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

Resources:

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

Smiling Depression: How Happy Faces Can Mask Depression

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

TMS at Kind Health Group

Related Videos:

Behind the Scenes at an Embark Outpatient Clinic

The Science of Stress with Dr. George Slavich

Personal Growth Through Social Support with Dr. Hansa Bhargava

Deliberate Practice with Scott D. Miller

About Dr. Nanos

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

About Rob

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

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

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Have a question for our experts? We want to hear from you! Submit your questions to: askatherapist@embarkbh.com

And so the pathology comes when you can't

get out of those negative pathways and find your way out

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

actually doing is is physically creating new synaptical

connections and creating new neuronal pathways in the brain

to allow for these positive networks to form.

Welcome, everybody to another episode of Sessions.

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

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

Dr. Nanos, to the podcast.

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

here.

Oh, great. And I particularly lots of times we

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

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

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

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

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

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

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

Diego and specifically in Encinitas, but maybe if you

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

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

Yeah, sure. So our practice is primarily

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

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

number of patients in our community and from around the

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

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

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

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

more inclusive and see this treatment in a different way?

Well, I would say so I have been practicing

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

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

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

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

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

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

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

I loved, and I still love practicing medicine and wanted

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

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

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

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

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

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

wonderful training ground for, for family medicine and just

had, you know, the best colleagues and greatest patients

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

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

concierge practice where we focus a lot more on prevention

and emotional and mental health in addition to physical health.

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

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

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

of therapists in the area to deliver emotional and, and

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

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

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

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

TMS treatments with pretty incredible results, probably

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

told. I'm very proud of that.

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

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

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

more this principles of integrated health and, you know,

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

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

becoming more of an integrated, holistic approach and I love

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

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

seeing real high effectiveness across the board."

My approach to medicine has always been to take

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

Lipitor prescriptions and Prozac prescriptions all day long,

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

lifestyle modification, and, you know, improving their mental

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

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

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

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

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

mental health treatment until really until now, and being able

to provide that to people and giving them hope, without

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

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

changed the direction of my career.

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

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

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

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

healing and health seems very purposeful to you.

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

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

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

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

you know, interested, curious people with critical thinking a

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

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

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

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

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

So I was the firstborn child of Greek

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

originally from Stamford, Connecticut, the suburb of New

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

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

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

like veal sandwiches for lunch, while everyone had peanut butter

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

to Greek school instead of doing sports in elementary

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

he received the care really changed the trajectory of his

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

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

that certainly was the impetus to get me into healthcare into

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

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

was kind of my origin story, if you will.

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

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

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

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

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

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

relationship.

Absolutely, and that's the foundation of what my

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

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

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

treat every, first of all ourselves with kindness, and

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

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

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

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

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

idea.

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

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

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

deemed an expert in understanding attachment and

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

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

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

the question down here, what is your philosophy of relationship

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

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

if you will.

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

foundation of the way we administer TMS, which is very

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

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

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

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

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

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

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

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

school, or how did that transpire?

So I was one of those medical students that

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

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

everything, surgery, OBGYN, psychiatry, internal medicine,

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

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

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

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

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

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

to that.

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

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

before you became aware of alternative, you know,

treatments?

So I was in a traditional practice for about

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

also very much the frontlines of being mental health care

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

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

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

especially post COVID, everyone, all our mental health care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

medicine of alternative medicine, integrative medicine,

holistic medicine, functional medicine, in addition to this

traditional Western medical model because as and I think

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

thinking, "Okay, Western medicine, allopathic medicine,

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

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

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

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

be in that space where we can look at everything critically

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

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

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

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

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

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

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

health and wellness space?

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

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

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

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

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

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

a tough balance for you.

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

searches here and there and off to the races!

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

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

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

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

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

are struggling with mental illness or people are struggling

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

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

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

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

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

every year it is getting where our mental health crisis is

escalating yearly, and of course, after the last three

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

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

don't necessarily even understand what defines a mental

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

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

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

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

lot of coexisting mental health disorders, particularly anxiety

and depression being the most prevalent that either people

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

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

care specialists, or primary care doctors tend to be the

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

healthcare in the country.

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

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

adolescents, and even the parents with all these somatic

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

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

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

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

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

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

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

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

some TMS and maybe we can define that?

So the summarization is something, you

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

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

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

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

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

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

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

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

that, you know, could potentially be harmful to

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

depending on where they are and their understanding and their

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

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

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

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

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

are very real somatic issues, that are a physical

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

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

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

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

therapy, and medication as needed for people, but

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

a really big stigma around medication for mental health

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

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

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

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

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

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

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

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

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

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

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

that there was something out there that I really feel is

going to be the next generation the next evolution in mental

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

the brain to really change those neural pathways and make a

difference for people in a longer term.

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

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

have some relational issues at home anxiety, depression,

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

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

about really figuring that out, and not just putting an

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

certainly in our practice. We get, people with these

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

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

get underneath there and figure out where's the infection

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

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

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

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

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

edge to actually explore this would be really great.

Yeah, absolutely. So TMS stands for

transcranial magnetic stimulation. And the second I

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

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

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

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

pulses into deep areas of the brain called the salience

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

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

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

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

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

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

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

hold in the greater community is because the way the original

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

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

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

therapeutic effect, at least 40 sessions, each session takes

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

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

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

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

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

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

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

falling off and not completing the treatments and not getting

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

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

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

conduct a number of randomized controlled clinical trials to

see if perhaps, condensing the protocol to a shorter timeframe

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

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

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

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

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

treatment to during those five to fifteen minute sessions,

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

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

treated over 40 hours in a week.

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

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

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

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

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

much validation and reliability behind these studies to be able

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

effective this the equal or even more effectiveness than to doing

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

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

probably ruffles some feathers in the TMS world.

Probably, but I think-

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

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

newer approach to doing something that we already know

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

scientifically validated, there's a lot of evidence behind

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

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

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

country are still doing the extended protocol and doing some

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

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

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

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

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

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

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

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

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

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

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

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

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

reframing, positive, you know, positive affirmations,

meditation, mindfulness, breathwork, journaling, any

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

therapists who will occasionally have- will have a whole TMS

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

therapist will come in and also work with those patients where

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

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

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

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

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

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

essentially does is give you better emotional control and

better ability to regulate your thoughts and behavior patterns,

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

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

health coaches are working with patients once a week for six

weeks after their treatment and then for an entire year monthly

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

to be.

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

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

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

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

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

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

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

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

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

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

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

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

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

Oh yeah, it has made all the difference

incorporating that health coaching component. We already

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

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

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

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

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

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

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

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

people with different experiences and different issues

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

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

you know, teenagers, adolescents, with severe anxiety

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

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

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

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

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

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

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

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

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

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

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

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

definitely it definitely takes a village.

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

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

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

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

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

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

this rates of adolescent suicidality, that, you know,

it's, we see a lot of recommendation from

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

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

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

Absolutely, and there's definitely a lot of

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

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

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

definitely a role for those treatments, as well and those

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

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

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

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

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

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

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

give people an extremely safe way to deal with really complex

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

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

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

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

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

brain where our depression and anxiety centers live, and what

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

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

know, a triggering event or something that is uncomfortable

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

well worn pathways of negativity, and so the pathology

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

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

TMS is actually doing is, physically creating new synaptic

connections and creating new neuronal pathways in the brain

to allow for these positive networks to form, so that

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

more space for these positive networks so that when you are

encountering something that's upsetting or difficult or

challenging in any way, instead of going right into that

negative loop, you have a positive loop to go into

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

pretty remarkable.

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

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

disrupting the existing neural synaptic connections, so it

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

new neuro plasticity to take place will be helpful.

It's not disrupting existing connections,

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

cases with traumatic brain injury and post concussive

syndrome, a lot of those patients have damaged

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

it can strengthen existing connections, so it's not

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

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

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

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

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

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

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

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

are that are challenging.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

could give you-

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

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

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

access, that would be great.

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

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

have a really great animated video that explains it in really

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

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

of the relevant research studies, and then links to

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

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

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

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

Of course!

And...?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

wearable sleep tracker on the market right now, and Apple

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

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

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

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

sleep, which correlate very closely with a lot of mental

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

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

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

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

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

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

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

the question was.

different, really quantitative data."

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

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

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

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

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

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

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

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

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

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

know, forever.

What an absolute tremendous practice. So just in

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

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

future hold for Dr. Nanos?

I want to bring this to as many people as

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

to the podcast all know, just interpersonal neurobiology, and

understanding the science of relationship is just really,

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

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

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

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

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

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

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

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

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

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

however you access podcasts through Apple or whatever, but

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

appreciate it!

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