|
Ryan Vidrine, M.D. - Guest
Ryan Vidrine, M.D. is a Board-Certified Psychiatrist who specializes in the treatment of OCD and related anxiety Disorders. He started his career in neuroscience and moved into psychiatry with a particular interest in the field of Interventional Psychiatry and Neuromodulation for treatment resistant conditions, which includes the use of ECT, TMS, ketamine/esketamine, and deep brain stimulation. During his residency training, Ryan worked in the UCSF OCD & Anxiety Specialty Clinic, developing expertise in the diagnosis and treatment of the full range of anxiety disorders, approaching patients from an Acceptance-Commitment Therapy (ACT) framework, which focuses on patient values as the anchor and impetus for behavioral changes. He is currently Director of OCD and Anxiety Services at Mindful Health Solutions and an Assistant Clinical Professor in the Department of Psychiatry at UCSF School of Medicine. Additionally, he completed training through the CIIS Psychedelic Therapy and Research Program in San Francisco, CA. |
|
W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using emotionally focused couples therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and oppositional and Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:32):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:20):
In this episode, I'll be interviewing Ryan Vidrine, M.D., who is a board-certified psychiatrist specializing in the treatment of OCD and related anxiety disorders. He started his career in neuroscience and moved into psychiatry with a particular interest in the field of interventional psychiatry and neuromodulation for treatment resistant conditions, which include the use of electroconvulsive therapy or ECT, transcranial magnetic stimulation or TMS, ketamine and S-ketamine, and deep brain stimulation. During his residency training, Ryan worked at the University of California, San Francisco Obsessive Compulsive Disorder and Anxiety Specialty Clinic, developing expertise in the diagnosis and treatment of the full range of anxiety disorders, approaching patients from an Acceptance Commitment Therapy Act framework, which focuses on patient values as the anchor and impetus for behavioral changes. He's currently director of the OCD and Anxiety Services at Mindful Health Solutions and Assistant Clinical Professor in the Department of Psychiatry at UCSF School of Medicine. Additionally, he completed the psychedelic therapy and research program training through California Institute of Integral Studies in San Francisco. Let's listen to the interview.
Keith Sutton, Psy.D. (03:37):
Well, hi Ryan. Welcome.
Ryan Vidrine, M.D. (03:39):
Hi, Keith. Thanks for having me.
Keith Sutton, Psy.D. (03:40):
Yeah, definitely. So, Ryan, I know you because we've shared some clients. You're a psychiatrist in the San Francisco Bay Area, and you also are involved with TMS. I think you used to be called TMS Solutions, but I think they changed the name for the group that you're with--
Ryan Vidrine, M.D. (03:58):
Correct. So, yeah, we're Mindful Health solutions now and doing a variety of things more than just the TMS at this point.
Keith Sutton, Psy.D. (04:04):
Yeah. Well-- and I was really interested in hearing about TMS and about-- we were just talking about you're also doing some work with ketamine, and also you've been doing some training in the work with MDMA and I think this is an area that a lot of therapists maybe don't know a lot about or something that's really kind of on the forefront. So, before we even kind of get into that, though, I'd love to hear your story about how you got, doing what you're doing.
Ryan Vidrine, M.D. (04:31):
Sure, yeah. As I did my residency training in psychiatry at UCSF, prior to that, I was convinced I was going into neurosurgery. So, I've always been really interested in the brain, how sort of people, you know, get to become who they are and was really interested in sort of procedural brain things. And then sort of had this epiphany while doing rotations in neurosurgery that I really was more interested in sort of, you know, people's behavior and how they choose what they do and become who they are, and so made the switch over into psychiatry, but with this interest and still sort of a procedural side. And then when I was-- when I got to UCSF, I worked in the OCD and Anxiety Clinic there and fell in love with working with those patients. I think OCD is one of the most interesting disorders. It's one of those artists too that has some of the most disabilities that no one sees from the outside. So, people are really silently suffering oftentimes, and so really enjoyed that. And then after training, I joined Mindful Hall Solutions and became the director of OCD and Anxiety Services there, and really specializing in, and mostly working with OCD and anxiety cases now. And I think, you know, one of the appeals to our practice has been that the longer anyone works in psychiatry, the more you realize that what we have as treatments, you know, are helpful, but not helpful enough for a lot of people or not without a lot of downsides. And having other tools in the toolbox is very appealing. And some of these procedural things certainly caught my interest.
Keith Sutton, Psy.D. (06:22):
Yeah, yeah, definitely. Now, yeah, let's-- can we talk about TMS first and kind of like what that is? And I'm always, you know-- and I've comment, you've had me over to your clinic and I got to kind of check out the machine and experience how it feels and so on. But yeah, I'm interested to learn more. And also, you know, also thinking about kind of when that might be an appropriate referral for a clinician to kind of refer for TMS. And I know that I think there's approvals for treatment with depression, and I know you've been doing work with TMS and related to anxiety and OCD and I was actually just listening to a podcast from a few years ago where they were just doing some research and actually using it with autism spectrum disorder. Not as something that would change, but more actually stimulating some of those neurons and actually the person, you know, experiencing things differently.
Ryan Vidrine, M.D. (07:17):
Yeah, so I mean-- so TMS is transcranial magnetic stimulation. So I mean, essentially what we're doing with that is an MRI string magnet but focused on the circuits in the brain where we know to be involved in depression and anxiety and other disorders. Like most of the treatments in terms of referrals, you know, the more treatment resistant someone has been, the more things they've tried, usually that attenuates your response. So, you know, I think a lot of people, we wonder in the future, you know, in your first episode of depression, could you go and get a course of TMS, not have to deal with the side effects of medications and probably get better? And the answer is probably, you know, the less treatment resistant, the better it works. But where we tend to get most referrals and see the most use is in more treatment resistant cases.
Ryan Vidrine, M.D. (08:10):
So, from the Star D data tells us that once someone's tried three or four medications, the chance that the next medication is going to put them into remission of their depression is less than 10%, probably. And so, that's the group that we've really looked at. And if you refer and go to TMS instead of that fourth, fifth medication, that same group of people has about a 30 to 40% of chance of remission of their depression symptoms. So, it really is in that specific population where we see the biggest difference in kind of separating from another med trial. So, it's also a little bit of a product of what insurance tends to cover these days. So, most of them require several med trials that is getting less stringent. So some have dropped down from things like four med trials and two augmentations and therapy to maybe two med trials. So that's kind of encouraging.
Keith Sutton, Psy.D. (09:04):
Okay. Great. And can you tell me a little bit about how TMS works?
Ryan Vidrine, M.D. (09:09):
Yeah, so like I said, we're focusing a magnetic field on specific circuits in the brain. Important to say we're not sending electricity through the brain. So, a lot of people have a question about, is this like ECT? So I usually describe it with patients as these neurons and these circuits are always sort of firing anyway at a certain rate, right? That is determined by the electromagnetic fields inside our brains. And so, with a device like TMS, we can manipulate that. It's sort of like tickling the neurons, if you will. So, we can go in and use a magnetic-- we alter the magnetic field in a particular way, we can increase the rate of firing, or if we alter it in a different way, we can decrease the rate of firing. And so, we can either strengthen or kind of weaken a particular circuit.
Keith Sutton, Psy.D. (09:58):
And is that because, like the positive and negative charges around the neurons that are kind of leading to the release of the neurotransmitters in the synapse?
Ryan Vidrine, M.D. (10:09):
A little bit. Yeah, exactly. So we're--
Keith Sutton, Psy.D. (10:12):
Ions or whatever. I'm not-- I don't remember exactly from my psychopharmacology class.
Ryan Vidrine, M.D. (10:17):
Yeah, exactly. That's sort of those ions. And the change kind of has an electromagnetic certain basal rate way the neurons fire. So we can go in and use a high frequency of stimulation with TMS and make them more likely to fire. It's thought to be excitatory in a lot of cases, as opposed to maybe sometimes we use a lower frequency that tends to slow that down or inhibit that circuit from firing more readily. So, yeah, we're thinking when we do this that, you know, in depression there's been some evidence that certain circuits maybe are hypoactive in the brain--
Keith Sutton, Psy.D. (10:51):
Yeah.
Ryan Vidrine, M.D. (10:52):
Or the term that I think things are moving more towards is looking at the functional connectivity in the brain. So how much is one network kind of communicating with another network in the brain? And oftentimes in these disorders we see there's an imbalance or, you know, our more limbic structures are sort of raging and the executive function structures have become too quiet and kind of unable to compete. And so, if we can strengthen certain circuits, we can kind of bring that balance back at play. That's kind of generally the idea.
Keith Sutton, Psy.D. (11:21):
So it's kind of like fixing up the roads and getting them to be more like highways or something like that, and rather--
Ryan Vidrine, M.D. (11:27):
Yeah. Making them a little more in tune with each other and--
Keith Sutton, Psy.D. (11:31):
Or bridging, you know, kind of those connections or so on. Interesting. And so, yeah, because you know, when I sound a little woo woo, like magnets and so on, you know, but like, yeah, that, that makes sense that the magnets are, you know, because yeah, there is that kind of positive negative kind of ions and how that affects whether or not the-- whether it's going to excite the neuron and produce the neurotransmitters. So, stimulating that to get those neurotransmitters going. And is this something that is done ongoing or more, or-- I'd even be interested in a little bit about like, the difference between that and like the medication. because it's a medication theoretically doing the same thing or different stuff and how's that kind of different
Ryan Vidrine, M.D. (12:13):
Yeah, the medications are-- well, you know, one thing we talk about with patients is the medications are systemic, so they're doing a lot of things and we have guesses, but you know, does anyone really know exactly what the meds are doing? And has sort of proven this is the clear mechanism as I-- there's a lot of debate about that. We know that, you know, with an SSRI, we can increase serotonin in certain synapses and get some circuits that are hyperactive to come back into a more normal balance, but we're doing that in a shotgun approach. So, TMS may do some similar things, we can affect circuit activity, but it's a lot more specific and local. And that's one of the big benefits. So, you know, you're not getting TMS throughout your entire body essentially. And so, that's why we-- a lot of people come to us because we're not seeing side effects in the same way that you see with the systemic medication--
Keith Sutton, Psy.D. (13:10):
Because the antidepressant is kind of affecting all the whole body. So that's why the person might be getting dry mouth or, you know, difficult--
Ryan Vidrine, M.D. (13:17):
Sexual side effects--
Keith Sutton, Psy.D. (13:18):
Like sexual side effects or, you know, these kind of things or appetite or so on, because it's kind of like impacting everything rather than being localized.
Ryan Vidrine, M.D. (13:28):
Exactly. So this is one of the tools that you can be a little bit more specific and targeted with. And, I talk to patients too about it being-- I think of it as kind of going to the gym for your brain circuits in a way, which again, can sound a little woo woo, but it's not a fast treatment. So it's not something you go in and it happens one time and you're not going to walk out, you know, dancing and walking on the clouds kind of thing. It's not a euphoric treatment. So, like the way that we think about it is that, you know, across-- we're kind of regardless of disorder across a lot of the mental health disorders, we see, you know, it may be trouble in attention, in mood regulation, these sort of specific functions that crosscut against different diagnoses, right.
Keith Sutton, Psy.D. (14:15):
Yeah.
Ryan Vidrine, M.D. (14:15):
People-- what we think is when we're strengthening that executive function circuitry, that kind of top down regulation, what we see is people tend to start to function better. They're not necessarily feeling happy, if you will, but they hold it together a little bit. They don't flip out on their partner quite as easily or something stressful happens and they'll come back and say, I just handled it a little bit better. And so--
Keith Sutton, Psy.D. (14:41):
Yeah. Interesting, so that reactivity is kind of decreased or that kind of connection, you're saying like between the upstairs, downstairs brain, kind of the Dan Siegel like, you know, the limbic system and kind of more that higher cortical area is kind of slowing things down, or sometimes I've heard about it, like, you know, it's almost like insulating. The kind of emotions to kind of help it can be a little bit more contained.
Ryan Vidrine, M.D. (15:03):
Yeah. And that's usually what we'll hear from people. So again, they say things more such as I handle stuff better. And we-- so we kind of see slowly week to week them--
Keith Sutton, Psy.D. (15:16):
Oh Ryan, hold on one sec. Sorry, my wife actually just opened up her headphones, and it connected. Okay, there we go. Sorry. So, you're saying usually that's what you see from people?
Ryan Vidrine, M.D. (15:03):
Yeah. They describe sort of this better handling of the world, better function, maybe their focus and energy feels like it's a little bit, you know, better. And so, they start to function in the world better and then what we see kind of lag behind that is then they start to sort of feel better. The depression starts to go away. They feel more confident and succeeding day to day, that kind of thing.
Keith Sutton, Psy.D. (15:23):
Yeah.
Ryan Vidrine, M.D. (15:24):
And that's where I liken it to sort of working out, you know, bicep curls for your circuits in a way, it's a slower treatment. So, usually a course of TMS is once a day Monday through Friday for anywhere between four to six weeks. And so they're coming in regularly. You're not going to see anything dramatic in the first two weeks. You know, it's really that third, fourth, fifth week where after you've come in and we've really exercised those circuits that we start to kind of see more benefits.
Keith Sutton, Psy.D. (15:53):
Yeah. And is it-- yeah. Is it lasting? Does that muscle stay or does it, you know, is again like a workout where if you stop working it, it kind of atrophies or?
Ryan Vidrine, M.D. (16:04):
Yeah, we see really different things. And they're, you know, really long-term studies are all sort of always hard, so we don't have tons of them. We have a couple that are good and go out to a year or two years, things like that. But, we have people that are in a pretty dark spot and sort of are able to pull themselves out of the hole with TMS and we don't see them again. Or they, you know, stay kind of in a better place. We have certainly seen people that come back a couple of times over their lifetime, again, when it's really bad. And then we have other patients that there's almost a rhythm to it. So, I've had someone who almost like clockwork every two years seems to get-- just feels sort of, the light's going dim, the energy draining. They feel this real kind of slowing down. They come in, they get the TMS, and they go back and they're fine. We will see people, sometimes it's three months or six months down the road, feel like they're relapsing again. It's all-- it's often a question of sort of what's maybe contributing to that depression, right. So, if they're in psychosocial setting, that is miserable. Well, TMS isn't changing that.
Keith Sutton, Psy.D. 17:12):
Yeah, if they're in a horrible job or if they're, you know, in a not good super stressful situation--
Ryan Vidrine, M.D. (17:18):
Exactly.
Keith Sutton, Psy.D. (17:18):
Yeah. One of those things. Yeah. So the-- so let me kind of come back to, because actually, I remember actually when I was first reaching out to you, somebody was also asking me about ECT. And kind of, you know, more recent and electro convulsion therapy. And I was wondering about, you know, similarities, differences from TMS and also, I don't know if you know much about what's going on now with that, because I know, you know. Yeah, most people think of it kind of way earlier sixties, like--
Ryan Vidrine, M.D. (17:49):
Yeah.
Keith Sutton, Psy.D. (17:49):
Kind of really, you know, psych hospitals kind of stuff. ECT. But, I think it's being a bit used now still too. I'd love to hear any thoughts on that and also similarities, differences to TMS.
Ryan Vidrine, M.D. (18:03):
Yeah. So ECT still is quite relevant to psychiatry. We actually have part of our practice does ECT as well. So it is an option within our practice. Difference-- I mean, ECT is one of still the most effective treatments for severe depression. In terms of looking at the research and the data and chance of recovery and remission, it's often hard to beat still to this day. The big difference is, ECT is something that usually is done in some sort of hospital setting or an outpatient hospital setting requires anesthesia. And we are putting electricity through the brain. Now ECT from the past and modern ECT is quite different. Surprisingly, even up to around 2000, though it was still sort of being done in this older way, but it really has, in the last probably 15 years or so, made some bigger advancements in terms of trying to mitigate side effects. So again, adjusting frequencies-- different frequencies of administering the ECT has been able to make it more tolerable, less side effects, like memory problems or, kind of confusion at the time of ECT, things like that--
Keith Sutton, Psy.D. (19:19):
Yeah.
Ryan Vidrine, M.D. (19:19):
So modern ECT is certainly better. Most of the side effects are from sending electricity through the brain. And so, that's a big difference in TMS or not doing that, you don't see memory impairment in TMS, you don't see nausea, confusion, you know, that kind of stuff. Brain fog from the TMS itself. If anything, people-- there's a mix of studies that say, you know, cognition is not really changing. Or maybe it's a little bit better than it was.
Keith Sutton, Psy.D. (19:49):
And is the-- and do you-- I don't know if you even know this info of kind of the mechanism of action of the ECT, like kind of what is it doing?
Ryan Vidrine, M.D. (19:59):
Again, there's like three or four ideas and hypotheses. It's again, it's like a little bit more local in some ways because it's not sending medicine throughout the whole system, but it's a shotgun approach, a brain stimulation. We're causing a seizure everywhere. So there's a few different hypotheses. Again, there's this hypothesis that we know that sort of where you initiate a seizure does lead to a whole host of blood flow changes in the brain. And if we change blood flow to parts of the prefrontal cortex, again, similar in TMS idea of we might increase certain activity over time, strengthen that circuitry and alter the kind of balance and networks talking to each other--that functional connectivity I mentioned. There's other kind of hypothesis that we're causing a dump and a release of catecholamines and all of the hormones and that does something. There's a few other thoughts. So again, we sort of know it works, but--
Keith Sutton, Psy.D. (20:58):
Yeah.
Ryan Vidrine, M.D. (20:59):
A lot of thoughts of what's happening both TMS and ECT increase the BD and F hormone that we know promotes neuroplasticity, it makes the brain a little bit more likely to change. So, both of them do that.
Keith Sutton, Psy.D. (21:13):
Okay. Cool. Yeah, so again, it's kind of like one theory that's similar to kind of building the roads and strengthening the highways or so on to kind of get those connections going and just, but like, kind of in a surge, like, you know, kind of--
Ryan Vidrine, M.D. (21:25):
Right.
Keith Sutton, Psy.D. (21:26):
Shock and awe to the brain. And so, the neuroplasticity actually I was curious about that because one of our-- the first podcast I did was with my colleague Jim, who is doing a lot of work around psilocybin. And kind of was talking about how the FDA has put it as a breakthrough treatment as effective or, then current treatments or something with less side effects or whatever it might be. And he was kind of talking about that the psilocybin kind of created like a window of neuroplasticity to like do something with, versus like antidepressants, which might take a month to get going. And then the neuroplasticity is just kind of happening all over the place, regardless of what's happening in the environment. So maybe not able to kind of focus so much of what you're doing in the therapy or treatment during the time of neuroplasticity. I don't know if you have any thoughts on that or how TMS, ECT or ketamine or the MDMA kind of play into neuroplasticity or kind of--
Ryan Vidrine, M.D. (22:28):
Yeah. I don't know if I have too much thoughts or solid knowledge on how they may differ. We do know that that is a common thread in all of those treatments that we do see an increase in specific markers of neuroplasticity. You know, again, with TMS, it's local and it's focal. So we're seeing it in specific parts of the brain that we're stimulating. Certainly. I would imagine that things like ketamine and psilocybin are a little bit more broadly throughout the brain increasing that--
Keith Sutton, Psy.D. (22:59):
Yeah.
Ryan Vidrine, M.D. (23:00):
Yeah.
Keith Sutton, Psy.D. (23:01):
And is there, and I know with the-- well actually, let's talk about the ketamine and MDMA first, and then I'll kind of come back to my question about kind of-- I was almost, I was wondering like, is there anything you're doing during the TMS like therapeutically?
Ryan Vidrine, M.D. (23:16):
Yeah.
Keith Sutton, Psy.D. (23:16):
But I thought maybe we could talk about some of those other ones because I know that there is a therapy component in addition to the medication or the, I guess the whatever the psilocybin or the MDMA or the so on. So, yeah. Can we talk a little bit about that?
Ryan Vidrine, M.D. (23:32):
Yeah, I mean, it certainly, with ketamine and with psilocybin and with MDMA, the kind of best practices at current would for most people would be around including a therapy component. The big question out here, and people talk about it is, you know, what happens if you give this chemical alone? Can people-- can they be by themselves in a room and have an experience that is curative in some way? Is it a chemical reaction? And most likely it's both. And so, I would say that a lot of people would feel that you can get a certain result just from the chemical loan, perhaps. It would be augmenting and further optimizing to include a potential therapy opponent. That's kind of probably how we usually think about it now.
Keith Sutton, Psy.D. (24:22):
Sure.
Ryan Vidrine, M.D. (24:23):
With something like psilocybin, right, there's more potential to, you know, have a particularly strong experience, maybe be confused, kind of not sure again, feel unsafe. And so the therapy component becomes a little bit about also safe container for something that really can take you to another world. With ketamine, there's a dissociative effect. It can be anxiety provoking for some patients, but not typically something where you're really going, you know, to another world kind of experience.
Keith Sutton, Psy.D. (24:55):
Yeah. Yeah.
Ryan Vidrine, M.D. (24:57):
So a little bit, you'll see in a number of places, really doing more of this kind of medical model of ketamine where patient's in a room, it's a comfortable spot, they get the drug, there's not a lot of talking, there's not a lot of therapy to it really at all sometimes, and we just know that the drug does something. And then you see a lot of clinics, especially around the Bay Area, that really believe in pairing the ketamine with therapy. And so, while someone is in this altered state accessing kind of different ways of thinking than they usually are--
Keith Sutton, Psy.D. (25:25):
Yeah.
Ryan Vidrine, M.D. (25:26):
Can we make a breakthrough in therapy? And I certainly am a believer that that offers a another level of advantage potentially.
Keith Sutton, Psy.D. (25:33):
Yeah. Hold one second, I'm going to close my window.
Keith Sutton, Psy.D. (25:45):
Interesting. So, yeah, so the-- so this kind of idea that wall there mean I, it makes sense, right? Because I mean, for efficiency and cost effectiveness, if you can just give something to somebody and that'll make things better, that becomes readily more available to everybody. Right. And then, but bringing in the therapy component, like you're saying, and particularly, yeah, there's a number of clinics around here that, that do that aspect also, you know, just like with antidepressants and therapy or so on, that that kind of combination that you can do some, some good work. So it's kind of interesting. Yeah. Like, and the, and I don't know if you, do you-- how do you think about the differences between the ketamine, the psilocybin and the MDMA? And I don't know if are that in-depth knowledgeable about all that stuff, but yeah.
Ryan Vidrine, M.D. (26:41):
They're all different. And I don't know, I think you could talk to a lot of people and get a different take on the sort of algorithm of where they might put them in a treatment repertoire. A lot of that currently is just sort of fixed on here's what's available legally. Right. So ketamine is broadly used because we can. And, you know, could I, do, I personally, I could imagine MDMA, for instance, being a better alternative than ketamine for a number of people, or maybe psilocybin depending on sort of, we know psilocybin to be particularly helpful with sort of these existential kind of, you know, someone with cancer dying and trying to wrestle with death and leaving their loved ones and their legacy. I mean, that's something that the research, trials and people with psilocybin and cancer were quite impressive. MDMA is particularly impressive in trauma and PTSD. So I think there's a lot of ways that-- and some of that is because that's what we've done the research in also.
Keith Sutton, Psy.D. (27:41):
Yeah. Yeah.
Ryan Vidrine, M.D. (27:42):
So there's some research, actually, you had brought up autism earlier and using MDMA to treat social anxiety and sort of social skills and autism. So I think there's a lot of ways we could probably start to think of it in the future. And right now it's really that mostly ketamine is the thing that's available. And kind of to the earlier idea of like therapy or not, some of these drugs, particularly thinking of MDMA, you could give someone MDMA and feel more relaxed, a drop in anxiety, potentially an elevated mood, but we also know it's incredibly pro-social. So when you take MDMA it releases-- you get that kind of oxytocin surge. So there's an element to it that's built to facilitate something with another person. And so we think that that's probably actually important at least if you're trying to make some sort of long-term changes--
Keith Sutton, Psy.D. (28:33):
Yeah.
Ryan Vidrine, M.D. (28:34):
Used to be used quite often in couples therapy, and certainly that's an area you could imagine it being immensely helpful.
Keith Sutton, Psy.D. (28:41):
Sure.
Ryan Vidrine, M.D. (28:41):
So they all have sort of their own sort of caveats probably best uses that we will, I think, tailor and figure out more and more over time--
Keith Sutton, Psy.D. (28:50):
Yeah.
Ryan Vidrine, M.D. (28:52):
Even with TMS, so TMS, there's-- we've been doing it for a long time. People come in, they sit in the chair, they get the treatment, they go home. More recent research is trying to say, okay, what about the state of their brain? What can we do while they're getting treatment? Is it CBT? Is it mindfulness?
Keith Sutton, Psy.D. (29:11):
Yeah, that's what I was wondering. Can you be stimulating, you know, kind of those pathways more Yeah. Through mindfulness or doing CBT or doing DBT skills or something like that.
Ryan Vidrine, M.D. (29:20):
Yeah.
Keith Sutton, Psy.D. (29:21):
While doing the TMS and kind of like, you know, almost Yeah. Build those roads in a little bit more, kind of stronger or so on.
Ryan Vidrine, M.D. (29:29):
Yeah. People are doing different work. So, what I'm doing mostly around OCD and this has been done with addiction, like smoking cessation. So there's some evidence that if you activate the circuitry that's involved in whatever you're trying to treat, so an OCD, if we were to kind of provoke or do an exposure around what people are afraid of, and then treat and then stimulate while they're in that particular brain state, that it might work better. So in some of this, like smoking cessation trials, I believe there were active stimulation groups and placebos, but then in the active groups, there was one that was just sort of active stimulation and then one that involves some sort of queuing or kind of provoking of the brain circuitry. And that group had better results than the just plain active. So--
Keith Sutton, Psy.D. (30:17):
Yeah.
Ryan Vidrine, M.D. (30:18):
That's where people are going. I mean, again, it makes sense if you've done therapy, if you think about this, if you've looked at kind of, you know, what we know to typically work certainly in OCD, a huge proponent of getting people to exposure therapy as much as we can. And so, you know, we don't have research on OCD that definitively says you have to do that.
Keith Sutton, Psy.D. (30:38):
Yeah.
Ryan Vidrine, M.D. (30:38):
No one's done a comparison for sure. There's some protocols being researched that don't provoke symptoms and people can still get better, but that's where the field is going.
Keith Sutton, Psy.D. (30:49):
Yeah, if you could tell me a little bit about that with the OCD and that piece. I've actually had some folks on our podcast that do OCD work and so on and exposure and stuff. And yeah, I would love to hear your kind of thoughts on that, you know, kind of OCD and TMS and medication.
Ryan Vidrine, M.D. (31:07):
Yeah. Yeah. With TMS, I would say I think of it in two ways. One is just what we have now that's been FDA cleared that people can access. And that particular protocol is stimulating the dorsum medial structures of the prefrontal cortex of areas that we know are involved in behavioral switching and learning, fear extinction, those kinds of things. And that's the protocol that has been approved that includes this provocation or kind of mini exposure that we do with patients. So every patient with OCD that comes in, we're really drilling down and trying to figure out what is the core fear here? What exactly is it and can we provoke that to an extent in the room paired with treatment? So we, at our practice, try to do that provocation piece of it.
Keith Sutton, Psy.D. (32:01):
So like if the person has OCD around contamination, you might have them touch like a doorknob or something if they're worried about germ contamination--
Ryan Vidrine, M.D. (32:08):
Yep.
Ryan Vidrine, M.D. (32:08):
Touch a doorknob, touch a trash can, the bottom of their shoe without washing. So we really want them to do this without being compulsing during the treatment.
Keith Sutton, Psy.D. (32:17):
So, really flaring up the obsession or that kind of anxiety reaction and then doing the TMS while they're doing the exposure?
Ryan Vidrine, M.D. (32:25):
Exactly. And, even just kind of getting them in that state. So what we ask them to rate their anxiety, we want to get them to that place where they're uncomfortable but not panicking, not kind of freaking out. They can sit there for 20 minutes to get the treatment without compulsing. It's a little bit of a mix of whether we kind of keep doing it the whole time or just sort of get them there and then do the treatment. It kind of depends on realistically person to person and how kind of motivated they are.
Keith Sutton, Psy.D. (32:51):
Sure.
Ryan Vidrine, M.D. (32:52):
But what we hear with that is to-- I don't hear a lot of my obsessions and intrusive thoughts when I weigh completely what we hear is, I feel more able to ignore them, or I can, I seem to be able to resist the compulsion easier. I can go longer. And so it looks like it kind of builds that, the hypothesis, I guess, that we're strengthening those circuits involved in resisting and kind of recognizing error and refocusing attention to a more useful place.
Keith Sutton, Psy.D. (33:24):
Yeah. I mean, the way that I've kind of thought about is like, right, the obsessions and intrusive thoughts don't really like totally go away where we're almost kind of like breaking that connection between the thought and then the anxiety reaction through kind of new learning and new circuitry--
Ryan Vidrine, M.D. (33:37):
Right.
Keith Sutton, Psy.D. (33:38):
So that they might still be having these thoughts or these things like, oh, like that's gross, or you're going to get sick from that. But then they're just like, you know, they're not necessarily reacting to it so much, they're kind of like acknowledging it--
Ryan Vidrine, M.D. (33:48):
Exactly.
Keith Sutton, Psy.D. (33:49):
And just kind of letting it be and float off or whatever, so on, in a way. And that, you mentioned something earlier about effective treatments without exposure. Can you say about that? I think--
Ryan Vidrine, M.D. (34:01):
Yeah.
Keith Sutton, Psy.D. (34:02):
Did I hear that right?
Ryan Vidrine, M.D. (34:03):
Yeah. So, you know, that FDA approved one that I said we're kind of doing with most people, a key term there is cognitive control. So this is a thing that gets studied a lot in OCD and other disorders and something that has been shown in certain in TMS, so we can increase cognitive control in these patients. And so, at least that protocol, we think that that's probably what we're doing. We're improving their cognitive control, their ability to ignore, to reset, to learn new pathways. Like you said. What's interesting is, okay, well what about other ways of targeting OCD, right? And so what if we could get at the part of the brain that we think generates intrusive thoughts or obsessions? And so people are trying to study this. So other brain targets, like the orbital frontal cortex is one of the kind of key places people are going after. Stanford is doing some research now, a little bit of a different target, more orbital kind of frontal in that way. And they're not doing necessarily provocations and things like that, trying to probably get at almost this core like generative piece of OCD--
Keith Sutton, Psy.D. (35:07):
Yeah. Yeah.
Ryan Vidrine, M.D. (35:08):
So we'll see. They've published some things on that. And you know, so we're kind of in that land of we've got an FDA approved that does something--
Keith Sutton, Psy.D. (35:16):
Yeah.
Ryan Vidrine, M.D. (35:17):
And we're going to see what comes out. OCD is fairly newer to the--
Keith Sutton, Psy.D. (35:22):
Yeah.
Ryan Vidrine, M.D. (35:22):
It's only approved since 2018.
Keith Sutton, Psy.D. (35:25):
Interesting. And so, and I'm assuming too, that they did placebo, so like doing some of that provocation exposure stuff without the TMS, like kind of having anything versus, and they found that the TMS in addition was more effective than just that exposure during that short period of time.
Ryan Vidrine, M.D. (35:40):
Exactly. And what's nice is in the TMS research, they've gotten pretty sophisticated with the placebo. So they use a coil that actually is emitting sound. They connect it to electrodes in the scalp. So there is actually a stimulating, sensory feeling that is typical of TMS. So it's really just that we're not sending anything down into the brain with the placebo coils.
Keith Sutton, Psy.D. (36:07):
Now, what about-- so as we talk about all this, I also think about complex PTSD, because I feel like my clients that have a more complex PTSD, you know, some that might get diagnosed, like borderline personality disorder and so on, you know, oftentimes are some of the clients that I think have the hardest time with with medication, because sometimes they're put on like mood stabilizers because they've got bipolar symptoms sometimes like depression. But when you're talking about that kind of emotional reactivity and kind of connecting that, that made me think because that oftentimes is the core, right? Is that their amygdala, their limbic system is reacting kind of disproportionately in the present due to the past trauma. And kind of the you know, the differences in brain, you know, development and areas and so on in folks that have experienced trauma, complex trauma, ongoing, you know, kind of situations growing up. Thoughts on that?
Ryan Vidrine, M.D. (37:08):
Yeah, I really like this question because it's something I think about a lot. You know, that-- so one thing we know is that there's sort of biotype of depression, it seems, right? So someone's depression may live more in a certain network or circuitry than a different person with depression. And so people have looked at this and said, can we kind of predict what types of depression will respond? We're not sure yet there's a mix. But there was some things published around, maybe the more underactive and hedonic I've been this way for years and years, may have a slightly less response. Now I'm always surprised, and I've seen those people get better too, but sort of was one thing that was published. I look for people when I'm thinking about will they respond as being more on that reactive side, right? Do they walk in, they start telling their story and they're crying and then they're running away and you gotta kind of bring them back to slow down and this kind of--
Keith Sutton, Psy.D. (38:03):
Yeah.
Ryan Vidrine, M.D. (38:03):
That kind of thing. Again, that cognitive control term. So if we can boost cognitive control, we can boost executive function, then we can help with a lot of those things that cut across different diagnoses. And people have talked about this, so those, certainly the people like you described, whether it's they're a little borderline, a little ADHD, a little OCD, a little, all those sort of, it's like everything's kind of going all over. We do tend to see people again, report I just function a little bit better. I hold it together a little bit better. And so--
Keith Sutton, Psy.D. (38:35):
Yeah. Yeah.
Ryan Vidrine, M.D. (38:36):
I know. I was optimistic when I first started doing TMS. I had a handful of patients with borderline personality that, you know, it's always so hard to get things to work and they reported I'm using less substances, I feel less impulsive. I--, you know, this is, again, little tweaks and functions that seem to be better. I'm not aware of large scale, high quality studies and not specific population. I know there's some case studies and published evidence, but--
Keith Sutton, Psy.D. (39:02):
Yeah.
Ryan Vidrine, M.D. (39:03):
Anecdotally from experience, we often see those people do a bit better.
Keith Sutton, Psy.D. (39:08):
Yeah. Yeah. Interesting. Okay.
Ryan Vidrine, M.D. (39:10):
If their psychosocial settings are somewhat stable. Right. So again, if they're homeless in between all that, I mean, that's a different story.
Keith Sutton, Psy.D. (39:17):
Yeah. If they're currently in a traumatizing situation, it's like, yeah. It's like you can't do EMDR with somebody while they're in like an abusive, you know, relationship--
Ryan Vidrine, M.D. (39:25):
Exactly.
Keith Sutton, Psy.D. (39:25):
Or something like that. Like, you have to get the foundation of some safety and stability kind of going before, you know, kind of working through those pieces. The-- how about ADHD, you know, that's an area and we've, that's, that's how we got connected around one of my clients that I were working with. Yeah. Does TMS have much, you know, to say about ADHD or kind of affecting, you know, in frontal lobe functioning, or especially as you're talking about some of the-- that executive functioning or connecting that cortex?
Ryan Vidrine, M.D. (39:53):
Yeah, from everything I'm saying you would certainly wonder, right? And think about that, and I think there are, people are studying this. I haven't seen a lot of data about it. It's certainly not gotten any kind of FDA clearance around that. Now there is some newer stuff on other types of brain stimulation. So, transcranial, direct current stimulation where you sort of are putting electrodes on the head. There's an approved treatment that I'm not super familiar with it, but essentially does some form of lower field electrical stimulation for ADHD got approved for kids. So it's being researched. There's some stuff out there. I'm-- in terms of the standard kind of TMS, we haven't really seen that be used on any kind of scale yet.
Keith Sutton, Psy.D. (40:43):
Yeah. Yeah. Okay. And yeah, so the question too, again, back to kind of like how do we determine about referring or so on. I mean, I think that, you know, part of it sounds like you're saying with insurance and such, like they want you to go through some other med trials, you know, it's probably yeah. Much cheaper to get prescription to Prozac or so on than maybe going through this. Is this kind of an expensive process like for, you know, through insurance or is this kind of something that's generally covered, or is that, you know, yeah. Is that why they're kind of saving it to four, you know, medication trials and then doing--
Ryan Vidrine, M.D. (41:20):
Yeah.
Keith Sutton, Psy.D. (41:20):
TMS.
Ryan Vidrine, M.D. (41:21):
You know, so it used to be and now at this point, most insurance plans will cover it. They've all got a little bit of a different set of requirements. And so, but it is getting easier to access. So usually what I would tell clinicians or therapists or whoever, if someone's tried a couple of meds, let's say two meds, they're in therapy and they're still having problems, it's reasonable to get a consultation. You know, and we would look at ins and outs of their particular plans and just kind of see what's going on and at least start the conversation. A lot-- most of us think that, like if you look at-- if we can get someone better with a course of TMS without side effects, without leading to weight gain and contribution to diabetes, you know, in the long run, that's probably cost effective.
Keith Sutton, Psy.D. (42:09):
Yeah.
Ryan Vidrine, M.D. (42:10):
Even though, you know, the cost of a TMS course is certainly more expensive than your prescription of Prozac for six weeks. But yeah, I think it's getting easier to access. We have several people, you know, it always depends on your plan and stuff, but for the actual patient, I mean, sometimes it's just copays. Sometimes people are fully covered because they've met their deductibles.
Keith Sutton, Psy.D. (42:35):
Yeah. Yeah.
Ryan Vidrine, M.D. (42:35):
And so certainly if you've tried a couple things and you're not where you want to be, or if you have a lot of medical problems where mixing multiple meds causes its own set of issues, or there's lots of side effects, even though what you're doing is somewhat working, then it's completely reasonable to get a consultation and kind of start that conversation.
Keith Sutton, Psy.D. (43:45):
Yeah, because I almost wonder too, I mean, it seems like almost like psychiatrists would be like the I don't know, not gatekeeper, but like the person that's like, okay, like we've done these medications, nothing's working, so let's kind of go to this next level. Like, and maybe that's something like the therapist might suggest to this client talk about with their psychiatrist or something like that, you know, because it's kind of, it sounds like they wouldn't necessarily bypass around, you know, like the psychiatrist or so on, but like, try a couple things. If that doesn't work, then do the TMS. And again, is that just because of cost? because like, could the TMS if the person went straight into TMS with depression, like that could also be potentially effective, right? If more just that--
Ryan Vidrine, M.D. (43:38):
It could totally be effective. You know, just like a first course of a medication is a lot more effective than a second course, and you also see higher placebo rates too. And so, I mean, probably the same thing if you went straight to TMS.
Keith Sutton, Psy.D. (43:52):
Yeah.
Ryan Vidrine, M.D. (43:52):
It's expensive. It's six weeks worth of coming into a clinic having multiple personnel, you know, to administer that treatment using devices. So, you know, it's depending on where you are in the country, probably ranging between, I don't know, 12 and $16,000 or so for a course of TMS if you paid out of pocket.
Keith Sutton, Psy.D. (44:15):
Yeah.
Ryan Vidrine, M.D. (44:15):
So that's just for the majority of people. Well, give me my prescription. I take it from home. It's very easy. Right.
Keith Sutton, Psy.D. (44:23):
Yeah, totally.
Ryan Vidrine, M.D. (44:24):
So TMS is also, it's got that cost factor, but then it's off of insurance on insurance can be very affordable. But then it's got this time intensive piece too, where you got to come in. So what's exciting, I would say, and interesting is that there's some people looking at a newer form of TMS called accelerated TMS. So Stanford is doing some studies on this right now in both depression and OCD.
Keith Sutton, Psy.D. (44:49):
Yeah.
Ryan Vidrine, M.D. (44:49):
They have people come in and they do TMS 10 times a day.
Keith Sutton, Psy.D. (44:54):
Wow.
Ryan Vidrine, M.D. (44:54):
It's broken up over the day and they condense that six weeks down to maybe it's a week or so. And so, potentially can we get to that same place in a much faster time?
Keith Sutton, Psy.D. (45:04):
Yeah.
Ryan Vidrine, M.D. (45:05):
There's some published data around doing it twice a day. Like if we just had someone come in twice a day and only have to do three weeks instead of six. And what we're seeing is like people are still getting better and they may get better faster. Insurance doesn't pay for that currently, so that's not something that we can offer the average person, but--
Keith Sutton, Psy.D. (45:23):
So the six weeks, the person is coming daily? Or how often are they coming per week?
Ryan Vidrine, M.D. (45:30):
So typical insurance plan will grant someone about 36 sessions of TMS, so 36 days of TMS. So, usually what we're doing is Monday through Friday, so five times a week for at least, I would say typically about 25 treatments. And then some people will go all the way to 30, that's kind of the standard protocol.
Keith Sutton, Psy.D. (45:49):
Yeah. Yeah.
Ryan Vidrine, M.D. (45:49):
And then usually use the remaining to taper off over two or three weeks, or we kind of reduce the frequency. Practically it can really depend. So, for instance, if some people are doing really, really well, they have a strong, robust response early.
Keith Sutton, Psy.D. (46:04):
Sure.
Ryan Vidrine, M.D. (46:04):
We may, you know, reduce their frequency to three times a week a little bit earlier. They get more weeks overall of TMS if they want to, but it's not as cumbersome. If they're not doing as well, we may kind of keep going all the way to the 30. So there's a little bit of tweak there, but--
Keith Sutton, Psy.D. (46:19):
Okay. So there's some barriers around like the person's gotta basically drive back and forth, back and forth or so on. So like doing something like you were mentioning about that intensive, like, you know, week long or something like that would probably potentially make it more available to folks that like yeah. Or doing like a hospitalization or partial hospital or so on.
Ryan Vidrine, M.D. (46:37):
Or especially people that live a little bit more remotely. I mean, that's the thing. We frequently have people who live about an hour away, and it's like, that's a lot of commuting.
Keith Sutton, Psy.D. (46:45):
Yeah. Yeah.
Ryan Vidrine, M.D. (46:46):
So, people nearby in the city, it is a thing, I mean, it's time intensive. People often think of it as sometimes worse than it is. So, we have lots of students who come between classes, people that come on their lunch break. If you think about people who do frequently go to the gym or pick off lunch, and the treatment itself day to day is about 20 minutes sometimes faster--
Keith Sutton, Psy.D. (47:08):
Yeah.
Ryan Vidrine, M.D. (47:09):
So, it is something you can get in and out of our office in 30 minutes and kind of go about your day.
Keith Sutton, Psy.D. (47:14):
Yeah. Now what-- and I think, so then, the question again is I think back to the effect, like, and again, what is the effect size or what's the, you know, like how, I think you were saying 30 to 40% of kind of folks that have kind of, you know, gone through these, you know, four med trials or so on, tend to respond. And, so more of the chronic depression kind of situations. Is that, was that right?
Ryan Vidrine, M.D. (47:40):
Yeah, so in, certainly in major depressive disorder, you know, around 30% you'll see like gets to remission. If you look at, you know, sort of a lower bar, a partial response. So, they still meet criteria, they're not in remission. Their PHQ-9 is, you know, greater than five--
Keith Sutton, Psy.D. (48:00):
Yeah.
Ryan Vidrine, M.D. (48:00):
You get up to about 60% of people. I think, depending on which studies you, you kind of go to that say, I clearly improved, I'm not remitted, but I've gotten better.
Keith Sutton, Psy.D. (48:11):
Yeah, not gone.
Ryan Vidrine, M.D. (48:11):
With OCD, the results in the trial, and it's pretty consistent with our own internal data in our practice, are somewhere around 40% met for full response criteria, which in those studies was a 30% or more reduction in the Y box scale.
Keith Sutton, Psy.D. (48:31):
Yep. Yep.
Ryan Vidrine, M.D. (48:32):
So around maybe a six point or so drop in your Y box, which is a pretty good drop. That's--
Ryan Vidrine, M.D. (48:36):
Yeah.
Ryan Vidrine, M.D. (48:36):
Not as good as we see when meds work really well.
Keith Sutton, Psy.D. (48:40):
Yeah.
Ryan Vidrine, M.D. (48:41):
And then if you drop that down, you say, okay, well, what about a 20% improvement in Y box?
Keith Sutton, Psy.D. (48:46):
Yeah.
Ryan Vidrine, M.D. (48:46):
Then over 50% of the people do some of that. So it doesn't work for everyone in either case, but a lot of people gets something.
Keith Sutton, Psy.D. (48:55):
Well, it's good, yeah. It's better than nothing, you know, it's worth a shot. Right.
Ryan Vidrine, M.D. (48:58):
Yeah.
Keith Sutton, Psy.D. (48:59):
Yeah, and then-- with the-- if you had your druthers of how you were going to do it and there was going to be no cost to anything. Yeah. Would you go medication first? Are you doing medication and TMS, like, let's say just with OCD, like what-- or exposure, you know, ERP, you know, like how would you set a course of treatment if time and money were no options?
Ryan Vidrine, M.D. (49:25):
Yeah, with OCD, I think-- I mean, it's important to say like the evidence behind the ERP is robust and much larger than anything else that we have. So, in terms of things like TMS and newer treatments, if I could pick it, I'd probably say, let's start you off with ERP plus TMS. Because I don't think TMS is going to conceptually teach you what your OCD is. I don't think it's going to necessarily help you broaden that perspective on healthy risk taking and this and that, and the same degree that you really get from working through exposure therapy. I do think TMS, like I said, when we're pairing it with exposures, absolutely enhances the therapy. So it may enhance the fear extinction, it may strengthen the parts of the brain that you're learning to kind of use and flex in those scenarios. And so I love the idea of someone in exposure therapy using TMS to maybe move that faster along.
Keith Sutton, Psy.D. (50:29):
Yeah. Yeah. Cool. Okay. I like it. And then how about the kids in adolescents? You know, I'm thinking of teenagers that I worked with that had really, you know, chronic depression and multiple medications and so on. Yeah. Are-- is it approved for adolescents and or--
Ryan Vidrine, M.D. (50:49):
It's not approved. We were hopeful. There was, I think, a large study that ultimately wasn't as successful as people had hoped. And so I don't believe it's approved yet. We have treated people who off of insurance, treated some adolescents. There's no reason to think necessarily that it would work less better. That's a population that even the data around medication sometimes isn't that great for, and there's also high placebo rates and this and that. So, you know, that's some of the thoughts about what might have happened in some of those studies not working as well. But, so right now, most plans require you to be usually 18. Sometimes, it's a little bit older before they'll cover it. So, that's the biggest barrier to us using it more. But we have treated some and, you know, similarly mix of success and, and not,
Keith Sutton, Psy.D. (51:42):
Yeah. Yeah. Okay. Yeah, I think my question still is always like, you know, how do I decide like, oh, like, here, let me refer you to TMS or ECT or like, it sounds like, are you all doing-- you're all doing everything that's legally available right now, right?
Ryan Vidrine, M.D. (51:57):
Pretty much.
Keith Sutton, Psy.D. (51:58):
And so you don't necessarily have a horse in the race. You know, that's why you changed the name too, from TMS solutions?
Ryan Vidrine, M.D. (52:03):
Yeah. I mean, it just-- we had people who thought that they couldn't come to us unless they were getting TMS and that's all that we did. And so we moved away from that. But yeah, we don't have a specific force in the race for sure. I mean, I think TMS and ketamine are both infinitely less kind of invasive and less of a process than getting ECT, so--
Keith Sutton, Psy.D. (52:24):
Yeah. Yeah.
Ryan Vidrine, M.D. (52:25):
I certainly still think of ECT as a further down the road before, I mean, make someone get anesthesia and all that.
Keith Sutton, Psy.D. (52:31):
So maybe like the TMS, the ketamine, and if those aren't working, then maybe the like ECT or something?
Ryan Vidrine, M.D. (52:37):
Yeah, I-- it depends on the patient a little bit and maybe how severe, so the ketamine, for instance, did get some approval around acute suicidality.
Keith Sutton, Psy.D. (52:45):
I see.
Ryan Vidrine, M.D. (52:48):
So, I still, in general, if you look at, you know, TMS has been around a little bit longer. It has more robust data comparatively to the ketamine so far, and it's so safe. I mean, the risks are so minimal with TMS--
Keith Sutton, Psy.D. (53:02):
Oh, TMS. Yeah. Totally.
Ryan Vidrine, M.D. (53:04):
So I usually, for most people, will still think of that one as the sensible first step. Now, if that person can't get approved for TMS, but they can for ketamine, sometimes it's easier. Or if they're in this really bad place where we want to see something perhaps a little bit quicker, maybe the ketamine, I might shop there first, but usually it's one of those two.
Keith Sutton, Psy.D. (53:23):
Okay. Interesting. Well, thank you so much for your time. It's really helpful to-- yeah, hear your perspective and these different kind of pieces and ECT and TMS and yeah, the ketamine, the MDMA, the psilocybin and kind of, you know, and medication and kind of thinking about those different ways that they affect, and it sounds like, right, the overarching piece is that it's creating more of that neuroplasticity and like kind of how much of the areas it's affecting and so on, right. For side effects and such. But again, it's kind of helping with the neuroplasticity to kind of create those new pathways and strengthen them and so on. So, yeah, I really appreciate you-- your time today. Thank you.
Ryan Vidrine, M.D. (54:09):
Yeah, it's been great. Thanks. Thanks for having me.
Keith Sutton, Psy.D. (54:11):
Okay. Take care.
Ryan Vidrine, M.D. (54:12):
You too.
Keith Sutton, Psy.D. (54:13):
Bye-bye.
Ryan Vidrine, M.D. (54:13):
Bye-bye.
Keith Sutton, Psy.D. (54:14):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using emotionally focused couples therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and oppositional and Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:32):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:20):
In this episode, I'll be interviewing Ryan Vidrine, M.D., who is a board-certified psychiatrist specializing in the treatment of OCD and related anxiety disorders. He started his career in neuroscience and moved into psychiatry with a particular interest in the field of interventional psychiatry and neuromodulation for treatment resistant conditions, which include the use of electroconvulsive therapy or ECT, transcranial magnetic stimulation or TMS, ketamine and S-ketamine, and deep brain stimulation. During his residency training, Ryan worked at the University of California, San Francisco Obsessive Compulsive Disorder and Anxiety Specialty Clinic, developing expertise in the diagnosis and treatment of the full range of anxiety disorders, approaching patients from an Acceptance Commitment Therapy Act framework, which focuses on patient values as the anchor and impetus for behavioral changes. He's currently director of the OCD and Anxiety Services at Mindful Health Solutions and Assistant Clinical Professor in the Department of Psychiatry at UCSF School of Medicine. Additionally, he completed the psychedelic therapy and research program training through California Institute of Integral Studies in San Francisco. Let's listen to the interview.
Keith Sutton, Psy.D. (03:37):
Well, hi Ryan. Welcome.
Ryan Vidrine, M.D. (03:39):
Hi, Keith. Thanks for having me.
Keith Sutton, Psy.D. (03:40):
Yeah, definitely. So, Ryan, I know you because we've shared some clients. You're a psychiatrist in the San Francisco Bay Area, and you also are involved with TMS. I think you used to be called TMS Solutions, but I think they changed the name for the group that you're with--
Ryan Vidrine, M.D. (03:58):
Correct. So, yeah, we're Mindful Health solutions now and doing a variety of things more than just the TMS at this point.
Keith Sutton, Psy.D. (04:04):
Yeah. Well-- and I was really interested in hearing about TMS and about-- we were just talking about you're also doing some work with ketamine, and also you've been doing some training in the work with MDMA and I think this is an area that a lot of therapists maybe don't know a lot about or something that's really kind of on the forefront. So, before we even kind of get into that, though, I'd love to hear your story about how you got, doing what you're doing.
Ryan Vidrine, M.D. (04:31):
Sure, yeah. As I did my residency training in psychiatry at UCSF, prior to that, I was convinced I was going into neurosurgery. So, I've always been really interested in the brain, how sort of people, you know, get to become who they are and was really interested in sort of procedural brain things. And then sort of had this epiphany while doing rotations in neurosurgery that I really was more interested in sort of, you know, people's behavior and how they choose what they do and become who they are, and so made the switch over into psychiatry, but with this interest and still sort of a procedural side. And then when I was-- when I got to UCSF, I worked in the OCD and Anxiety Clinic there and fell in love with working with those patients. I think OCD is one of the most interesting disorders. It's one of those artists too that has some of the most disabilities that no one sees from the outside. So, people are really silently suffering oftentimes, and so really enjoyed that. And then after training, I joined Mindful Hall Solutions and became the director of OCD and Anxiety Services there, and really specializing in, and mostly working with OCD and anxiety cases now. And I think, you know, one of the appeals to our practice has been that the longer anyone works in psychiatry, the more you realize that what we have as treatments, you know, are helpful, but not helpful enough for a lot of people or not without a lot of downsides. And having other tools in the toolbox is very appealing. And some of these procedural things certainly caught my interest.
Keith Sutton, Psy.D. (06:22):
Yeah, yeah, definitely. Now, yeah, let's-- can we talk about TMS first and kind of like what that is? And I'm always, you know-- and I've comment, you've had me over to your clinic and I got to kind of check out the machine and experience how it feels and so on. But yeah, I'm interested to learn more. And also, you know, also thinking about kind of when that might be an appropriate referral for a clinician to kind of refer for TMS. And I know that I think there's approvals for treatment with depression, and I know you've been doing work with TMS and related to anxiety and OCD and I was actually just listening to a podcast from a few years ago where they were just doing some research and actually using it with autism spectrum disorder. Not as something that would change, but more actually stimulating some of those neurons and actually the person, you know, experiencing things differently.
Ryan Vidrine, M.D. (07:17):
Yeah, so I mean-- so TMS is transcranial magnetic stimulation. So I mean, essentially what we're doing with that is an MRI string magnet but focused on the circuits in the brain where we know to be involved in depression and anxiety and other disorders. Like most of the treatments in terms of referrals, you know, the more treatment resistant someone has been, the more things they've tried, usually that attenuates your response. So, you know, I think a lot of people, we wonder in the future, you know, in your first episode of depression, could you go and get a course of TMS, not have to deal with the side effects of medications and probably get better? And the answer is probably, you know, the less treatment resistant, the better it works. But where we tend to get most referrals and see the most use is in more treatment resistant cases.
Ryan Vidrine, M.D. (08:10):
So, from the Star D data tells us that once someone's tried three or four medications, the chance that the next medication is going to put them into remission of their depression is less than 10%, probably. And so, that's the group that we've really looked at. And if you refer and go to TMS instead of that fourth, fifth medication, that same group of people has about a 30 to 40% of chance of remission of their depression symptoms. So, it really is in that specific population where we see the biggest difference in kind of separating from another med trial. So, it's also a little bit of a product of what insurance tends to cover these days. So, most of them require several med trials that is getting less stringent. So some have dropped down from things like four med trials and two augmentations and therapy to maybe two med trials. So that's kind of encouraging.
Keith Sutton, Psy.D. (09:04):
Okay. Great. And can you tell me a little bit about how TMS works?
Ryan Vidrine, M.D. (09:09):
Yeah, so like I said, we're focusing a magnetic field on specific circuits in the brain. Important to say we're not sending electricity through the brain. So, a lot of people have a question about, is this like ECT? So I usually describe it with patients as these neurons and these circuits are always sort of firing anyway at a certain rate, right? That is determined by the electromagnetic fields inside our brains. And so, with a device like TMS, we can manipulate that. It's sort of like tickling the neurons, if you will. So, we can go in and use a magnetic-- we alter the magnetic field in a particular way, we can increase the rate of firing, or if we alter it in a different way, we can decrease the rate of firing. And so, we can either strengthen or kind of weaken a particular circuit.
Keith Sutton, Psy.D. (09:58):
And is that because, like the positive and negative charges around the neurons that are kind of leading to the release of the neurotransmitters in the synapse?
Ryan Vidrine, M.D. (10:09):
A little bit. Yeah, exactly. So we're--
Keith Sutton, Psy.D. (10:12):
Ions or whatever. I'm not-- I don't remember exactly from my psychopharmacology class.
Ryan Vidrine, M.D. (10:17):
Yeah, exactly. That's sort of those ions. And the change kind of has an electromagnetic certain basal rate way the neurons fire. So we can go in and use a high frequency of stimulation with TMS and make them more likely to fire. It's thought to be excitatory in a lot of cases, as opposed to maybe sometimes we use a lower frequency that tends to slow that down or inhibit that circuit from firing more readily. So, yeah, we're thinking when we do this that, you know, in depression there's been some evidence that certain circuits maybe are hypoactive in the brain--
Keith Sutton, Psy.D. (10:51):
Yeah.
Ryan Vidrine, M.D. (10:52):
Or the term that I think things are moving more towards is looking at the functional connectivity in the brain. So how much is one network kind of communicating with another network in the brain? And oftentimes in these disorders we see there's an imbalance or, you know, our more limbic structures are sort of raging and the executive function structures have become too quiet and kind of unable to compete. And so, if we can strengthen certain circuits, we can kind of bring that balance back at play. That's kind of generally the idea.
Keith Sutton, Psy.D. (11:21):
So it's kind of like fixing up the roads and getting them to be more like highways or something like that, and rather--
Ryan Vidrine, M.D. (11:27):
Yeah. Making them a little more in tune with each other and--
Keith Sutton, Psy.D. (11:31):
Or bridging, you know, kind of those connections or so on. Interesting. And so, yeah, because you know, when I sound a little woo woo, like magnets and so on, you know, but like, yeah, that, that makes sense that the magnets are, you know, because yeah, there is that kind of positive negative kind of ions and how that affects whether or not the-- whether it's going to excite the neuron and produce the neurotransmitters. So, stimulating that to get those neurotransmitters going. And is this something that is done ongoing or more, or-- I'd even be interested in a little bit about like, the difference between that and like the medication. because it's a medication theoretically doing the same thing or different stuff and how's that kind of different
Ryan Vidrine, M.D. (12:13):
Yeah, the medications are-- well, you know, one thing we talk about with patients is the medications are systemic, so they're doing a lot of things and we have guesses, but you know, does anyone really know exactly what the meds are doing? And has sort of proven this is the clear mechanism as I-- there's a lot of debate about that. We know that, you know, with an SSRI, we can increase serotonin in certain synapses and get some circuits that are hyperactive to come back into a more normal balance, but we're doing that in a shotgun approach. So, TMS may do some similar things, we can affect circuit activity, but it's a lot more specific and local. And that's one of the big benefits. So, you know, you're not getting TMS throughout your entire body essentially. And so, that's why we-- a lot of people come to us because we're not seeing side effects in the same way that you see with the systemic medication--
Keith Sutton, Psy.D. (13:10):
Because the antidepressant is kind of affecting all the whole body. So that's why the person might be getting dry mouth or, you know, difficult--
Ryan Vidrine, M.D. (13:17):
Sexual side effects--
Keith Sutton, Psy.D. (13:18):
Like sexual side effects or, you know, these kind of things or appetite or so on, because it's kind of like impacting everything rather than being localized.
Ryan Vidrine, M.D. (13:28):
Exactly. So this is one of the tools that you can be a little bit more specific and targeted with. And, I talk to patients too about it being-- I think of it as kind of going to the gym for your brain circuits in a way, which again, can sound a little woo woo, but it's not a fast treatment. So it's not something you go in and it happens one time and you're not going to walk out, you know, dancing and walking on the clouds kind of thing. It's not a euphoric treatment. So, like the way that we think about it is that, you know, across-- we're kind of regardless of disorder across a lot of the mental health disorders, we see, you know, it may be trouble in attention, in mood regulation, these sort of specific functions that crosscut against different diagnoses, right.
Keith Sutton, Psy.D. (14:15):
Yeah.
Ryan Vidrine, M.D. (14:15):
People-- what we think is when we're strengthening that executive function circuitry, that kind of top down regulation, what we see is people tend to start to function better. They're not necessarily feeling happy, if you will, but they hold it together a little bit. They don't flip out on their partner quite as easily or something stressful happens and they'll come back and say, I just handled it a little bit better. And so--
Keith Sutton, Psy.D. (14:41):
Yeah. Interesting, so that reactivity is kind of decreased or that kind of connection, you're saying like between the upstairs, downstairs brain, kind of the Dan Siegel like, you know, the limbic system and kind of more that higher cortical area is kind of slowing things down, or sometimes I've heard about it, like, you know, it's almost like insulating. The kind of emotions to kind of help it can be a little bit more contained.
Ryan Vidrine, M.D. (15:03):
Yeah. And that's usually what we'll hear from people. So again, they say things more such as I handle stuff better. And we-- so we kind of see slowly week to week them--
Keith Sutton, Psy.D. (15:16):
Oh Ryan, hold on one sec. Sorry, my wife actually just opened up her headphones, and it connected. Okay, there we go. Sorry. So, you're saying usually that's what you see from people?
Ryan Vidrine, M.D. (15:03):
Yeah. They describe sort of this better handling of the world, better function, maybe their focus and energy feels like it's a little bit, you know, better. And so, they start to function in the world better and then what we see kind of lag behind that is then they start to sort of feel better. The depression starts to go away. They feel more confident and succeeding day to day, that kind of thing.
Keith Sutton, Psy.D. (15:23):
Yeah.
Ryan Vidrine, M.D. (15:24):
And that's where I liken it to sort of working out, you know, bicep curls for your circuits in a way, it's a slower treatment. So, usually a course of TMS is once a day Monday through Friday for anywhere between four to six weeks. And so they're coming in regularly. You're not going to see anything dramatic in the first two weeks. You know, it's really that third, fourth, fifth week where after you've come in and we've really exercised those circuits that we start to kind of see more benefits.
Keith Sutton, Psy.D. (15:53):
Yeah. And is it-- yeah. Is it lasting? Does that muscle stay or does it, you know, is again like a workout where if you stop working it, it kind of atrophies or?
Ryan Vidrine, M.D. (16:04):
Yeah, we see really different things. And they're, you know, really long-term studies are all sort of always hard, so we don't have tons of them. We have a couple that are good and go out to a year or two years, things like that. But, we have people that are in a pretty dark spot and sort of are able to pull themselves out of the hole with TMS and we don't see them again. Or they, you know, stay kind of in a better place. We have certainly seen people that come back a couple of times over their lifetime, again, when it's really bad. And then we have other patients that there's almost a rhythm to it. So, I've had someone who almost like clockwork every two years seems to get-- just feels sort of, the light's going dim, the energy draining. They feel this real kind of slowing down. They come in, they get the TMS, and they go back and they're fine. We will see people, sometimes it's three months or six months down the road, feel like they're relapsing again. It's all-- it's often a question of sort of what's maybe contributing to that depression, right. So, if they're in psychosocial setting, that is miserable. Well, TMS isn't changing that.
Keith Sutton, Psy.D. 17:12):
Yeah, if they're in a horrible job or if they're, you know, in a not good super stressful situation--
Ryan Vidrine, M.D. (17:18):
Exactly.
Keith Sutton, Psy.D. (17:18):
Yeah. One of those things. Yeah. So the-- so let me kind of come back to, because actually, I remember actually when I was first reaching out to you, somebody was also asking me about ECT. And kind of, you know, more recent and electro convulsion therapy. And I was wondering about, you know, similarities, differences from TMS and also, I don't know if you know much about what's going on now with that, because I know, you know. Yeah, most people think of it kind of way earlier sixties, like--
Ryan Vidrine, M.D. (17:49):
Yeah.
Keith Sutton, Psy.D. (17:49):
Kind of really, you know, psych hospitals kind of stuff. ECT. But, I think it's being a bit used now still too. I'd love to hear any thoughts on that and also similarities, differences to TMS.
Ryan Vidrine, M.D. (18:03):
Yeah. So ECT still is quite relevant to psychiatry. We actually have part of our practice does ECT as well. So it is an option within our practice. Difference-- I mean, ECT is one of still the most effective treatments for severe depression. In terms of looking at the research and the data and chance of recovery and remission, it's often hard to beat still to this day. The big difference is, ECT is something that usually is done in some sort of hospital setting or an outpatient hospital setting requires anesthesia. And we are putting electricity through the brain. Now ECT from the past and modern ECT is quite different. Surprisingly, even up to around 2000, though it was still sort of being done in this older way, but it really has, in the last probably 15 years or so, made some bigger advancements in terms of trying to mitigate side effects. So again, adjusting frequencies-- different frequencies of administering the ECT has been able to make it more tolerable, less side effects, like memory problems or, kind of confusion at the time of ECT, things like that--
Keith Sutton, Psy.D. (19:19):
Yeah.
Ryan Vidrine, M.D. (19:19):
So modern ECT is certainly better. Most of the side effects are from sending electricity through the brain. And so, that's a big difference in TMS or not doing that, you don't see memory impairment in TMS, you don't see nausea, confusion, you know, that kind of stuff. Brain fog from the TMS itself. If anything, people-- there's a mix of studies that say, you know, cognition is not really changing. Or maybe it's a little bit better than it was.
Keith Sutton, Psy.D. (19:49):
And is the-- and do you-- I don't know if you even know this info of kind of the mechanism of action of the ECT, like kind of what is it doing?
Ryan Vidrine, M.D. (19:59):
Again, there's like three or four ideas and hypotheses. It's again, it's like a little bit more local in some ways because it's not sending medicine throughout the whole system, but it's a shotgun approach, a brain stimulation. We're causing a seizure everywhere. So there's a few different hypotheses. Again, there's this hypothesis that we know that sort of where you initiate a seizure does lead to a whole host of blood flow changes in the brain. And if we change blood flow to parts of the prefrontal cortex, again, similar in TMS idea of we might increase certain activity over time, strengthen that circuitry and alter the kind of balance and networks talking to each other--that functional connectivity I mentioned. There's other kind of hypothesis that we're causing a dump and a release of catecholamines and all of the hormones and that does something. There's a few other thoughts. So again, we sort of know it works, but--
Keith Sutton, Psy.D. (20:58):
Yeah.
Ryan Vidrine, M.D. (20:59):
A lot of thoughts of what's happening both TMS and ECT increase the BD and F hormone that we know promotes neuroplasticity, it makes the brain a little bit more likely to change. So, both of them do that.
Keith Sutton, Psy.D. (21:13):
Okay. Cool. Yeah, so again, it's kind of like one theory that's similar to kind of building the roads and strengthening the highways or so on to kind of get those connections going and just, but like, kind of in a surge, like, you know, kind of--
Ryan Vidrine, M.D. (21:25):
Right.
Keith Sutton, Psy.D. (21:26):
Shock and awe to the brain. And so, the neuroplasticity actually I was curious about that because one of our-- the first podcast I did was with my colleague Jim, who is doing a lot of work around psilocybin. And kind of was talking about how the FDA has put it as a breakthrough treatment as effective or, then current treatments or something with less side effects or whatever it might be. And he was kind of talking about that the psilocybin kind of created like a window of neuroplasticity to like do something with, versus like antidepressants, which might take a month to get going. And then the neuroplasticity is just kind of happening all over the place, regardless of what's happening in the environment. So maybe not able to kind of focus so much of what you're doing in the therapy or treatment during the time of neuroplasticity. I don't know if you have any thoughts on that or how TMS, ECT or ketamine or the MDMA kind of play into neuroplasticity or kind of--
Ryan Vidrine, M.D. (22:28):
Yeah. I don't know if I have too much thoughts or solid knowledge on how they may differ. We do know that that is a common thread in all of those treatments that we do see an increase in specific markers of neuroplasticity. You know, again, with TMS, it's local and it's focal. So we're seeing it in specific parts of the brain that we're stimulating. Certainly. I would imagine that things like ketamine and psilocybin are a little bit more broadly throughout the brain increasing that--
Keith Sutton, Psy.D. (22:59):
Yeah.
Ryan Vidrine, M.D. (23:00):
Yeah.
Keith Sutton, Psy.D. (23:01):
And is there, and I know with the-- well actually, let's talk about the ketamine and MDMA first, and then I'll kind of come back to my question about kind of-- I was almost, I was wondering like, is there anything you're doing during the TMS like therapeutically?
Ryan Vidrine, M.D. (23:16):
Yeah.
Keith Sutton, Psy.D. (23:16):
But I thought maybe we could talk about some of those other ones because I know that there is a therapy component in addition to the medication or the, I guess the whatever the psilocybin or the MDMA or the so on. So, yeah. Can we talk a little bit about that?
Ryan Vidrine, M.D. (23:32):
Yeah, I mean, it certainly, with ketamine and with psilocybin and with MDMA, the kind of best practices at current would for most people would be around including a therapy component. The big question out here, and people talk about it is, you know, what happens if you give this chemical alone? Can people-- can they be by themselves in a room and have an experience that is curative in some way? Is it a chemical reaction? And most likely it's both. And so, I would say that a lot of people would feel that you can get a certain result just from the chemical loan, perhaps. It would be augmenting and further optimizing to include a potential therapy opponent. That's kind of probably how we usually think about it now.
Keith Sutton, Psy.D. (24:22):
Sure.
Ryan Vidrine, M.D. (24:23):
With something like psilocybin, right, there's more potential to, you know, have a particularly strong experience, maybe be confused, kind of not sure again, feel unsafe. And so the therapy component becomes a little bit about also safe container for something that really can take you to another world. With ketamine, there's a dissociative effect. It can be anxiety provoking for some patients, but not typically something where you're really going, you know, to another world kind of experience.
Keith Sutton, Psy.D. (24:55):
Yeah. Yeah.
Ryan Vidrine, M.D. (24:57):
So a little bit, you'll see in a number of places, really doing more of this kind of medical model of ketamine where patient's in a room, it's a comfortable spot, they get the drug, there's not a lot of talking, there's not a lot of therapy to it really at all sometimes, and we just know that the drug does something. And then you see a lot of clinics, especially around the Bay Area, that really believe in pairing the ketamine with therapy. And so, while someone is in this altered state accessing kind of different ways of thinking than they usually are--
Keith Sutton, Psy.D. (25:25):
Yeah.
Ryan Vidrine, M.D. (25:26):
Can we make a breakthrough in therapy? And I certainly am a believer that that offers a another level of advantage potentially.
Keith Sutton, Psy.D. (25:33):
Yeah. Hold one second, I'm going to close my window.
Keith Sutton, Psy.D. (25:45):
Interesting. So, yeah, so the-- so this kind of idea that wall there mean I, it makes sense, right? Because I mean, for efficiency and cost effectiveness, if you can just give something to somebody and that'll make things better, that becomes readily more available to everybody. Right. And then, but bringing in the therapy component, like you're saying, and particularly, yeah, there's a number of clinics around here that, that do that aspect also, you know, just like with antidepressants and therapy or so on, that that kind of combination that you can do some, some good work. So it's kind of interesting. Yeah. Like, and the, and I don't know if you, do you-- how do you think about the differences between the ketamine, the psilocybin and the MDMA? And I don't know if are that in-depth knowledgeable about all that stuff, but yeah.
Ryan Vidrine, M.D. (26:41):
They're all different. And I don't know, I think you could talk to a lot of people and get a different take on the sort of algorithm of where they might put them in a treatment repertoire. A lot of that currently is just sort of fixed on here's what's available legally. Right. So ketamine is broadly used because we can. And, you know, could I, do, I personally, I could imagine MDMA, for instance, being a better alternative than ketamine for a number of people, or maybe psilocybin depending on sort of, we know psilocybin to be particularly helpful with sort of these existential kind of, you know, someone with cancer dying and trying to wrestle with death and leaving their loved ones and their legacy. I mean, that's something that the research, trials and people with psilocybin and cancer were quite impressive. MDMA is particularly impressive in trauma and PTSD. So I think there's a lot of ways that-- and some of that is because that's what we've done the research in also.
Keith Sutton, Psy.D. (27:41):
Yeah. Yeah.
Ryan Vidrine, M.D. (27:42):
So there's some research, actually, you had brought up autism earlier and using MDMA to treat social anxiety and sort of social skills and autism. So I think there's a lot of ways we could probably start to think of it in the future. And right now it's really that mostly ketamine is the thing that's available. And kind of to the earlier idea of like therapy or not, some of these drugs, particularly thinking of MDMA, you could give someone MDMA and feel more relaxed, a drop in anxiety, potentially an elevated mood, but we also know it's incredibly pro-social. So when you take MDMA it releases-- you get that kind of oxytocin surge. So there's an element to it that's built to facilitate something with another person. And so we think that that's probably actually important at least if you're trying to make some sort of long-term changes--
Keith Sutton, Psy.D. (28:33):
Yeah.
Ryan Vidrine, M.D. (28:34):
Used to be used quite often in couples therapy, and certainly that's an area you could imagine it being immensely helpful.
Keith Sutton, Psy.D. (28:41):
Sure.
Ryan Vidrine, M.D. (28:41):
So they all have sort of their own sort of caveats probably best uses that we will, I think, tailor and figure out more and more over time--
Keith Sutton, Psy.D. (28:50):
Yeah.
Ryan Vidrine, M.D. (28:52):
Even with TMS, so TMS, there's-- we've been doing it for a long time. People come in, they sit in the chair, they get the treatment, they go home. More recent research is trying to say, okay, what about the state of their brain? What can we do while they're getting treatment? Is it CBT? Is it mindfulness?
Keith Sutton, Psy.D. (29:11):
Yeah, that's what I was wondering. Can you be stimulating, you know, kind of those pathways more Yeah. Through mindfulness or doing CBT or doing DBT skills or something like that.
Ryan Vidrine, M.D. (29:20):
Yeah.
Keith Sutton, Psy.D. (29:21):
While doing the TMS and kind of like, you know, almost Yeah. Build those roads in a little bit more, kind of stronger or so on.
Ryan Vidrine, M.D. (29:29):
Yeah. People are doing different work. So, what I'm doing mostly around OCD and this has been done with addiction, like smoking cessation. So there's some evidence that if you activate the circuitry that's involved in whatever you're trying to treat, so an OCD, if we were to kind of provoke or do an exposure around what people are afraid of, and then treat and then stimulate while they're in that particular brain state, that it might work better. So in some of this, like smoking cessation trials, I believe there were active stimulation groups and placebos, but then in the active groups, there was one that was just sort of active stimulation and then one that involves some sort of queuing or kind of provoking of the brain circuitry. And that group had better results than the just plain active. So--
Keith Sutton, Psy.D. (30:17):
Yeah.
Ryan Vidrine, M.D. (30:18):
That's where people are going. I mean, again, it makes sense if you've done therapy, if you think about this, if you've looked at kind of, you know, what we know to typically work certainly in OCD, a huge proponent of getting people to exposure therapy as much as we can. And so, you know, we don't have research on OCD that definitively says you have to do that.
Keith Sutton, Psy.D. (30:38):
Yeah.
Ryan Vidrine, M.D. (30:38):
No one's done a comparison for sure. There's some protocols being researched that don't provoke symptoms and people can still get better, but that's where the field is going.
Keith Sutton, Psy.D. (30:49):
Yeah, if you could tell me a little bit about that with the OCD and that piece. I've actually had some folks on our podcast that do OCD work and so on and exposure and stuff. And yeah, I would love to hear your kind of thoughts on that, you know, kind of OCD and TMS and medication.
Ryan Vidrine, M.D. (31:07):
Yeah. Yeah. With TMS, I would say I think of it in two ways. One is just what we have now that's been FDA cleared that people can access. And that particular protocol is stimulating the dorsum medial structures of the prefrontal cortex of areas that we know are involved in behavioral switching and learning, fear extinction, those kinds of things. And that's the protocol that has been approved that includes this provocation or kind of mini exposure that we do with patients. So every patient with OCD that comes in, we're really drilling down and trying to figure out what is the core fear here? What exactly is it and can we provoke that to an extent in the room paired with treatment? So we, at our practice, try to do that provocation piece of it.
Keith Sutton, Psy.D. (32:01):
So like if the person has OCD around contamination, you might have them touch like a doorknob or something if they're worried about germ contamination--
Ryan Vidrine, M.D. (32:08):
Yep.
Ryan Vidrine, M.D. (32:08):
Touch a doorknob, touch a trash can, the bottom of their shoe without washing. So we really want them to do this without being compulsing during the treatment.
Keith Sutton, Psy.D. (32:17):
So, really flaring up the obsession or that kind of anxiety reaction and then doing the TMS while they're doing the exposure?
Ryan Vidrine, M.D. (32:25):
Exactly. And, even just kind of getting them in that state. So what we ask them to rate their anxiety, we want to get them to that place where they're uncomfortable but not panicking, not kind of freaking out. They can sit there for 20 minutes to get the treatment without compulsing. It's a little bit of a mix of whether we kind of keep doing it the whole time or just sort of get them there and then do the treatment. It kind of depends on realistically person to person and how kind of motivated they are.
Keith Sutton, Psy.D. (32:51):
Sure.
Ryan Vidrine, M.D. (32:52):
But what we hear with that is to-- I don't hear a lot of my obsessions and intrusive thoughts when I weigh completely what we hear is, I feel more able to ignore them, or I can, I seem to be able to resist the compulsion easier. I can go longer. And so it looks like it kind of builds that, the hypothesis, I guess, that we're strengthening those circuits involved in resisting and kind of recognizing error and refocusing attention to a more useful place.
Keith Sutton, Psy.D. (33:24):
Yeah. I mean, the way that I've kind of thought about is like, right, the obsessions and intrusive thoughts don't really like totally go away where we're almost kind of like breaking that connection between the thought and then the anxiety reaction through kind of new learning and new circuitry--
Ryan Vidrine, M.D. (33:37):
Right.
Keith Sutton, Psy.D. (33:38):
So that they might still be having these thoughts or these things like, oh, like that's gross, or you're going to get sick from that. But then they're just like, you know, they're not necessarily reacting to it so much, they're kind of like acknowledging it--
Ryan Vidrine, M.D. (33:48):
Exactly.
Keith Sutton, Psy.D. (33:49):
And just kind of letting it be and float off or whatever, so on, in a way. And that, you mentioned something earlier about effective treatments without exposure. Can you say about that? I think--
Ryan Vidrine, M.D. (34:01):
Yeah.
Keith Sutton, Psy.D. (34:02):
Did I hear that right?
Ryan Vidrine, M.D. (34:03):
Yeah. So, you know, that FDA approved one that I said we're kind of doing with most people, a key term there is cognitive control. So this is a thing that gets studied a lot in OCD and other disorders and something that has been shown in certain in TMS, so we can increase cognitive control in these patients. And so, at least that protocol, we think that that's probably what we're doing. We're improving their cognitive control, their ability to ignore, to reset, to learn new pathways. Like you said. What's interesting is, okay, well what about other ways of targeting OCD, right? And so what if we could get at the part of the brain that we think generates intrusive thoughts or obsessions? And so people are trying to study this. So other brain targets, like the orbital frontal cortex is one of the kind of key places people are going after. Stanford is doing some research now, a little bit of a different target, more orbital kind of frontal in that way. And they're not doing necessarily provocations and things like that, trying to probably get at almost this core like generative piece of OCD--
Keith Sutton, Psy.D. (35:07):
Yeah. Yeah.
Ryan Vidrine, M.D. (35:08):
So we'll see. They've published some things on that. And you know, so we're kind of in that land of we've got an FDA approved that does something--
Keith Sutton, Psy.D. (35:16):
Yeah.
Ryan Vidrine, M.D. (35:17):
And we're going to see what comes out. OCD is fairly newer to the--
Keith Sutton, Psy.D. (35:22):
Yeah.
Ryan Vidrine, M.D. (35:22):
It's only approved since 2018.
Keith Sutton, Psy.D. (35:25):
Interesting. And so, and I'm assuming too, that they did placebo, so like doing some of that provocation exposure stuff without the TMS, like kind of having anything versus, and they found that the TMS in addition was more effective than just that exposure during that short period of time.
Ryan Vidrine, M.D. (35:40):
Exactly. And what's nice is in the TMS research, they've gotten pretty sophisticated with the placebo. So they use a coil that actually is emitting sound. They connect it to electrodes in the scalp. So there is actually a stimulating, sensory feeling that is typical of TMS. So it's really just that we're not sending anything down into the brain with the placebo coils.
Keith Sutton, Psy.D. (36:07):
Now, what about-- so as we talk about all this, I also think about complex PTSD, because I feel like my clients that have a more complex PTSD, you know, some that might get diagnosed, like borderline personality disorder and so on, you know, oftentimes are some of the clients that I think have the hardest time with with medication, because sometimes they're put on like mood stabilizers because they've got bipolar symptoms sometimes like depression. But when you're talking about that kind of emotional reactivity and kind of connecting that, that made me think because that oftentimes is the core, right? Is that their amygdala, their limbic system is reacting kind of disproportionately in the present due to the past trauma. And kind of the you know, the differences in brain, you know, development and areas and so on in folks that have experienced trauma, complex trauma, ongoing, you know, kind of situations growing up. Thoughts on that?
Ryan Vidrine, M.D. (37:08):
Yeah, I really like this question because it's something I think about a lot. You know, that-- so one thing we know is that there's sort of biotype of depression, it seems, right? So someone's depression may live more in a certain network or circuitry than a different person with depression. And so people have looked at this and said, can we kind of predict what types of depression will respond? We're not sure yet there's a mix. But there was some things published around, maybe the more underactive and hedonic I've been this way for years and years, may have a slightly less response. Now I'm always surprised, and I've seen those people get better too, but sort of was one thing that was published. I look for people when I'm thinking about will they respond as being more on that reactive side, right? Do they walk in, they start telling their story and they're crying and then they're running away and you gotta kind of bring them back to slow down and this kind of--
Keith Sutton, Psy.D. (38:03):
Yeah.
Ryan Vidrine, M.D. (38:03):
That kind of thing. Again, that cognitive control term. So if we can boost cognitive control, we can boost executive function, then we can help with a lot of those things that cut across different diagnoses. And people have talked about this, so those, certainly the people like you described, whether it's they're a little borderline, a little ADHD, a little OCD, a little, all those sort of, it's like everything's kind of going all over. We do tend to see people again, report I just function a little bit better. I hold it together a little bit better. And so--
Keith Sutton, Psy.D. (38:35):
Yeah. Yeah.
Ryan Vidrine, M.D. (38:36):
I know. I was optimistic when I first started doing TMS. I had a handful of patients with borderline personality that, you know, it's always so hard to get things to work and they reported I'm using less substances, I feel less impulsive. I--, you know, this is, again, little tweaks and functions that seem to be better. I'm not aware of large scale, high quality studies and not specific population. I know there's some case studies and published evidence, but--
Keith Sutton, Psy.D. (39:02):
Yeah.
Ryan Vidrine, M.D. (39:03):
Anecdotally from experience, we often see those people do a bit better.
Keith Sutton, Psy.D. (39:08):
Yeah. Yeah. Interesting. Okay.
Ryan Vidrine, M.D. (39:10):
If their psychosocial settings are somewhat stable. Right. So again, if they're homeless in between all that, I mean, that's a different story.
Keith Sutton, Psy.D. (39:17):
Yeah. If they're currently in a traumatizing situation, it's like, yeah. It's like you can't do EMDR with somebody while they're in like an abusive, you know, relationship--
Ryan Vidrine, M.D. (39:25):
Exactly.
Keith Sutton, Psy.D. (39:25):
Or something like that. Like, you have to get the foundation of some safety and stability kind of going before, you know, kind of working through those pieces. The-- how about ADHD, you know, that's an area and we've, that's, that's how we got connected around one of my clients that I were working with. Yeah. Does TMS have much, you know, to say about ADHD or kind of affecting, you know, in frontal lobe functioning, or especially as you're talking about some of the-- that executive functioning or connecting that cortex?
Ryan Vidrine, M.D. (39:53):
Yeah, from everything I'm saying you would certainly wonder, right? And think about that, and I think there are, people are studying this. I haven't seen a lot of data about it. It's certainly not gotten any kind of FDA clearance around that. Now there is some newer stuff on other types of brain stimulation. So, transcranial, direct current stimulation where you sort of are putting electrodes on the head. There's an approved treatment that I'm not super familiar with it, but essentially does some form of lower field electrical stimulation for ADHD got approved for kids. So it's being researched. There's some stuff out there. I'm-- in terms of the standard kind of TMS, we haven't really seen that be used on any kind of scale yet.
Keith Sutton, Psy.D. (40:43):
Yeah. Yeah. Okay. And yeah, so the question too, again, back to kind of like how do we determine about referring or so on. I mean, I think that, you know, part of it sounds like you're saying with insurance and such, like they want you to go through some other med trials, you know, it's probably yeah. Much cheaper to get prescription to Prozac or so on than maybe going through this. Is this kind of an expensive process like for, you know, through insurance or is this kind of something that's generally covered, or is that, you know, yeah. Is that why they're kind of saving it to four, you know, medication trials and then doing--
Ryan Vidrine, M.D. (41:20):
Yeah.
Keith Sutton, Psy.D. (41:20):
TMS.
Ryan Vidrine, M.D. (41:21):
You know, so it used to be and now at this point, most insurance plans will cover it. They've all got a little bit of a different set of requirements. And so, but it is getting easier to access. So usually what I would tell clinicians or therapists or whoever, if someone's tried a couple of meds, let's say two meds, they're in therapy and they're still having problems, it's reasonable to get a consultation. You know, and we would look at ins and outs of their particular plans and just kind of see what's going on and at least start the conversation. A lot-- most of us think that, like if you look at-- if we can get someone better with a course of TMS without side effects, without leading to weight gain and contribution to diabetes, you know, in the long run, that's probably cost effective.
Keith Sutton, Psy.D. (42:09):
Yeah.
Ryan Vidrine, M.D. (42:10):
Even though, you know, the cost of a TMS course is certainly more expensive than your prescription of Prozac for six weeks. But yeah, I think it's getting easier to access. We have several people, you know, it always depends on your plan and stuff, but for the actual patient, I mean, sometimes it's just copays. Sometimes people are fully covered because they've met their deductibles.
Keith Sutton, Psy.D. (42:35):
Yeah. Yeah.
Ryan Vidrine, M.D. (42:35):
And so certainly if you've tried a couple things and you're not where you want to be, or if you have a lot of medical problems where mixing multiple meds causes its own set of issues, or there's lots of side effects, even though what you're doing is somewhat working, then it's completely reasonable to get a consultation and kind of start that conversation.
Keith Sutton, Psy.D. (43:45):
Yeah, because I almost wonder too, I mean, it seems like almost like psychiatrists would be like the I don't know, not gatekeeper, but like the person that's like, okay, like we've done these medications, nothing's working, so let's kind of go to this next level. Like, and maybe that's something like the therapist might suggest to this client talk about with their psychiatrist or something like that, you know, because it's kind of, it sounds like they wouldn't necessarily bypass around, you know, like the psychiatrist or so on, but like, try a couple things. If that doesn't work, then do the TMS. And again, is that just because of cost? because like, could the TMS if the person went straight into TMS with depression, like that could also be potentially effective, right? If more just that--
Ryan Vidrine, M.D. (43:38):
It could totally be effective. You know, just like a first course of a medication is a lot more effective than a second course, and you also see higher placebo rates too. And so, I mean, probably the same thing if you went straight to TMS.
Keith Sutton, Psy.D. (43:52):
Yeah.
Ryan Vidrine, M.D. (43:52):
It's expensive. It's six weeks worth of coming into a clinic having multiple personnel, you know, to administer that treatment using devices. So, you know, it's depending on where you are in the country, probably ranging between, I don't know, 12 and $16,000 or so for a course of TMS if you paid out of pocket.
Keith Sutton, Psy.D. (44:15):
Yeah.
Ryan Vidrine, M.D. (44:15):
So that's just for the majority of people. Well, give me my prescription. I take it from home. It's very easy. Right.
Keith Sutton, Psy.D. (44:23):
Yeah, totally.
Ryan Vidrine, M.D. (44:24):
So TMS is also, it's got that cost factor, but then it's off of insurance on insurance can be very affordable. But then it's got this time intensive piece too, where you got to come in. So what's exciting, I would say, and interesting is that there's some people looking at a newer form of TMS called accelerated TMS. So Stanford is doing some studies on this right now in both depression and OCD.
Keith Sutton, Psy.D. (44:49):
Yeah.
Ryan Vidrine, M.D. (44:49):
They have people come in and they do TMS 10 times a day.
Keith Sutton, Psy.D. (44:54):
Wow.
Ryan Vidrine, M.D. (44:54):
It's broken up over the day and they condense that six weeks down to maybe it's a week or so. And so, potentially can we get to that same place in a much faster time?
Keith Sutton, Psy.D. (45:04):
Yeah.
Ryan Vidrine, M.D. (45:05):
There's some published data around doing it twice a day. Like if we just had someone come in twice a day and only have to do three weeks instead of six. And what we're seeing is like people are still getting better and they may get better faster. Insurance doesn't pay for that currently, so that's not something that we can offer the average person, but--
Keith Sutton, Psy.D. (45:23):
So the six weeks, the person is coming daily? Or how often are they coming per week?
Ryan Vidrine, M.D. (45:30):
So typical insurance plan will grant someone about 36 sessions of TMS, so 36 days of TMS. So, usually what we're doing is Monday through Friday, so five times a week for at least, I would say typically about 25 treatments. And then some people will go all the way to 30, that's kind of the standard protocol.
Keith Sutton, Psy.D. (45:49):
Yeah. Yeah.
Ryan Vidrine, M.D. (45:49):
And then usually use the remaining to taper off over two or three weeks, or we kind of reduce the frequency. Practically it can really depend. So, for instance, if some people are doing really, really well, they have a strong, robust response early.
Keith Sutton, Psy.D. (46:04):
Sure.
Ryan Vidrine, M.D. (46:04):
We may, you know, reduce their frequency to three times a week a little bit earlier. They get more weeks overall of TMS if they want to, but it's not as cumbersome. If they're not doing as well, we may kind of keep going all the way to the 30. So there's a little bit of tweak there, but--
Keith Sutton, Psy.D. (46:19):
Okay. So there's some barriers around like the person's gotta basically drive back and forth, back and forth or so on. So like doing something like you were mentioning about that intensive, like, you know, week long or something like that would probably potentially make it more available to folks that like yeah. Or doing like a hospitalization or partial hospital or so on.
Ryan Vidrine, M.D. (46:37):
Or especially people that live a little bit more remotely. I mean, that's the thing. We frequently have people who live about an hour away, and it's like, that's a lot of commuting.
Keith Sutton, Psy.D. (46:45):
Yeah. Yeah.
Ryan Vidrine, M.D. (46:46):
So, people nearby in the city, it is a thing, I mean, it's time intensive. People often think of it as sometimes worse than it is. So, we have lots of students who come between classes, people that come on their lunch break. If you think about people who do frequently go to the gym or pick off lunch, and the treatment itself day to day is about 20 minutes sometimes faster--
Keith Sutton, Psy.D. (47:08):
Yeah.
Ryan Vidrine, M.D. (47:09):
So, it is something you can get in and out of our office in 30 minutes and kind of go about your day.
Keith Sutton, Psy.D. (47:14):
Yeah. Now what-- and I think, so then, the question again is I think back to the effect, like, and again, what is the effect size or what's the, you know, like how, I think you were saying 30 to 40% of kind of folks that have kind of, you know, gone through these, you know, four med trials or so on, tend to respond. And, so more of the chronic depression kind of situations. Is that, was that right?
Ryan Vidrine, M.D. (47:40):
Yeah, so in, certainly in major depressive disorder, you know, around 30% you'll see like gets to remission. If you look at, you know, sort of a lower bar, a partial response. So, they still meet criteria, they're not in remission. Their PHQ-9 is, you know, greater than five--
Keith Sutton, Psy.D. (48:00):
Yeah.
Ryan Vidrine, M.D. (48:00):
You get up to about 60% of people. I think, depending on which studies you, you kind of go to that say, I clearly improved, I'm not remitted, but I've gotten better.
Keith Sutton, Psy.D. (48:11):
Yeah, not gone.
Ryan Vidrine, M.D. (48:11):
With OCD, the results in the trial, and it's pretty consistent with our own internal data in our practice, are somewhere around 40% met for full response criteria, which in those studies was a 30% or more reduction in the Y box scale.
Keith Sutton, Psy.D. (48:31):
Yep. Yep.
Ryan Vidrine, M.D. (48:32):
So around maybe a six point or so drop in your Y box, which is a pretty good drop. That's--
Ryan Vidrine, M.D. (48:36):
Yeah.
Ryan Vidrine, M.D. (48:36):
Not as good as we see when meds work really well.
Keith Sutton, Psy.D. (48:40):
Yeah.
Ryan Vidrine, M.D. (48:41):
And then if you drop that down, you say, okay, well, what about a 20% improvement in Y box?
Keith Sutton, Psy.D. (48:46):
Yeah.
Ryan Vidrine, M.D. (48:46):
Then over 50% of the people do some of that. So it doesn't work for everyone in either case, but a lot of people gets something.
Keith Sutton, Psy.D. (48:55):
Well, it's good, yeah. It's better than nothing, you know, it's worth a shot. Right.
Ryan Vidrine, M.D. (48:58):
Yeah.
Keith Sutton, Psy.D. (48:59):
Yeah, and then-- with the-- if you had your druthers of how you were going to do it and there was going to be no cost to anything. Yeah. Would you go medication first? Are you doing medication and TMS, like, let's say just with OCD, like what-- or exposure, you know, ERP, you know, like how would you set a course of treatment if time and money were no options?
Ryan Vidrine, M.D. (49:25):
Yeah, with OCD, I think-- I mean, it's important to say like the evidence behind the ERP is robust and much larger than anything else that we have. So, in terms of things like TMS and newer treatments, if I could pick it, I'd probably say, let's start you off with ERP plus TMS. Because I don't think TMS is going to conceptually teach you what your OCD is. I don't think it's going to necessarily help you broaden that perspective on healthy risk taking and this and that, and the same degree that you really get from working through exposure therapy. I do think TMS, like I said, when we're pairing it with exposures, absolutely enhances the therapy. So it may enhance the fear extinction, it may strengthen the parts of the brain that you're learning to kind of use and flex in those scenarios. And so I love the idea of someone in exposure therapy using TMS to maybe move that faster along.
Keith Sutton, Psy.D. (50:29):
Yeah. Yeah. Cool. Okay. I like it. And then how about the kids in adolescents? You know, I'm thinking of teenagers that I worked with that had really, you know, chronic depression and multiple medications and so on. Yeah. Are-- is it approved for adolescents and or--
Ryan Vidrine, M.D. (50:49):
It's not approved. We were hopeful. There was, I think, a large study that ultimately wasn't as successful as people had hoped. And so I don't believe it's approved yet. We have treated people who off of insurance, treated some adolescents. There's no reason to think necessarily that it would work less better. That's a population that even the data around medication sometimes isn't that great for, and there's also high placebo rates and this and that. So, you know, that's some of the thoughts about what might have happened in some of those studies not working as well. But, so right now, most plans require you to be usually 18. Sometimes, it's a little bit older before they'll cover it. So, that's the biggest barrier to us using it more. But we have treated some and, you know, similarly mix of success and, and not,
Keith Sutton, Psy.D. (51:42):
Yeah. Yeah. Okay. Yeah, I think my question still is always like, you know, how do I decide like, oh, like, here, let me refer you to TMS or ECT or like, it sounds like, are you all doing-- you're all doing everything that's legally available right now, right?
Ryan Vidrine, M.D. (51:57):
Pretty much.
Keith Sutton, Psy.D. (51:58):
And so you don't necessarily have a horse in the race. You know, that's why you changed the name too, from TMS solutions?
Ryan Vidrine, M.D. (52:03):
Yeah. I mean, it just-- we had people who thought that they couldn't come to us unless they were getting TMS and that's all that we did. And so we moved away from that. But yeah, we don't have a specific force in the race for sure. I mean, I think TMS and ketamine are both infinitely less kind of invasive and less of a process than getting ECT, so--
Keith Sutton, Psy.D. (52:24):
Yeah. Yeah.
Ryan Vidrine, M.D. (52:25):
I certainly still think of ECT as a further down the road before, I mean, make someone get anesthesia and all that.
Keith Sutton, Psy.D. (52:31):
So maybe like the TMS, the ketamine, and if those aren't working, then maybe the like ECT or something?
Ryan Vidrine, M.D. (52:37):
Yeah, I-- it depends on the patient a little bit and maybe how severe, so the ketamine, for instance, did get some approval around acute suicidality.
Keith Sutton, Psy.D. (52:45):
I see.
Ryan Vidrine, M.D. (52:48):
So, I still, in general, if you look at, you know, TMS has been around a little bit longer. It has more robust data comparatively to the ketamine so far, and it's so safe. I mean, the risks are so minimal with TMS--
Keith Sutton, Psy.D. (53:02):
Oh, TMS. Yeah. Totally.
Ryan Vidrine, M.D. (53:04):
So I usually, for most people, will still think of that one as the sensible first step. Now, if that person can't get approved for TMS, but they can for ketamine, sometimes it's easier. Or if they're in this really bad place where we want to see something perhaps a little bit quicker, maybe the ketamine, I might shop there first, but usually it's one of those two.
Keith Sutton, Psy.D. (53:23):
Okay. Interesting. Well, thank you so much for your time. It's really helpful to-- yeah, hear your perspective and these different kind of pieces and ECT and TMS and yeah, the ketamine, the MDMA, the psilocybin and kind of, you know, and medication and kind of thinking about those different ways that they affect, and it sounds like, right, the overarching piece is that it's creating more of that neuroplasticity and like kind of how much of the areas it's affecting and so on, right. For side effects and such. But again, it's kind of helping with the neuroplasticity to kind of create those new pathways and strengthen them and so on. So, yeah, I really appreciate you-- your time today. Thank you.
Ryan Vidrine, M.D. (54:09):
Yeah, it's been great. Thanks. Thanks for having me.
Keith Sutton, Psy.D. (54:11):
Okay. Take care.
Ryan Vidrine, M.D. (54:12):
You too.
Keith Sutton, Psy.D. (54:13):
Bye-bye.
Ryan Vidrine, M.D. (54:13):
Bye-bye.
Keith Sutton, Psy.D. (54:14):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.