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The Basics of Transcranial Magnetic Stimulation


The Basics of Transcranial Magnetic Stiumulation

October 5, 2022

Transcranial magnetic stimulation (TMS) is a non-invasive, drug-free procedure that uses magnetic coils to stimulate and influence the brain’s activity. Utilizing a unique mechanism entirely different from the standard array of psychiatric medications, TMS represents an important alternative for individuals who have not responded to other treatment options.

 

Below are answers to some common questions about TMS.

How Does TMS Work?

Most currently available medical treatments for psychiatric conditions require patients to ingest a drug that eventually enters the brain and alters its functioning in ways that alleviate symptoms of mental illness. For example, selective serotonin reuptake inhibitors, such as Prozac, Zoloft, and Lexapro, latch on to parts of neurons (tiny nerve cells in the brain) and prevent them from reabsorbing serotonin, a change which has been linked to improvements in anxiety, depression, and other conditions.

 

In contrast to these treatments, TMS is drug-free and noninvasive, meaning its active ingredient is not something that must be ingested or implanted. Instead, TMS impacts the brain from the outside. More specifically, it uses magnetic coils placed just above the scalp to send magnetic pulses into specific regions of the brain associated with mood regulation.

In turn, these pulses induce a series of changes in the brain that improve mood and alleviate symptoms of depression. As Latitia McDaniel, assistant TMS program director at Heading Health states:

 

By targeting these specific areas of the brain, TMS stimulates and strengthens these neural pathways. Like training a muscle, over time, the inactive signals begin firing and reconnecting properly again, thus restoring the emotional control center.

What is it Used to Treat?

TMS is approved by the U.S. Food and Drug Administration (FDA) to treat the following conditions:

 

  • Major-depressive disorder (including treatment-resistant depression)
  • Obsessive-compulsive disorder (OCD)
  • Migraines
  • Smoking Cessation

 

In addition to being FDA-approved, treatment-resistant depression (i.e., depression that has not adequately responded to one or more antidepressant drugs) is now covered by several insurance companies. At Heading, we work with most insurance plans, from United Healthcare to Medicare to Blue Cross Blue Shield. Click here for a full list of participating providers and to schedule a consultation to determine whether TMS is covered for you. 

 

Aside from the above-mentioned conditions, researchers continue to examine whether TMS might be useful for other mental illnesses not currently approved by the FDA, including:

 

  • Bipolar disorder
  • Eating disorders
  • Generalized anxiety disorder
  • Panic disorder
  • Schizophrenia
  • Substance abuse
  • Post-traumatic stress disorder.

 

What is the Treatment Like?

TMS treatment for Major Depressive Disorder typically consists of three-minute or 20-minute sessions that occur five days a week over six weeks.

 

Undergoing TMS is a quick and straightforward process. At each appointment, patients sit in a relaxing chair as the practitioner places the magnetic coil in the correct location on their head. As the treatment begins, patients may feel a light tapping on their head that eventually dissipates. While rare, some individuals may feel some discomfort on their scalp, though this can be resolved by rotating or moving the magnetic coil or through other easy modifications.

 

After the session has ended, patients are free to drive home and continue their day as usual.

 

How Does Heading Health Do TMS Differently?

At Heading health, we focus on utilizing the best available tools to ensure our treatments are delivered precisely, reliably, and consistently.

 

One of the ways we accomplish this with TMS is with the Magstim StimGuide, the first navigational system specifically designed for the clinical market. After the target location has been identified, the StimGuide stores the location using four distinct parameters captured by a 3D snapshot of the treatment area. When administering TMS, this tool helps practitioners consistently identify the target area by emitting a green light when all four parameters are aligned.

 

In addition, our machines come outfitted with MagStim’s E-Z Cool Coil Coil, which has a built-in intelligence cooling system capable of at least a 37-minute protocol.  

 

Talk with your doctor to determine whether this treatment is right for you, or you can schedule an appointment with one of our team of psychiatrists or therapists to advise you on this or any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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Nutritional Therapy for Mental Health


Nutritional Therapy for Mental Health

October 1, 2022

When trying to treat depression and anxiety, most people turn to psychotherapy, oral medications, or some other medical intervention.

 

While these treatments are effective and often a vital part of many individuals’ mental health toolkits, they aren’t the only ways to prevent and treat mental illness. In particular, research increasingly suggests that our diets can have a significant impact on our mental health. For example, a 2017 study found that around a third of subjects who switched to a Mediterranean-style diet no longer had symptoms of depression by the end of the trial, compared to eight percent of the participants who made no dietary changes. 

 

Nutritional therapists utilize these findings to help patients with a wide range of conditions by offering evidence-based, individualized advice on dietary and other lifestyle changes they can make to support their bodies and, in turn, their minds. 

 

Let’s look at some answers to common questions about nutritional therapy and its role in mental health. 

How Does Nutritional Therapy Impact Mental Health?

It’s common knowledge that what we eat can impact our physical health. For example, it’s well known that eating a diet high in sugar can increases one’s odds of developing diabetes and that high cholesterol, high sodium diets can increase the risk of developing heart disease.

 

But how can nutrition have an impact on mental health conditions? While the connections between diet and mental health are complex, there are, essentially, two ways in which what we eat can improve or harm our mental well-being.

 

First, the nutrients in our food get sent to the brain, altering its functioning in various ways that can impact mental health. For example, antioxidants, found in high levels in fruits and vegetables, can make their way into the brain and decrease oxidative stress, which has been implicated in several mental illnesses. Second, they can impact the health of our gut microbiomes. This collection of bacteria, viruses, fungi, and microbes performs a variety of roles, from producing some of the brain’s serotonin to regulating immune function, which can impact brain health and, ultimately, our psychological well-being.

What Conditions Can Nutritional Therapy Be Used to Treat?

From depression to schizophrenia, nutritional therapy can be used to treat a wide range of mental health conditions. This is partly because many mental disorders are caused or exacerbated by a set of common factors one can impact with their diet. As our resident expert and registered dietician, Sally Twellman notes:

 

Inflammation appears to be a common factor in mental illness, and dysfunction in the gut is often at the root of chronic inflammation. When you look at the research, regardless of the manifestation of mental illness, symptoms typically improve by decreasing inflammation and replenishing the micronutrients that one needs to thrive. And this is really across the board.

How Does Heading Health do Nutritional Therapy Differently?

Heading Health’s approach to nutritional therapy is unique in several important ways.

 

First, our nutritional therapy can be combined with in-house teletherapy or telepsychiatry. This is critical because nutritional therapy is often best used to amplify the effects of other treatments, like psychotherapy or medications, rather than as a stand-alone solution. Second, we utilize a holistic, evidence-based approach, which encompasses more than the standard dietary changes, like those involving proteins, calories, and carbs. As Sally notes when discussing her approach to nutritional therapy:

 

Often when we discuss nutrition modification, we only focus on proteins, calories, fat, and carbohydrates. That’s important. But then we often forget that the real medicine in our food comes from vitamins, minerals, and phytochemicals. If we don’t have those basic building blocks and we don’t have those correct signaling molecules, it’s difficult for our brains to function optimally.

 

Importantly, we don’t stop at dietary changes. We also include lifestyle modifications (e.g., exercise, meditation, journaling, breathwork, etc.), which are known to positively affect mental health and can enhance the effects of dietary alterations.

 

Overall, we look at the whole person and consider how they can make small but meaningful adjustments that complement other treatments they are receiving to optimize their mental health.

 

Talk with your doctor to determine whether nutritional therapy is right for you, or you can schedule an appointment with one of our team of psychiatrists or therapists to advise you on this or any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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FDA Approves Fast Acting Antidepressant – Auvelity


FDA Approves Fast-Acting Antidepressant: Auvelity

September 23, 2022

On August 19, the U.S. Food and Drug Administration (FDA) approved Axsome Therapeutics’ Auvelity for the treatment of major depressive disorder (MDD) in adults. This new drug has several significant benefits over traditional antidepressants, making it an exciting advancement that offers new hope for individuals struggling with depression.

Here are six key takeaways.

#1: It’s Rapid Acting

One of the main drawbacks of many oral antidepressants is that they can take a long time to work. For example, selective serotonin reuptake inhibitors (SSRIs), like Zoloft, Prozac, and Lexapro, can take four to six weeks before they even begin to take effect.

 

Given how debilitating depression and anxiety can be, rapid symptom relief is critical. Initial studies indicate that patients taking Auvelity showed improvements in depression severity scores in as little as one week.

#2: It Works Through a Novel Mechanism of Action

The standard array of antidepressants works primarily on one or more of three of the brain’s chemical messengers: serotonin, norepinephrine, and dopamine. More specifically, they increase the amount of these neurotransmitters in the space between neurons (nerve cells in the brain that receive and relay information to each other).

 

Auvelity contains two compounds, bupropion, and dextromethorphan. This treatment combination works by inhibiting N-Methyl-D-aspartate (NMDA) receptors, which increases the intracellular levels of glutamate, an excitatory neurotransmitter found throughout the central nervous system (CNS). This increase in glutamate causes the release of another chemical called brain-derived neurotrophic (BDNF) factor, which may help symptoms of depression by allowing neurons to form new connections more easily.

 

#3: It Can Be Taken Orally

Auvelity is the first FDA-approved NMDA antagonist for depression that can be taken orally as opposed to intravenously (through an IV), intramuscularly (injected into the muscle), or intranasally (sprayed into the nose). While these alternative routes of administration have their advantages, some may feel they lack the convenience of a pill that can be taken in the comfort of one’s home.

 

#4: It is Not Associated with Weight Gain or Sexual Dysfunction

Even when the standard antidepressants are effective, they can come with side effects that lead patients to discontinue them despite their therapeutic effects.

 

Likely due to its novel mechanism of action, dextromethorphan-bupropion was not found to be associated with weight gain or sexual dysfunction, two of the more commonly experienced side effects. Additionally, the clinical trials found that, unlike ketamine or Spravato (intranasal esketamine), dextromethorphan-bupropion did not cause transient psychotomimetic effects (i.e., delusions, delirium, perceived distortions of space and time, etc.). 

 

#5: It Can Be Used as a First-Line Treatment

Though there are other treatments for depression that work through novel mechanisms, such as Spravato and TMS, they are approved by the FDA for treatment-resistant depression (i.e., depression that has not responded to multiple oral antidepressants).

 

A lack of FDA approval often results in a lack of insurance coverage. This means patients who would prefer to try one of these novel treatments but have yet to undergo a series of trials with standard oral antidepressants must first wait through weeks or months of potentially unsuccessful treatments.

 

Auvelity changes this. Because it is FDA approved for major depressive disorder full stop, doctors can use it as a first-line treatment for depression before a patient has tried other antidepressants.

 

#6: It is Not the Same as Ketamine or Spravato

While ketamine, Spravato, and Auvelity are all NMDA antagonists, Auvelity is unique in ways that makes them difficult to compare. For example, Auvelity exerts its NMDA antagonism continuously but at a lower level of intensity. In contrast, ketamine and Spravato cause a flood of glutamate in a relatively short period of time. The differential effect of this on treatment outcomes is not yet known, as no studies have compared these medications directly. 

 

Talk with your doctor to determine whether this treatment is right for you, or you can schedule an appointment with one of our team of psychiatrists or therapists to advise you on this or any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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Ketamine and Alcohol Use Disorder​


Ketamine and Alcohol Use Disorder

September 13, 2022

Alcohol Use Disorder (AUD), a condition characterized by a problematic pattern of alcohol consumption despite physical, mental, and social consequences, is among one of the most common and costly psychiatric conditions. According to National Center for Drug Abuse Statistics, the condition affects around 10 percent of Americans aged 12 and older and is responsible for three million deaths every year.

 

Because AUD remains a difficult condition to treat, researchers are actively seeking novel therapeutic solutions. Due largely to its well-documented effects on depression, many experts are investigating whether ketamine may prove helpful against AUD. As Professors Celia Morgan and Amy McAndrew note:

 

Depressive symptoms are common in individuals entering treatment for AUD, and the likelihood of alcohol relapse is elevated in patients with such symptoms.

 

Ketamine may support alcohol abstinence by temporarily alleviating depressive symptoms during the high-risk relapse period in the weeks after detoxification.

 

Early experiments have produced promising results, with several studies finding ketamine improved abstinence and lowered relapse rates. For example, one study found that 66 percent of patients with AUD who received ketamine infusions alongside psychotherapy were abstinent one year later compared to 24 percent of patients who did not receive ketamine.

 

Recent Study Suggests Therapy Makes Ketamine a More Effective Treatment For AUD

While some experts feel that ketamine can be highly impactful when delivered on its own in the absence of any therapy, others feel patients must be supervised and receive guidance from experts during and after treatment for it to be consistently effective. As Rosaline Watts, a leading scholar in the field of psychedelic research, explains when discussing one of her recent experiments, “the drug was a catalyst to the therapeutic process, not the therapeutic process itself.”

 

With the importance of therapy in mind, a team of researchers led by Morgan and McAndrew set out to directly assess the role of therapy in ketamine-based treatments with a focus on mindfulness. In their study, they reason that:

 

The subjective experiences that accompany ketamine infusions may provide a new perspective that may be helpful in psychological therapy. Ketamine induces a dose-dependent sense of dissociation and disembodiment that has been described as facilitating an “observer state” similar to that described in mindfulness, which may be helpful for allowing patients to consider thoughts and emotions from a more removed perspective.

 

 

Methods

The researchers conducted a double-blind-placebo controlled study to assess the importance of therapy in ketamine-assisted treatments for AUD. This means special precautions were taken so that neither the subjects nor the experimenters knew what treatment they received, which helps ensure the results are more objective, reliable, and free from bias.

 

Because the researchers wanted to examine the effects of both ketamine and therapy on AUD, they needed two placebos (i.e., “inactive” treatments), resulting in four possible treatment combinations.

 

  1. Ketamine infusions with psychological therapy/mindfulness-based relapse prevention
  2. Saline (drug placebo) infusions with psychological therapy/mindfulness-based relapse prevention
  3. Ketamine infusions with alcohol education (“therapy placebo” where subjects were taught general facts about addiction and alcohol use disorder)
  4. Saline infusions with alcohol education

 

Findings – Efficacy and Safety

After three treatment sessions the researchers noticed several important outcomes. They found the number of days abstinent at three and six months after treatment was higher in the groups that received ketamine either with or without therapy, corroborating findings from earlier experiments.

                                                                                               Photo Credit to Professors Morgan and McAndrew

 

The team found some promising results when it comes to whether mindfulness makes ketamine a more effective tool against AUD. In particular, they found that relative to the subjects that received saline with alcohol education (i.e., both placebos), the group that received ketamine alongside mindfulness-based relapse prevention showed the largest percentage increase in the number of days they remained abstinent. However, the latter finding was not statistically significant, meaning future studies will need to verify that the combination of ketamine infusions with mindfulness-based relapse prevention is more effective than ketamine alone.

 

Because ketamine has the potential for abuse when used in recreational settings, Morgan and McAndrew sought to assess whether this might make it a less viable option for individuals with AUD. To do so, they tracked whether subjects used ketamine during the follow-up portion of the experiment after the supervised ketamine infusions had been administered.

 

They found that around six percent of the subjects reported using ketamine on one occasion during this period. Importantly, these individuals stated they had used ketamine recreationally before the experiment. Future studies will be needed to further determine whether AUD puts one at a greater risk of using ketamine outside supervised settings.

 

Conclusion

Though the research is in its early stages, evidence suggests that ketamine, whether used alone or in conjunction with therapy, may help individuals recovering from AUD maintain sobriety.

 

As researchers continue to explore and identify new psychiatric uses for ketamine, it is becoming increasingly clear that psychological therapy is required to unlock the full benefits of this treatment. Patients and practitioners alike should bear this in mind as they consider ketamine as a therapeutic alternative.

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What To Expect At Your First Psychiatrist Appointment

What To Expect At Your First Psychiatrist Appointment

January 28, 2022

telehealth-psychiatry-image

Whether it is over the phone or in person, seeking help for your mental health can be daunting if you do not know what to expect. This article will give you some useful pointers to empower you to work in collaboration with our psychiatrists on starting your journey to recovery.

 

1.  Come prepared

Before your appointment, it might be useful to take some time to think about the reason for your visit. What symptoms or struggles are impacting you the most? How and when did they start? If possible, keep a diary of your symptoms over a couple of weeks. This is helpful to monitor their frequency, intensity, identify a particular time of day, potential triggers, and things that make you feel better, etc. Sleep patterns, appetite, and weight fluctuations are equally valuable sources of information for your doctor.


It is also useful to gather some details about your childhood from your family, including your birth, your developmental milestones (at what age did you start walking, talking, etc.), your behavior as a child and how you did in school. Ask your relatives if there is a history of mental illness in your family – this may be a sensitive subject but can be relevant as you might be more susceptible to certain conditions.


If you have been referred by another healthcare provider, bring your consultation letters including previous diagnoses, treatments, and medications you have been on. Make sure to bring hospital discharge letters if you had previous admissions or inpatient treatment.

 

2.  What you are likely to talk about
If this is your first contact with a psychiatrist, the appointment is likely to take about an hour.


At first, your healthcare provider may give you the opportunity to talk freely about your presenting complaint. After that, you will be asked a series of more detailed questions on your childhood, education, family, current situation, medical history, etc. They might ask you questions on some of the more intimate aspects of your life, including relationships, sexuality, illicit drugs, or if you ever had trouble with the law. This enables your psychiatrist to make a 360° assessment of your mental health and how it affects you in your daily life. If you feel uncomfortable answering certain questions, do not hesitate to let your doctor know. Do not forget that professionals are bound by confidentiality and none of the information you disclose will be shared with your relatives or the authorities.


Depending on the reason for your visit, they might ask very detailed questions about treatments and therapies you have already tried, including over the counter and herbal or non-conventional treatments – did they help? What side effects did you suffer from? Why did you stop? This will allow your doctor to tailor his approach to give you the best chance of positive outcomes. Finally, give your psychiatrist any information that has not come up in questions, but you believe to be relevant to your circumstances – you know yourself best.

 

3.  Outcome of your consultation
For someone suffering from debilitating symptoms, getting to put a name on your illness might feel therapeutic. It enables you to give an identity to the enemy you are battling, and to connect with other individuals going through the same journey. However, it is important to understand that your provider might not be able to give you a diagnosis at the time of the first consultation. Many diagnostic criteria rely on temporality, i.e., length of time you have been suffering from symptoms, and sometimes a positive diagnosis can only be made retrospectively, many months down the line. Whilst this might be frustrating, it is paramount not to rush as being given a certain label can have long-lasting consequences in terms of treatment you will be offered or will not qualify for.


However, your psychiatrist might still be able to provide you with a working diagnosis or provisional diagnosis to allow treatment planning whilst waiting for all the diagnostic criteria to be filled.


Coming to the end of your consultation, you will make a plan in conjunction with your psychiatrist about how to go forward. You might be offered a combination of therapy, medication, and other treatments such as TMS or novel agents. Remember you are the main actor of your recovery, and the decision on what treatment modality you believe will suit your circumstances is ultimately yours, guided by the advice of your psychiatrist. They will explain in detail the modalities, side effects, and evidence behind every option, to allow you to make an informed decision. You might wish to take more time to read through patient leaflets, do your own research, or talk about it with your next of kin. Other things to discuss are the frequency of follow-ups and monitoring and making a contingency plan for you to refer to in case your mental health deteriorates, such as urgent helplines and contact numbers.

 

If you have further questions about scheduling with a psychiatrist, another mental health provider, or how to best prepare for your appointment, give us a call at 512-777-2591 and we would be happy to assist you.

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