Ep 111 Transcranial Magnetic Stimulation for Mental Healthcare with Dr. Brent Nelson

Interview with Dr. Brent Nelson regarding how his experiences in both the computer software and finance industries inspired his career in neurology and led to his passion in treating complex neurological disorders including Major Depressive Disorder.

Dr. Nelson was born and raised in the Twin Cities. He attended the University of St. Thomas in Saint Paul, receiving a Bachelor’s degree in Biology with a research focus in neuroscience and brain stimulation. During and post-college, he spent 9 years doing software development in manufacturing and the financial services industry.

In 2006, he decided to go back to school and subsequently completed a medical degree at the University of Minnesota in 2011. He then completed a general psychiatry residency there along with a clinical research fellowship in neuromodulation. After graduation, he spent a year as a fulltime faculty member and as Executive Director of the transcranial magnetic stimulation program at the University of Minnesota and the Minneapolis VA Medical Center. His clinical focus was on treatment-resistant depression and mental health management in epilepsy and other complex neurological disorders. His research focused on non-surgical brain stimulation in depression, brain injury, and schizophrenia.

Dr. Nelson serves as an Adult Interventional Psychiatrist and  the Chief Medical Information Officer at PrairieCare, which is focused on ground-breaking technologies used in the treatment of complex disorders such as Major Depressive Disorder.

PrairieCare, a division of Newport Healthcare, is one of the nation's most innovative psychiatric health systems, offering psychiatric services for all ages, including free mental health assessments, clinic services, intensive outpatient programs (IOP), partial hospital programs (PHP) and residential services. 

In his free time, Dr. Nelson enjoys software development, IoT maker projects, 3D design, and woodworking. He is also very active in advocacy and trying to improve access to novel therapies for those on public and low-income medical plans.

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Transcript

Ep 111 Transcranial Magnetic Stimulation for Mental Healthcare with Dr. Brent Nelson

[00:00:00] Cynthia: You are listening to the Well Connected Twin Cities podcast. I'm your host, Cynthia Shockley, and I'm here to learn alongside you through meaningful conversations with health and wellness practitioners. This is your time to experience some mindset shifts, learn practical tips, and get excited about what is possible.

[00:00:22] We want you to own the power of choice in your personal well being journey. Let's discover what's possible right here in our Twin Cities community.

[00:00:33] I'm super excited today to have a conversation with Dr. Brent Nelson of Prairie Care. Dr. Nelson was born and raised in the Twin Cities. He attended the University of St. Thomas in St. Paul, receiving a bachelor's degree in biology with a research focus in neuroscience and brain stimulation.

[00:00:50] During and post college, he spent nine years doing software development in manufacturing and the financial service industry. In 2006, he decided to go back to school and subsequently completed a medical degree at the University of Minnesota in 2011. He then completed a general psychiatry residency along with a clinical research fellowship in neuromodulation.

[00:01:13] After graduation, he spent a year as a full time faculty member and an executive director of the Transcranial Magnetic Stimulation Program at the University of Minnesota and the Minneapolis VA Medical Center. His clinic focused on treatment resistant depression and mental health management and epilepsy and other complex neurological disorders.

[00:01:34] His research focused on non surgical brain stimulation and depression. brain injury and schizophrenia. Dr. Nelson serves as the chief medical information officer and as a consultant for the Center for Neurotherapeutics at Prairie Care, which is focused on groundbreaking technologies used in the treatment of complex disorders such as major depressive disorder.

[00:01:55] Prairie Care, a division of Newport Health Care, is one of the nation's most innovative psychiatric health systems, offering psychiatric services for Dr. Nelson is free mental health care, including free mental health assessments, clinic services, intensive outpatient programs, partial hospital programs, and residential services.

[00:02:14] And here we are with Dr. Brent Nelson. Welcome. We're so happy to have you here. 

[00:02:20] Brent: Thank you so much for having me. 

[00:02:22] Cynthia: So if you don't mind just telling us as you sit here today, what. Brings you joy and purpose in your life. 

[00:02:29] Brent: Yeah. Thank you for the question. I think I'm probably best described as a card carrying nerd. So really the fusion between many things and those things are often either very technical or science oriented but also humanistic and honestly, I think I'm.

[00:02:48] propelled by just an interest in seeing how many complicated things fit together and what better than the human person, the human experience, the brain, the path and journey people take through the world, through their life and trying to figure out how all of that complexity, really determines who they are and their happiness or their sadness, or, what the next steps are and just being there with them.

[00:03:14] Cynthia: Yeah, because geez, the human mind talk about complex. 

[00:03:21] Brent: Yes. 100 billion neurons, 100 trillion connections, very complicated. And that's just the biological substrate. That's not even taking into account all of the complicated Information that's that's running in the brain, much less this whole thing that we don't even know about yet called the human person and the soul and self awareness.

[00:03:42] We just don't even know about that yet. 

[00:03:45] Cynthia: Well, I know that you it's So you started your career in software development, which is, I feel like, weirdly associated with neurology and how everything connects and networks together.

[00:03:56] So what brought you into software development after you had been studying biology and researching neuroscience? 

[00:04:03] Brent: Yeah. I was this recreational programmer prior to getting into college. I've been programming since I was about 12 and I was lucky to have, a family with some access to technology.

[00:04:16] And one summer I was really my mom was a stay at home mom and one summer I was really in just. making her buggy because I was bored. And my dad had just bought us our first computer and he had a programming background and said, here's the deal. You're making your mom really, like frantic because you're getting into trouble.

[00:04:33] So you're going to learn to program. So he, each night, he would give me a chapter and I would try it and explore it. And then he'd come home and we, talk about what I did it. And really what it did is it cultivated this just curiosity in how software and hardware work together.

[00:04:49] Then I got into college and undergrad and really, had been programming for quite some time. And I was getting into neuroscience, biology and neuroscience. specifically, and there was this just curious overlap between the two. And so the pro the program I went to had this computing and the experimental sciences, and this is in the mid nineties.

[00:05:06] So it's really forward thinking on their part. And they let me really explore the space and what sort of, the world and life is all about these sort of happy happenstances. But at the same time, the. com boom was just taking off. And I managed to get an internship doing in a manufacturing group that made the little carts in the airport that carried luggage around, Smart Cart Inc.,

[00:05:27] which was a really fun first job, doing software development and desktop support. And then I switched over into financial services because that whole market was taking off. And what I learned there was really how to manipulate large amounts of data. They had vast quantities of data.

[00:05:43] At that time, they're gendering 20 terabytes a month of user traffic data. And that was my job was to go through it and to figure out how it connected and how we could get our heads around all that complexity and then actually tell a story with it. So I did that in parallel with the neuroscience work.

[00:05:59] And that was back at the time where some of the AI was really first coming online. And so I was trying to figure out how does all of this big data the technologies and techniques really fit together with what I'm learning about in neuroscience, which were cells and neurons and animals and even, some of the human models.

[00:06:16] And I thought, wow, this is it. This is the thing that there's gotta be a way to combine these two at some point once I learn enough. 

[00:06:24] Cynthia: Yeah. Oh my goodness. How nice that your interests align with. the direction society's moving in, right? Like the data analytics, the software development, the neuroscience, and all these new tools coming into the world.

[00:06:41] And so then you decided at one point after you had been in software, been in the finance, been in the data analytics, that you were going to go back to school. What made you Decide it's time. 

[00:06:54] Brent: Yeah. I, I had always thought about medical school. I had done volunteering. I really I really had always spoken to me, but as I got farther into software, I thought, I really need to see what this world is about.

[00:07:06] So I'm gonna go out and I'm gonna go work for a while and I'm gonna, I'm gonna work. financial services, I'm already connected. And what I found was I really found enjoyment in the technology, but I was still lacking that really interesting application into impact on human life and on on someone's wellbeing.

[00:07:26] And at a certain point I came to really just a crossroads where I thought, Wow. I need to make a change. And if I'm going to make a change and really fulfill that other sort of core need I need to go back to school and really get enough of the training and credentialing to be able, one, to work with people, but two, to then think about at a deep level, how the two can come together.

[00:07:51] And so I decided to apply to med school lucky to get in the university of Minnesota and had the. the difficult task of telling my boss at the time that I was going to quit and go back to school. And that was tough. 

[00:08:04] Cynthia: Yeah. And it, on the surface, it seems like such a big shift, but it sounds like both of these passions of yours were both like running alongside each other the whole time.

[00:08:14] Brent: They really were. And I was lucky to have the people around me in my life, my wife, my family, they were right there with me. And they're like yeah, this is something you've talked about forever. For sure. Quit your high paying job and find it and go back to school. 

[00:08:29] Cynthia: Awesome. So good to have that support and people who really see you and they're like, yep, this makes sense.

[00:08:36] Brent: It was. And it, that, I think that's really something I've carried with me is, you really can be confident in a decision when those that know you the best are like, this is consistent with who you are. And they reassure you around that, because there's a lot of doubts.

[00:08:51] The process is hard. The schooling is terrible, and to have them there being like, yeah, no, this is who you are was really gratifying. 

[00:08:59] Cynthia: And you really, you touch on something that I know I personally struggled with because I was pre med went from being really excited about med school to just as the realities of it sunk in.

[00:09:13] And I started learning about. different ways of healing Eastern care in the concept of integrative care and holistic care. And I just started to see how the Western medical system maybe wasn't aligned with some of the things that I saw as truth as I saw, would be optimal for people's health.

[00:09:33] Have you ever had that experience of conflict in how you'd like to show up for your patients, the demands of clinical life or even the schooling itself? And how are you able to navigate 

[00:09:43] Brent: that? 

[00:09:43] Absolutely. It really is a daily challenge. The health care system is really wonderful in some ways and is really broken in other ways.

[00:09:52] There's a tremendous amount of provider burnout that happens. There's a tremendous amount of med student burnout, resident burnout. Really, the process of medicine, whether that's training or practice is riddled with, yeah. administrative overhead and with, rules about the finances of healthcare, which none of us, I was in finance, I left, it was here we go again, and so I've had to be very mindful about trying to stay away from that because I do really think it, it gets away from what we're doing as a team, the patient and I as a team.

[00:10:26] And so I think Being aware as I'm going along of what things specifically are showing up on an average day and how does it fit in, is this an artificial thing that the health system is pushing me to do? Is it something that we need to think outside of the box? A lot of my work now as an interventional psychiatrist because people are in a really difficult place it, a lot of my work Often requires me to be really thinking outside of the box and, bringing to bear the best we have of medical science and practice, but also being really open to the whole rest of the world and to, complimentary and integrative medicine.

[00:11:02] And I see that a lot in my practice. And, I'm really often trying to get additional training and knowledge around all the other things that are offered in the world for folks. And it's interesting, a really great example for the path that psychiatrists take are, we have a very heavy focus on medication management, very traditional there's tons of literature on it.

[00:11:23] And the program I trained in actually had a really strong training in psychotherapy as well, which really harkens back to some of the origins of psychiatry and psychology. And with a very strong biological sense that I had, it was, I'm like, Oh, it's all about the software and it's all about neural networks and it's all about a hardware and, I had a very naive view when I came into medical school and as well as in a residency that was enough that if we could, twiddle the right neuron and we could, nudge the system in the right way neurochemically, that, oh, that's going to fix it all.

[00:11:55] And what I learned as I was getting experienced in psychotherapy and I was really just learning to be more humanistic with the folks I was working with. It's like there's more to it than that. And, it's a necessary part of the equation in many cases where we need to be considering the biological model.

[00:12:11] We need to be thinking about the neurotransmitters, thinking about, what can we do there? But there's all of these other elements, facets, dimensions that we need to be very mindful of because those are all in play. Or our opportunities as well. If we can really align with this individual 

[00:12:27] and, it's funny because it actually drove me to take this bit of a special interest track into some quantum mechanics, actually trying to figure out like. What happens in the quantum space? And there's all of this stuff we don't understand. And that just doesn't make sense at face value.

[00:12:41] And it's if that's a thing, then we're probably missing a whole bunch of things that we need to have an open mind about.

[00:12:48] Cynthia: And I'm so glad that you. Had that training and you were receptive, right? So a part of that too with the concept of hardware, software, I feel is the user interface, right?

[00:13:01] What's the user experience? And that's where the psychotherapy comes in, because everything could be working fine, but how is the user actually applying all of that and interfacing with it? 

[00:13:12] Brent: That's right. It's a good way to think about it. And what's extra tricky too is the hardware is the software in the brain.

[00:13:19] And so it gives us this really curious, both comparison that we can make, about thinking about it that way, but also gives us a bit of a difficulty too, because we, there's this for a long time and still there's a tremendous amount of stigma in mental health. And we see that every single day and things improve, things are improving.

[00:13:40] they really are. if we can find one silver was getting people to ack health is real, is common

[00:13:46] The tricky bit is that knee jerk reaction we all have to if we have a feeling we have something where we're feeling down or feeling anxious, we automatically go to assuming it's our own shortcoming, just about everyone does that. And I think it actually has to do with it being this hardware is the software kind of thing.

[00:14:04] thing because we'll feel something, which is probably the hardware telling us something. And then we quickly make this assumption about it, which is the software, but it like feeds back into the hardware and makes the hardware change. So it's it's this really tricky thing. And it's that the reason that the fact that it's that tricky thing that makes it so important that we.

[00:14:23] acknowledge its complexity and we acknowledge our limitations in our understanding. And we really lean in again to this individual and what their experience is. 

[00:14:33] Cynthia: Yes, exactly. So in your experience, because you mentioned It's not just hardware, software, there's all these other elements involved.

[00:14:43] At Well Connected, we really appreciate this whole person approach, so in your professional opinion and experience, what are some other behaviors or tools that you've seen really support people in their mental health journey?

[00:14:55] Yeah, 

[00:14:56] Brent: that's such a great question. Honestly, it's a hard question to answer because there's so many of and really, the idea of the way the community has taken the lead in understanding and describing all the things that are helpful has been fabulous because it's far more power and far more people working in the space than could be done if we're like everything needs to just be a simple, double blind placebo controlled trial, right?

[00:15:22] That's a tiny little number. And really, if we open our minds and we lean into all of the things that people notice as being powerful, we really learn a lot. The things I see the most common is I see a lot of benefits of meditation and mindfulness. And that's really, not only have people been doing it for thousands of years and have, shown us that it's highly effective, there's now a lot of literature behind it.

[00:15:45] And it fits in incredibly well with all sorts of other modalities, including medicines and brain stimulation and all that. We see wonderful things from acupuncture. from massage. I

[00:15:56] mean, the things. Exercise has of data behind it, even thing for us all to do, g typical lifestyle th It really has a huge impa in your community, having of friends, family,

[00:16:09] you k are your people being con with that village i so a lot of it, there are things we already know eating well, avoiding really artificial things that our body doesn't know what to do with avoiding toxic exposures in our environment, trying to stay away from things that we know are really hard on our body.

[00:16:30] Minimizing alcohol where possible, staying hydrated. There's just, there's thousands of things that. Are sort of those things that, as we were growing up, a lot of them or our sort of family would just tell us, Hey, you need to eat your broccoli. That's true. What 

[00:16:45] Cynthia: a thunk.

[00:16:47] Brent: And it's really hard sometimes. And so I think that's the key piece that I found to be most effective is like being able to recognize that we know a lot of these things, but that's also really hard to actually integrate them into our lives because of, 100 different things.

[00:17:01] Cynthia: Yeah, and, that's where, so I'm a health coach currently, and that's my main jam, and that's why it's helpful to have That kind of support of what are the goals? What are the barriers getting in the way? How do we address them? Let's make a plan. Let's create a vision and to have a strategy to Implement because yeah, if you just decide, I should eat better I should exercise better, but you're still in the same environment in the same routine it's hard to break out of that cycle and it's especially hard if The neurons in your brain aren't firing the way they ought to. 

[00:17:40] 

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[00:18:40] 

[00:18:41] Cynthia: So I'd love to get back into some of this work that you've been doing on neuromodulation. I know you focused on research there. Can you explain what exactly the definition of neuromodulation is and how TMS, transcranial magnetic stimulation, specifically works in that space? 

[00:19:01] Brent: Sure. So your first question is actually one of my favorite because there's actually like the International Neuromodulation Society that defines it.

[00:19:10] And the definition is so incredibly broad, literally everything is neuromodulation, anything that affects the state of the functioning of the brain at the end of the day. And that's how I start every talk I give on TMS I start with that quote, actually, because it's important for us not to lose sight of the forest for the trees.

[00:19:27] And when I talk about transcranial magnetic, magnetic stimulation, I'm talking about just one type of neuromodulation, one type of us being able to change how the brain is functioning in some way, shape or form. And when we talk about it, there's a couple of ways you can do specifically the stimulation.

[00:19:46] So there are direct. stimulation approaches which are starting to become actually more commonly available out in the sort of the consumer market, where there are these machines where you'll use like a, it's got a nine volt battery hooked to it. And then you'll put some electrodes on the scalp, usually soaked in saline, and it'll actually pass a tiny little bit of current from one side to the other.

[00:20:07] And what that does is that stimulates the brain underneath, not to actually fire, but to be more likely to send messages. So we always say, cells that fire together, wire together. So that's how the brain works. If you're, if your cells are active, usually they're going to increase their connection. If they get deactivated, then often they'll decrease the connection.

[00:20:28] And so the idea of these really low current, low voltage devices is that they're just really nudging the neurons underneath to to move along into fire. Now that's contrasted with the transcranial magnetic stimulation, which is what we do a lot and is most used. clinically it's FDA approved, more common.

[00:20:45] That's actually going to use stronger magnets in order to induce the neurons underneath to fire. And so not only are they just more likely to fire, they are actually firing. And so we're really pushing the areas of brain underneath the coil to to work a little bit harder and to nudge them in a direction that we're hoping they need to be nudged.

[00:21:08] Cynthia: Yeah, I still remember when I was training to be a TMS tech and the doctors were explaining to me the process and at the same time I was taking physics and learning about electromagnetic flux and I'm like, Oh, here's the application. 

[00:21:25] Brent: Exactly. Induction. It's just amazing. It's it is like a little bit of modern magic, really.

[00:21:31] I 

[00:21:32] Cynthia: love that phrase. Modern magic. Yeah, so this you just wear this device right on your head and how would you describe, if someone's walking into a transcranial magnetic simulation session, what would that process look like? What would they expect? 

[00:21:48] Brent: Yeah, so that's a great question.

[00:21:49] So part of it's going to depend on the machine. for the specifics. But in general, you're going to be in a doctor's office. It's going to be, there's going to be a comfy chair of some sort. And then there's a TMS machine there. These are very expensive, unfortunately, machines that have a coil on them.

[00:22:07] And the coil sometimes looks like a wand of sorts and other coils actually look like a helmet. So they look like those old school hair dryers you would find in a salon. And really the way it works is the machines. coils. So the wand or the helmet is placed in a specific location for each individual in order to get to the location that we were looking for with depression, which is what's called the dorsolateral prefrontal cortex.

[00:22:33] DLPFC is the most common place that's being stimulated. And then what the people do is you sit down in the chair. We take the coil, we do some mapping. So we're going to find the right location. We're also going to figure out through some testing how much energy is required to be delivered. And then someone's going to get their first treatment that same day.

[00:22:52] Treatments are usually approximately 20 minutes, depends on the machine. What happens is you'll get a couple of seconds of actual stimuli. So the machine will run. For two to sec, two seconds on average at a time, and then there's time off. There's rest, 20 seconds, 30 seconds, and it'll just do that a bunch of times.

[00:23:10] Those are called trains. And what we know to be true is if it does the pulse is really fast, it causes the brain underneath to get more active. If the pulses are really slow and regular, like the TikTok of a, like a grandfather clock, then. it's actually going to make the area of the brain underneath the coil a little bit less active.

[00:23:29] So we get to choose the where, the how much and the how we're doing the stimulation. And the person sitting there in the chair, they're wide awake, they're going to feel it because they're wide awake. And for the first couple of weeks, it can be a little Sharp and pokey can feel like a lot of people call it the woodpecker feels like a woodpecker pecking away, which I've never had a woodpecker on my head, but when I had the machine running, it felt like a woodpecker to it.

[00:23:56] Cynthia: Huh. Just intuition tells me this is what a woodpecker feels like. 

[00:24:00] Brent: I think so. I think so. And in the Tens of thousands of treatments I've done that is like the most common by far and away response people will say. And what's amazing, and again this is the amazing nature of the human brain and body, is after a couple of weeks it really goes from being a little sharp and pokey and woodpecker like to being really nothing at all, like very tolerable.

[00:24:22] Your scalp just adapts and allows the stimuli to just be ignored and so that they're really it's just the brain underneath that are being stimulated at that point Which is pretty darn cool. 

[00:24:33] Cynthia: It is super cool how we adapt You know when I worked at the clinic, I was at a la clinic doing tms as a tms tech and I remember at the time first of all, it was very, it felt very casual, right?

[00:24:48] The doctors would come, make sure the measurements were all set, and then we would watch TV together while they're getting treatment, and maybe I'll take a couple of surveys, see how they're doing, take some notes, but otherwise, they're like, yeah, I just want some distraction from any discomfort, and so we just watch TV together.

[00:25:06] But also, at the time, Because this was probably, gosh, 2012 to, 2012 to 2015 is where I worked there and at the time I know that insurance wasn't available and it was very much a service that was exclusive to some of the like LA elite because it was expensive. It was like tens of thousands of dollars and I'm wondering, currently, where does TMS stand in terms of availability, accessibility, is there insurance coverage for it now?

[00:25:43] Brent: Yes, it's tremendously different. From 2012 to about 2015, the insurance market was very dynamic. Really, Medicare took the lead at covering it and with a really straightforward policy, which is fabulous to see. And then a lot of the commercial payers really followed suit. It took a little bit longer to get the Medicaid and medical assistance programs to come on board, but really as it stands today, coverage is just about universal for sure in Minnesota but generally nationally.

[00:26:12] And so it's gone from being a very niche, cash only sort of endeavor to becoming a standard of care for treatment resistant depression. That is insurance. And honestly, we have a very busy program and we are entirely insurance and we feel it's very important and what's nice is the way that all the insurance companies have set up who's allowed to do TMS as well as like how it's covered are all very consistent.

[00:26:41] And so it's moved the needle quite a bit on setting more predictable approachable standards for everyone involved. 

[00:26:50] Cynthia: Yeah, that's wonderful. 

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[00:27:38] Cynthia: So for someone who maybe has. Tried medication, tried lifestyle management, tried multiple ways, and they just feel like, gosh, I am still feeling terrible and depressed, and I'm just not, I'm not feeling better.

[00:27:54] At what point would you say it's time for someone to try TMS? What are some of those parameters to get covered by insurance? 

[00:28:02] Brent: It's a great question. There's this tension between the number of appointments or the burden. that are put on patients to do the treatments because it is quite a few appointments versus trying to get intervention with the depression as early as possible and trying to treat it when the depression is less severe because easier to treat depression is easier to treat.

[00:28:24] When it's less severe, it's just easier. So really, what I encourage people to do is to get assessed as soon as possible and then to have the criteria figured out. And really, the criteria are pretty approachable. As far as the FDA is concerned, really, you really only need one or two medication trials before you become appropriate for the treatment.

[00:28:44] And what the literature has shown, like the non vendor sponsored literature, has shown that, if, The depression is less severe, TMS works better. And it's that kind of, that's that same mentality, right? So you really wanna give people access to the treatments as soon as possible, the Medicare criteria and generally the insurance criteria.

[00:29:04] for the most part is going to generally be for medicine trials to from different classes, which people with moderate to severe depression. It almost universally will have tried, the med trials happen usually pretty quickly. The other thing they require, and this is what I think is really fabulous about all the way the standards were written is they have to have tried psychotherapy as well.

[00:29:25] And in my experience, that's going to be the most important aspect of someone's opportunity for success with TMS is to have that really well satisfied. But that's really about it. The really, the only restrictions are the rule outs. And it has to be used for depression only, although now obsessive compulsive disorder and smoking cessation are also FDA approved can't use it.

[00:29:48] If someone has a diagnosis of bipolar or of psychosis, like schizophrenia or schizoaffective disorder, those aren't allowed. If someone's had a stroke. Or has a degenerative neurological disorder. If those aren't allowed yet, although there's a lot of research happening in Alzheimer's and some really compelling things around helping depression and Alzheimer's, which is really cool.

[00:30:10] And then the other big bit is, are there any medical contraindications? So does someone have metal in their body? And usually if they're, if it's more than 30 centimeters away, so if it's down, below, really below their neck, down into their chest, certainly down in the lower extremities. It's not a concern.

[00:30:26] But anything in the, the head or the neck region, that's ferrous. So it's a type of metal that would be magnetic that it's not allowed. But if there's metal there, that's MRI safe. Generally we can work with, with the device manufacturers to ensure safety and to be able to forge ahead.

[00:30:42] Cynthia: Yeah, that is so great that the qualifications aren't all the way up here, right? They're not, you have to jump through all these hoops. I feel like that tends to be an issue sometimes with insurance coverage, but it sounds like there's enough support with TMS, enough research being done, enough success stories to say, okay, yeah, like we can definitely cover this.

[00:31:08] Brent: Absolutely. And there's been some really cool research studies looking at the just even from the finances, here it is again, get away from finance, 

[00:31:15] Cynthia: but it's interwoven, you 

[00:31:16] Brent: know, it's everywhere. But that, really using TMS actually saves insurance companies compared to the treatment as usual for severe depression.

[00:31:25] Convulsive therapy, where there's anesthesia, there's hospitalization, really you're talking about tens of thousands of dollars of savings. And so I think we see this movement and the insurance companies that are motivated by, the finances of health care. And in fact, one of the larger insurers in the country just loosened their requirements and made it now.

[00:31:47] So it's only two medication trials. So I think they're seeing, the benefits and they're seeing the really positive outcomes. As well as, like you said, all of the, there's thousands and thousands of papers now on TMS showing its safety and its efficacy. So I think it's really. It's really finally bringing that, that language that traditional Western biomedicine is used to using is bringing that language forward and not to health so that people can get care that they need in a way that actually respects parody.

[00:32:17] Cynthia: Yes, exactly. And I also love to bring in a little bit of personal anecdote experience. If you wouldn't mind sharing, do you have any examples come to mind of a patient who maybe had a really great success story with TMS? Just sharing some non identifying story around their own success.

[00:32:44] Brent: Honestly, I have hundreds of patients now that we've worked with that have had really fabulous outcomes. It's incredible when someone goes from really being fundamentally non functional in their life, which is where we'll often see, people have had 15, 20 medicine trials, multiple hospitalizations, multiple suicide attempts, even ECT trials with bad side effects.

[00:33:09] And we get them in we really work hard to understand their path and their narrative. And then we do TMS and they get better and they start grappling with now what I've been feeling terrible for so long. I've been in misery for so long. Now I get to decide what's next. And they're like, should I go back to work?

[00:33:31] Do I go back to school? What do I do? And working with them through that process is just so incredible because it is at first, when we were getting this, we were noticing this and people were like how do I, how do I. not be depressed. It was like, wow, this is the question.

[00:33:51] But yeah, of course, it's the question. They've had this barrier for so long, and now it's gone. And they're starting to get used to the opportunity. And you know what, when we're done, then we'll always see them for a follow up after a month. And then it's really said it really, the apprehension is gone.

[00:34:05] And they're like, I just feel better. And these are all the things I'm doing. And it is so gratifying because it's usually engagement with friends and family. It's thinking about what's next in their path. It's, being in the world again, it's doing things they enjoy finding they're really finding their, their hobbies, their interests, all of these things that have just been gone for years and years.

[00:34:26] And I honestly there's nothing, there's really nothing like that because it's like you can feel their joy and it's just an incredible 

[00:34:35] Cynthia: thing. I still remember something standing out with one of the patients I was working with for The whole time I was at the clinic and she said, because I asked him what does it feel like?

[00:34:48] What's the difference that you're experiencing? Cause I can do the PHQ 9 and, have those data, but I want to hear from you. And she said for her, it was like, There's this dark cloud that just pervades in her life. After treatment, it just, it lifts, and it's actually blue skies, and she can see clearly, and she can engage differently, and so it was just really cool to hear.

[00:35:13] What a difference it can make when your neurons are firing actively in your frontal cortex and 

[00:35:20] Brent: what a difference, right? Yeah, we need to, and that's, what's been exciting about, getting the insurance on board is people then can have access to that. They get to work with their provider to figure out, okay, is this something that's going to, is going to be an opportunity for me.

[00:35:35] And when we're like, yeah, let's move forward, and then it works. It's wow, is that fun? And really, the, to, to your point about, what they're noticing, the other really interesting thing is when the families notice, I'll have people that come in with a caregiver and for the first, handful of weeks, I'll say, how you doing?

[00:35:51] And they're like, I'm not feeling anything. And then at, about two weeks say, yeah, I'm still not really feeling anything. And then the family members, like in the background in my office, like waving their arms and like giving me a thumbs up and like they're seeing it, and it's incredible.

[00:36:05] Cause they're like, this is a person I haven't met in so long. And then a couple of weeks later, the patient's wow, I feel better. And I'm like, your family member. or friend, they saw it two weeks ago. They're like, really? I'm like, this is how depression works. It, it really brings that cloud down.

[00:36:20] And when it starts to lift, everyone around is Whoa, there it is. And it's there. Everyone's excited. To

[00:36:27] Cynthia: come back and for your loved ones to re recognize you like, Oh, there you are. Yes. For someone who would be interested in getting assessed for TMS, I know there's the clinic, the TMS clinic in St. Louis Park. What would that process look like for them? Yeah. 

[00:36:46] Brent: So there, there are a bunch of different clinics in, in, in Minnesota for the St.

[00:36:50] Louis Park University of Minnesota has a really great program, Prairie Care, where I'm at, we have programs in Edina and in Woodbury. There's a number of groups now. A lot of the major health systems have it. And what's really amazing about that is we've Those of us have been doing a long time. It's a small community, so we've settled on really common standards following all the literature and what the insurance companies recommend, but it always just starts with a referral.

[00:37:15] And the way the clinics work is you know you're working with your normal prescriber typically it's a psychiatrist but it could be a primary care provider as well. They'll usually fill out a referral that has some just checklist make sure that you know there's been some med trials and that kind of metal and that, generally medically speaking, it's okay.

[00:37:31] They send it in and then usually you'll see someone like me. It'll be a 45 to 60 minute appointment. We'll go through your whole history. We'll do all of the screening, all the rule outs. We'll do the medical safety stuff. And then by the end, we'll have a good sense of whether it's safe or not to proceed and whether it's approved, would be likely to be approved.

[00:37:50] And then the patient gets to decide. Often there'll be a, prior authorization process with insurance, but that's a well traveled path that's based on the questions we ask. And then once that's all done, they start. Simple as that. 

[00:38:03] Cynthia: Yeah, as simple as the medical procedure can be, right? Oh, sure.

[00:38:08] Yeah, but that is pretty streamlined. I'm really happy to hear that. Insurance companies have come on board. It makes such a big difference. I know even with the field of health coaching, there's an effort to get insurance companies to cover. I'd imagine when people get to that point where they're like, Oh, how do I live now without depression?

[00:38:31] That's a perfect time for a coach to come in and be like, let's dream about it. Let's make a plan. Let's strategize. And so it'd be so cool if. All of that could be supported that whole person approach. And it's on its way. It's happening slowly, but surely, 

[00:38:46] Brent: Slowly, but surely, no, you're spot on.

[00:38:48] And honestly, with the way the health system works and insurance works, there's so much quicker. and even really still slo like a procedure, you kno constantly pushing us, we You really need a care is in my opinion we've gotten depression b wellness. And that's where

[00:39:08] Figuring out typically people will have been disabled because the depression is so severe and it's like, how is this now going to affect my disability? What's the, is there a return to work? These are complicated questions to answer that really you need someone that understands your journey, understands your goals, and can work with you to figure out now what is you know, how do we continue to engage in wellness?

[00:39:30] And that's why health coaching, I'm a strong believer in health coaching, because this is your person. It's I always compare it to Pilates, you can go learn how to do Pilates in the gym, but really it's like you figure it out pretty fast. It's really about doing it then with somebody that can help you tune and adjust and not just know, but turn it into something that your body is good at doing and that you're then getting the benefits from.

[00:39:52] And whether it's health coaching or therapy or meditation or, so many of these things, like having some there, somebody there walking with you to, to one, give you solidarity and companionship on the journey, but also giving you tips and tricks and feedback and making a space to do that work is so important.

[00:40:14] Cynthia: Exactly. One day we will be there and it's coming together. I see it. I always ask at the end of conversations on this podcast, if there's just one takeaway that you would hope that the audience walks away with from this conversation, what would that be?

[00:40:31] Brent: Sure. Yeah. Minus is really about access and next steps, really communicating that for depression, people deserve to have wellness and they deserve to have the treatments that they feel are going to be, are going to be needed. And TMS can be one of those treatments. It's accessible.

[00:40:52] It's covered by insurance. It's effective. It's really tolerable. And so I think having people have enough information to have it on their radar so that they can ask the appropriate questions in their own health journey, I think is so important. The other bit I think is really also very important for people to keep track of because depression takes hope away.

[00:41:13] I really think it's important for people that are struggling with depression to know that there's hope things are coming more rapidly than they ever have. The world is supporting a journey through depression in a way that it hasn't. And the new opportunities, the new treatments, new therapies make a future for people struggling with depression.

[00:41:34] And so if I can be the voice of external hope in their path, I think that's really important. 

[00:41:41] Cynthia: Beautifully said. There is so much more support,

[00:41:46] this is a real condition. This is something that deserves attention and funding and research, and we're starting to see the benefits of that. And TMS is just one of those, one of many tools that are here and available to tap into. Thank you so much, Dr. Nelson. It's been a really fun conversation.

[00:42:07] I appreciate all that you do professionally and just the light and joy you bring into this world as well.

[00:42:13] Brent: I certainly appreciate being able to participate because I agree really interesting conversation and there's so much opportunity and looking forward to the future. 

[00:42:24] Cynthia: Thank you so much for listening to the Well Connected Twin Cities podcast. Did you learn something new? Did you feel that spark of hope and excitement for what is possible? Because so much is possible. Tell us about it in a review on Apple podcast. Not only would we absolutely love hearing from you, but these reviews help our ratings and help other curious minds like you find this resource.

[00:42:49] We are always better together. Thank you again and see you next time.