Ep. 164 | Beyond Sadness: Understanding Difficult-to-Treat Depression and How TMS Works

Karin Ryan (00:02.798)
Hello and welcome to another episode of Everyday Therapy Podcast. I am Dr. Karen Ryan, your host, and I am here today with Dr. Suzanne Jasperg, who is our special guest helping us talk about depression and a very specific treatment for depression, TMS. And so we're so thankful that you're here because what we find is that sometimes depression can be missed or not recognized. So we're gonna spend some time talking about like how do we find it, how do we recognize it, and then just making sure that.

you're empowered to know what's out there to help you. So welcome Dr. Jasper. Thank you so much for being here with me. Thank you. Yeah, how are you doing today? I am good on this rainy day. It is a rainy day today. will you just start by telling, you know, our listeners a little bit about what got you into psychiatry and the mental health world? Yeah, that's a great question. I didn't actually really think I would be a psychiatrist in medical school. I majored in biochemistry, so I was really interested in like

endocrinology and enzymes and things like that. But in my clinical rotations I found psychiatry to be really fascinating. Mm-hmm. And it also became very apparent that people who had untreated mental health conditions did not do well on the medical floor. Right? It was very difficult for them to take care of their other physical health when their mental health was not well treated. And so it just seemed really important to focus on if you want somebody to be

fully healthy. Yeah, absolutely. It makes me so thankful that there are rotations and finding those areas of interest because you've done such great work how work. how long have you been a psychiatrist? I graduated from residency in twenty fourteen. Okay. So good like twelve years. But when you're in residency obviously you're doing the work as well. So Yep it's a four year psychiatry residency. Yeah, so sixteen we'll say, right, we'll give you credit for residency which I think most residents would appreciate, right? Like

doing the work. Yeah. And and so you do outpatient mental health care here at Sage of Behavioral Health, right? Yep, I do. Yeah, absolutely. And so one of the things we're talking about today, right, is depression, right? And the different ways it presents. And I feel like it's always helpful to remind people because we tend to think of depression as kind of feeling sad. And certainly that can be part of it. Like feeling sad, being tearful, low energy. But there's different ways that depression can present, right? Like what are some of the ways you see

Karin Ryan (02:30.604)
depression presenting that people might not first recognize as depression? That's a good question. I mean some people who don't have prominent sadness really have a lot of irritability. Mm-hmm.

that can be something that is a little harder to recognize sometimes. Yeah. and then just a lot of like really low motivation, trouble getting things done. You know, you'll see it at work where people have cognitive problems, right? The cognitive symptoms of depression are really, really prominent. Like a brain fog, right? Like feeling like your brain's just not as sharp or working as it wants to. And yeah. Mm-hmm. Hear a lot of people talking about reading. Like, my gosh, I just read this paragraph and I did not retain any of it. Yeah, which makes work really hard.

For sure. Absolutely. And so when you think about that piece of irritability too, I just think about what does that look like?

and and I have experienced it and seen it as just like annoyed with things. Like things that wouldn't normally annoy you just really tick you off. Right? And just not having patience for things and feeling like you want to snap or like you know I mean snap like chirp back at somebody and things like that, right? Mm-hmm. Yeah, absolutely.

And certainly it can present physically as well with like we call it somatic or some physical complaints too, right? Like what are some of the main physical complaints that can come with depression?

Karin Ryan (03:51.074)
Yeah, mean people will, you know, have trouble sleeping. They won't you maybe either sleep way too much or not enough, wake up really early in the morning. A lot of people will lose their appetite. Yeah. And so, you know, you'll see people who can't really not sure why they've lost weight but they have. Yeah. Those kinds of things. Yeah. And like maybe not even enjoying eating or having the interest in like making food, right? Where it's like I know I have to. Right. But I don't have any interest in this. Yeah, it doesn't bring me any joy.

Yeah. And I think it's helpful to understand too what causes depression, right? Or like the root drivers of depression. And sometimes it's hard to just think it's not just one cause, but there can be like an intersection of different things. Yeah. What do you find are some of the main things that can contribute or lead to depression for somebody?

I mean certainly like life stressors or traumatic events or, you know, hardship in someone's life can prompt depression. Sometimes it comes out of absolutely nowhere and it's just really biological and organic and there's no really reason why people would be depressed but they are Yeah. Yeah. And when you say biological and organic, can you explain with your wonderfully educated mind like what that means? What does it mean to be like truly biologically kind of created? I mean I think we think about

Depression is kind of

two contributors. One is the neurochemistry of the brain, right? So somebody's neurons not firing at that the rate that they should, whether that's a connectivity problem or a neurotransmitter supply problem. Mm-hmm. but one of the things that TMS aims to help with is the neurocircuitry of the brain, right? And so kind of the functionality of the computer yeah of the brain. Yeah, that's awesome. And so when you you're talking about neurotransmitters,

Karin Ryan (05:38.644)
I think of it as do you have enough of what you need to like think and feel and behave in the way that is kind of natural and helps you thrive as a human. Right? And so neurotransmitters can like kind of this it's this big word we hear a lot and it's really just how does does the brain have what it needs? Does it have the fuel it needs, right, to help you

Through life. Is that a way to is that an accurate way to think about it? Yeah. Yeah. Cause it's kind of like, you know, if we don't have enough calories, we feel really tired, right? We know for individuals who have diabetes, right? That's an insulin-related issue. And I think it's really helpful to think about depression about that as well. Like that's why medications help, because there is a deficiency in something or in a d decreased activity in certain neurotransmitters or pathways that are leading to some of these symptoms. Is that a right way to think about it?

Yeah, that I mean that is one of the theories and sometimes when you think about depression that's more difficult to treat.

even if you supply the brain with all the extra neurotransmitter in the world, if the neuron isn't firing fast enough for that to make a difference, it's not gonna help. Yeah, 'cause it's just not gonna it's not there. Mm-hmm. Yeah, absolutely. And we're gonna get your it's a little tease for you as we talk about some like treatment resistant depression. Right, 'cause there's different types of depression as well, right? You did a nice job of kind of explaining that there's sometimes there's causes, right? We know that there's situational depression where we experience stress or

triggered by a major life event and that's hard for us to adjust to. that there's major depressive disorder, which is a clinical depression with increased intensive s excuse me, intense symptoms that impact daily functioning, right? So that's a longer period of time, not a long period, but at least two weeks of really feeling down and having those symptoms. what is persistent depression or persistent depressive disorder?

Karin Ryan (07:35.573)
So like a depression that lasts for a really long time. Mm-hmm. some people have depressed episodes that have lasted for decades at this point. Right. Which is really difficult to deal with. Yeah, it felt like they've had like no relief where there's always been kind of a lower grade but definitely impactful like depression. Mm-hmm. Yeah, absolutely. And then there's seasonal.

you know, depression. We know that sometimes seasonal like we call it seasonal affective disorder, season changes can lead to mood changes. yeah, do you find that there's an increase in

some depressive symptoms with clients in like the fall, winter time. Yep. As I mean right now here Sept early September we start losing daylight really quickly. Yeah. And so that's also one of the times where people you start light therapy for that and things like that. Yeah, absolutely. And we know there's postpartum, you know, connections as well. Yep. Yeah, 'cause there's so many hormonal and different changes happening. And so

just kind of as you're thinking through knowing that depression doesn't just present one way and your symptoms may be different just like if we have a flu or a common cold, right? Like some of us might be super like congested, another person's like, my gosh, my throat just hurts so bad. And so we experience there's similarities, but we can experience it differently and there's different types of them. So I think just knowing that there are those different types and naming it and being able to like do some research and explore like, well what am I experiencing here? We just empower people, right, to do that. So

What is treatment resistant depression?

Karin Ryan (09:09.368)
Well, I will say I hate that term. Do you? What's a better term? Well, I don't think anything is truly treatment resistant. I think some people have very difficult to treat depression. Right? Yeah. And some people, you know, take a hundred milligrams of Zoloft and feel way better and other people have not had that experience. And so I think that there's just some depression that responds really well to first line treatment and there's some depression that's stickier and just really doesn't. But it doesn't mean that we won't be able to treat it. Yeah.

Okay, say that again. What is the term you prefer? Difficult to treat depression. Difficult to treat depression. I appreciate that 'cause I feel like it helps remove any sort of belief that like you're not doing treatment right. For that you'll never get better. Yes. Absolutely. So it removes that element of like, well if I just if I was doing the right treatment or the right things I would feel better or I'm never gonna feel better.

Right, 'cause that hope and belief is so key, don't you think? Mm-hmm. Yeah, absolutely. Yeah, so difficult to treat depression. And so what would you say, you know, are some of the signs for when it would be helpful to seek some additional support? if somebody's experiencing depressive symptoms, just in general, as it j in general psych as we call it, like when would you encourage somebody to come in and maybe talk to a medication provider for their depression?

Anytime s people's symptoms are at least moderate, then therapy plus medication is going to help somebody get better faster. Yeah. And so moderate being what? Like how would somebody know when they were experiencing moderate depression as opposed to mild? That's a really subjective question. And very good.

I think people just have a good sense in their gut of like, this feels significant and it's not getting better how I hoped it would. Or it's really starting to impact my social life or my work life. Yeah. anytime somebody has a drive just that things aren't getting better like they want them to, I think that that warrants seeing somebody. Yeah. And I think the reminder to people that they always deserve to feel better.

Karin Ryan (11:24.494)
Yeah, and that you don't have to figure it out alone.

Yeah. And so that idea of if somebody were to come in and you they actually let's say I'm using quotes here, like only had mild depression, you would never look at them and be like, Why are you here? You only have mild depression. You would be having a conversation with them about how they're feeling, how they wanna feel, like what would like an increase in functioning and feeling better look like for you, right? Yeah, I think anyone that takes the time to show up deserves to be taken seriously. Yeah, absolutely. And like that we wanna just help you feel better. Mm-hmm, right? Yeah.

You bet. You bet. And just as a reminder too of you know, that there are great resources too. So there are always a twenty four hour right crisis line. Nine eighty eight is there. Many counties have like Cope, they'll have direct trained professionals who will respond, come to the house or answer twenty four or seven lines and help figure things out. That, you know, there's general therapists always available to help work through things as well. And what I would imagine, right too, as you highlighted

you know, Dr. Jasper that it's helpful to have, you know, the talk therapy, the therapy and medication. And that's something that we, you know, I feel really good about what we offer at Sage and right, is that we do have comprehensive care where we can have individual therapy, you know, psychiatric care, medication management, we have testing. And we have some other really cool forms of treatment here. And one of them being TMS. Mm-hmm. Yeah. And so what is your role

in the TMS kind of program or care here at SAIGEN? Yeah, so I'm the director of interventional psychiatry which includes TMS, which stands for transcranial magnetic stimulation. Mm-hmm. So it's a treatment for depression that uses essentially a magnetic field to deliver energy to the brain in a way that helps depression that medication has not been able to help, or in people who can't tolerate medication. Yeah.

Karin Ryan (13:23.958)
So it delivers energy to the brain. How does it do that?

Tell us your magical ways, Dr. Jasper. So the so kind of the oldest or more traditional form of energy delivery is ECT. Mm-hmm. that takes electrodes and delivers current from one electrode to the other and the brain intentionally has a seizure in that process, which is very effective. But for that to be safe you have to be under anesthesia. Yep. which has risks. Yeah. And there is the potential of memory loss. So the idea behind TMS is to deliver energy to the

brain in a way that does not have those side effects. Yeah. So it uses essentially a rapidly alternating magnetic field to deliver energy through induction rather than conduction, which is how you know, current flows. And so it's a gentler form of energy delivery and then there's no anesthesia, there's no seizure, and there's no memory loss. Yeah. So people are awake during treatment, they're getting energy delivered to their head through this magnetic field that kind of feels like a woodpecker pecking on their head.

or like a tapping sensation on their scalp. Is it painful at all? It's an intense and sort of strange feeling, but it's not painful. Okay. And if it's uncomfortable there's adjustments that we can we can make. Yeah.

But it's a twenty minute treatment that just sort of repetitively taps on your head and it's five days a week for thirty six sessions. So people come into clinic every day and have their treatment and they can drive to clinic and drive home. Some people come in the middle of their work day and go back to work. so it is a really cool and much more gentle way of delivering energy to the brain. Yeah, 'cause like you're saying, if they're able to drive there and drive back, they're like fully awake, they're fully alert

Karin Ryan (15:15.33)
And like they do w you're doing well after treatment. Yep. Each day. Yeah. How long does it t how long does each one take, each treatment take? The treatment itself is twenty minutes. So it's twenty minutes of stimulation. It'll it'll pulse and then the machine breaks and then it pulses and it does that repetitively for twenty minutes. Yeah. Yeah. And so you're just sitting there why this is happening. Mm-hmm. Mm-hmm. Can you like talk? Can you look at your phone? Can you like why you're having it? Or

Okay. Yeah. I mean we have you wear earplugs, it's the tapping sensation is a little bit noisy. but people read, knit, watch videos on their phone, chat with the operator, whatever they want to do. So like truly are like doing just fine sitting there, but there's that sensation happening. Yep. Yeah. How do most people feel like right after, like as they get up? Do they notice anything or n not really? Some people feel a little bit tired. Yeah. Not sedated, but kind of like I don't know, like you took a test or something, yeah.

Did a little work. Yeah. Yeah. every once in a while, kind of when people are getting used to it, it'll give people a little bit of like a tension type headache, but that usually goes away within the first week. Sure. So sure. How do you know like where to send the what did you call like the magnetic energy? Is that what you said? Yeah. Yeah. How do you know where to send the magnetic energy in the brain? So the stimulation aims at the dorsal lateral prefrontal cortex. So like the front part of the brain that the frontal lobe.

That are, you know, really involved in a lot of circuitry loops and you know higher order executive functioning. And there's no marker for that area. But you can deliver single pulses with the machine to find the area on your brain in the motor cortex that moves your thumb. There's a lot of brain space dedicated to having opposable thumbs. So you can say more about that. Okay, just this is if I wish you could see her because she's got her cute little thumbs and they're going back and forth.

Fourth. So explain that a little bit of like that why why that part of the brain and the thumbs. I think that's very cool. So there's a motor strip that goes down kind of the center of your brain and different parts of that motor strip will move your arm, your hand, your foot, you know, as you go down the motor strip. And so you can find the area on your cortex that moves your thumb. Yeah. And when you find the area that moves your thumb the best so that it's moving your thumb and not your wrist and

Karin Ryan (17:43.329)
and not your arm. Then you lower the amount of energy to find the least amount of energy to move your thumb. And then we know based on MRI studies the stimulation needs to be, you know, six centimeters in front of that. And that's where the the stimulation area is in the

Frontal lobes. Very cool. So if I were to try to summarize this in terms I understand, it would be like that there's been a ton of research in like what part of the brain is most associated with like depression and symptoms or like decreased functioning. What area of the brain, if we can help improve its functioning, right, and the energy in it, then we see there's a direct relation to like depressive symptoms and like functioning better and doing better. Yep.

Okay. So you can tell with like glucose uptake studies, right? You were talking about needing calories. The brain needs a lot of calories. And in depression the frontal lobes are down regulated, they're not using as much sugar. Yeah. And then when depression gets treated, those areas light back up and turn back on. They they essentially like start taking what they need.

Whereas they were kinda like not taking what they need. Right. So we need that part of the brain to be assertive and take what they need. So it's a little assertiveness of that brain. Yes. When people are on TMS, when they start TMS, do they like stop their medications? Do they stop therapy? Or what do you typically guide them to do if they're doing TMS treatment? So some people come to TMS because they really can't tolerate medications. They take them and they feel sick or have t terrible side effects.

And so those people often are not on on any medication and TMS will work. Yeah. but it probably will work better and keep you better longer if you're on a medication. Yeah. So if we can we do like people to be on some sort of baseline antidepressant therapy.

Karin Ryan (19:33.059)
We absolutely want people to continue therapy. Okay. Right? So we're putting energy into the brain. It's kind of like going to the gym on a steroid. Yeah. Like we're putting energy into the brain. The therapy helps drive the right circuit loops to turn back on.

So you're supercharging your therapy if you're doing it at the same time as you're doing TMS. Yeah. Yeah, so as a therapist I'm thinking, you know, if I've got a client who's seen you and doing TMS and then they're coming in during their TMS stream, this is the time where if we do those like cognitive interventions and those behavioral interventions and we're trying to shift patterns and behaviors of interactions and increase social activities, this is the time to do that because you now have this energy in the brain and if we

kind of put it in the right way, those neural circuits of like positive self talk and affirmations and shifting out of negative self talk and engaging in activities that bring us joy and peace or satisfaction, we're gonna see better results. Yeah. And so it's like take opportunities of that energy now and feed those neural circuits that we want to really reinforce. Yep. Yeah. I oftentimes think about the brain, Doctor Jasper, as like a bunch of different roads

And the roads that we go on all the time are the ones where the ruts become deep, it's become smoother, we work out all like so it becomes like a flat area. Whereas if we don't use them, the weeds grow over, it's harder to navigate. And so that piece of like we want to put our energy and like the more we th shift how we think, the more we reinforce those paths. And so that's kind of what's happening, right? Is we're opening all these roads and saying, like, hey, we've got access to all of And so let's reinforce the things that help us. Yep. Yeah. Yeah.

how would somebody get started on TMS? If you find yourself like listening and you're thinking about yourself or a loved one and you think, you know, yeah, you've tried a couple of medications or medications really like have not sat well for you or you've been struggling with persistent depression, you know, for a long time, how would somebody even get started? Yeah, I mean we would love to see anyone who's interested for an

Karin Ryan (21:38.329)
what we do is have a initial evaluation to make sure that they're medically appropriate for TMS. there are some risks to TMS, so people who have had like an epilepsy diagnosis it wouldn't be safe for sure. It is a magnetic field, so it's similar to getting an MRI, you have to be able to not have any metal in your head, those kinds of things. Sure, like earrings or like dental pieces kind of things. Most dental pieces are okay because they're MRI safe and

earrings, most people can take them out. Yeah. Okay. Yep. But like pacemakers or deep brain stimulators, vagus nerve stimulators, those kinds of things. Okay. So we do a have a medical screening. and then we have TMS currently at Sagent in both our Maple Grove and our Eden Prairie clinics. Mm-hmm. And we really try to get people in quickly and get them started quickly. Yeah. Yeah. And my understanding, right, is that there are

Your yourself is included, but then there's other psychiatrists or medical providers who are TMS providers. So skilled, trained, they're the ones that are gonna like do the intake, that there's people who are gonna assess and make sure it's safe just like you said, a medical screening and walk you through and talk about it. So if you call, you can call and just get information about it and ask some questions of like, Hey, could this be a good fit for me? Mm-hmm. Yeah. Yep. Yeah. If you call you'll get routed to the TMS team and we have a great group of

people who are very skilled at getting people started and and connected. Yeah, in my experience, because I work in Eden the Prairie office where TMS is, whoop whoop, is how passionate the providers who do TMS are. Yeah. Right? And I think of the like passion because just want to help people feel better, right? And that hope. But also because you believe in it and because it's really effective, right? Like how effective is TMS?

Yeah, I mean it's extremely effective. And so in treatment resistant depression populations, you're still getting like a s between a seventy and eighty percent response rate. Yes. So people are getting at least fifty percent better. Yeah. And you know, upwards of sixty some percent of people get total remission. So sixty percent of people get total remission. Which is huge. It's huge, especially when a lot of these people have tried ten, twelve

Karin Ryan (23:57.849)
medications that haven't helped to to pivot to something that has a success rate of, you know, an eighty percent likelihood that you'll feel significantly better is really great odds. Really great odds. Yeah, and it's it sounds like it's it's a commitment, right? 'Cause you're coming in every day, you know, weekdays, not on the weekends, and you have to come in for thirty to thirty six. But when you think about it, like what, that's like a month and a half.

Two months? How long does that work out to be? It's about seven and a half weeks. Yeah. But you think about it, that's two weeks of like real dedication to this, but then

Look at how much better you're gonna feel. Yeah, it goes fast. Yeah. It does. And if people need it, you know, we can help facilitate paperwork and things like that if you need some time off of work or those kinds of things. We also have a depression intensive outpatient program. Mm-hmm. And so sometimes if people's symptoms are really bad, maybe they're doing that at the same time. As well, sure. So that daily support and able to like be in like in a group setting and getting those couple hours of support while also doing the twenty to thirty minute TMS.

treatment, you bet. Yeah, really that comprehensive care. what I one one time I came in and there were a bunch of bunch of donuts in the break room and they were from a TMS patient who had had such great success and wanted to thank the team for how much better she felt and how they kinda helped hang on to that hope for her and get her into that care. And so I feel like that really said a lot. Yeah.

I mean selfishly I like doing TMS because it's so rewarding.

Karin Ryan (25:33.9)
Right, to see people over those seven weeks get so significantly better. Yeah. Is really amazing. Yeah. that's great to hear. And so if again, if you find yourself kinda thinking about your own experience, your own experience with depression, just knowing that we're here, that there's really amazing treatment out there, including TMS, that can help you feel better even if you have difficult to treat depression. Right, Dr. Jasper? Yeah. Well thank you so much for joining.

today really appreciate it and if you have any interest in learning more you can go to sagentbh.com and learn about TMS or just give us a call and we will walk you through it and help you through all the steps. But we appreciate you all listening. Take care.