgroup.com, and if

Georgine Nanos:

you scroll to the TMS section, there's a lot of links there. We

Georgine Nanos:

have a really great animated video that explains it in really

Georgine Nanos:

simple terms that a lot of people find very helpful, and

Georgine Nanos:

then we have a number of patient testimonials, as well as a lot

Georgine Nanos:

of the relevant research studies, and then links to

Georgine Nanos:

those, which then link you to other studies as well. So you

Georgine Nanos:

can go down a long rabbit hole of the great studies.

Rob Gent:

That's incredible. Well, I got to ask this because

Rob Gent:

I want to is that, have you tried it yourself?

Georgine Nanos:

Of course!

Rob Gent:

And...?

Georgine Nanos:

Yes, I was one of the first patients, so I, you

Georgine Nanos:

know, I didn't feel like I could in good conscience recommend

Georgine Nanos:

something that I hadn't- this dramatic, I hadn't tried myself.

Georgine Nanos:

So I, myself, have had some mild anxiety just by virtue of being

Georgine Nanos:

a human, and in this world, and being a doctor and a mom, so I-

Georgine Nanos:

and I have some insomnia as well, so I tried it about a year

Georgine Nanos:

Well I think it was great because for all of those, you

Georgine Nanos:

ago, and for me, you know, my- I have thoughts going a million

Georgine Nanos:

miles a minute at all times, can't like shut it down and very

Georgine Nanos:

typical type 'A' person and- yes, exactly. For me, it helped

Georgine Nanos:

really give me a sense of calm and focus and helped me center

Georgine Nanos:

know, research type data people, you know, scientific method,

Georgine Nanos:

myself in a way that I frankly never experienced before. I was

Georgine Nanos:

sleeping much better than I ever had. Oh, and this is the other

Georgine Nanos:

thing that I forgot to mention. The other thing we started

Georgine Nanos:

introducing for our patients in the last couple of months is an

Georgine Nanos:

you're correlating all of this data, which is actually pretty

Georgine Nanos:

aura ring. So we give all of our TMS patients an aura ring, and

Georgine Nanos:

if you're not familiar with an aura ring, it's a little, tiny,

Georgine Nanos:

wearable device here that is worn as a ring and as a bunch of

Georgine Nanos:

sensors in it, and what that does, it's probably the best

Georgine Nanos:

wearable sleep tracker on the market right now, and Apple

Georgine Nanos:

unique. I know other TMS does a depression inventory on a

Georgine Nanos:

Watches are great too, we can get theater from Apple Watches,

Georgine Nanos:

but most people tend to take their watch off at night, but

Georgine Nanos:

the ring is the best way to track sleep and variations in

Georgine Nanos:

sleep, which correlate very closely with a lot of mental

Georgine Nanos:

regular basis, but it's- I haven't seen the robustness of

Georgine Nanos:

health issues as well. So we're looking at sleep, heart rate

Georgine Nanos:

variability, oxygen saturation, steps, activity, all that stuff,

Georgine Nanos:

so we're measuring all of that data as well and conducting a

Georgine Nanos:

study based on that, and so we're, we're gathering lots of

Georgine Nanos:

information. I somehow derailed myself, I don't remember what

Georgine Nanos:

saying, "Hey, no, let's correlate all the all of this

Georgine Nanos:

the question was.

Georgine Nanos:

different, really quantitative data."

Georgine Nanos:

Right, and that's what a lot of people want, so we obviously do,

Georgine Nanos:

you know, all the standard questionnaires, GED seven, PCL

Georgine Nanos:

five, PHQ, nine, all that, you know, repeatedly over and over

Georgine Nanos:

and over, but having this, like you said, this quantitative data

Georgine Nanos:

is definitely new in this area. So we're really, excited to see

Georgine Nanos:

what that is going to start looking like, and so generally,

Georgine Nanos:

when people sign up for TMS, I have them, we size them for the

Georgine Nanos:

aura ring, and we have to start wearing at least a couple of

Georgine Nanos:

weeks before they're treated, and then obviously, during the

Georgine Nanos:

treatment week, and then they continue to wear it for, you

Georgine Nanos:

know, forever.

Rob Gent:

What an absolute tremendous practice. So just in

Rob Gent:

kind of closing, I want to ask you, like, you're developing

Rob Gent:

this practice, you're venturing out to TMS I mean, what does the

Rob Gent:

future hold for Dr. Nanos?

Georgine Nanos:

I want to bring this to as many people as

Georgine Nanos:

possible. I just think everybody can benefit from it, even if,

Georgine Nanos:

you know, we, we all have had some trauma in our lives, and

Georgine Nanos:

we've all been through a collective trauma of COVID at a

Georgine Nanos:

baseline. So there's that. My goal is to make this- to educate

Georgine Nanos:

people as much as possible about it, whether they get it with me

Georgine Nanos:

or with anyone else, I don't care, I want people to know

Georgine Nanos:

about it, and have the ability to, to get treated and find, you

Georgine Nanos:

know, a way to live their best possible lives, and that's the

Georgine Nanos:

most important thing to me; for us all to find joy in our lives

Georgine Nanos:

and purpose, and, I think the other piece of it too, is, for

Georgine Nanos:

what I've seen in the way we practice is building that human

Georgine Nanos:

connection with people, and that's really important to me,

Georgine Nanos:

too, and we're building these very deep relationships, and

Georgine Nanos:

that's always how I've wanted to practice medicine, and I think

Georgine Nanos:

in a world where there's a lot of movement away from human

Georgine Nanos:

connection, we're trying to bring it back because that's

Georgine Nanos:

where- that's where I think we can all find more meaning.

Rob Gent:

And finally, Dr. Nanos because those of us who listened

Rob Gent:

to the podcast all know, just interpersonal neurobiology, and

Rob Gent:

understanding the science of relationship is just really,

Rob Gent:

it's, it's where we're at, in trying to move forward and we're

Rob Gent:

seeing that more and more and rates of empathy are lower than

Rob Gent:

ever in our society, people are lonelier than ever, and yet

Rob Gent:

clustered closer together, so I just love that you're- you have

Rob Gent:

such an amazing practice really weaving it all in and thank you

Rob Gent:

for being on today! You've certainly educated all of us and

Rob Gent:

educated me. I can't tell you how grateful I am that you've

Rob Gent:

been a part of the podcast. Thank you, and please get on Dr.

Rob Gent:

Nanos's website and look that up if you want to learn more about

Rob Gent:

TMS and her practice, and you can access this podcast where-

Rob Gent:

however you access podcasts through Apple or whatever, but

Rob Gent:

Dr. Nanos, thank you so much for joining us today. Really

Rob Gent:

appreciate it!

Georgine Nanos:

Thank you so much, Rob. It's been a pleasure!