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Greenbrook TMS Care Team Spotlight: A Conversation with Dr. Misty Borst
Daniel Hageman
Dr. Misty Borst joined Greenbrook TMS in November 2016 as Medical Director at our Columbia center in Maryland. Originally from South Carolina, Dr. Borst has worked in both inpatient and outpatient settings and has been treating patients with TMS since 2016. Dr. Borst is board certified in adult psychiatry and is a member of the American Psychiatric Association as well as the Maryland Psychiatric Society. Read on to learn about her thoughts on TMS therapy.
How did you become interested in psychiatry?
Once I was into my psychiatry rotation during medical school, I loved it. I loved the amount of gray area in psychiatry—For four patients, even if they all have depression, that depression was different in each of them. I really appreciated that the gray area felt artistic- a lot of thought had to be put into each particular person’s situation. I’m sure that’s true for all types of medicine, but it really resonated with me in the world of psychiatry.
What drew you to TMS?
The statistics are quite compelling. When you look at the success rates once a patient has tried a certain number of medications, TMS therapy is statistically a far better option for many depressed patients. In addition, TMS is personalized for each patient and as a treatment modality, it has so few side effects. Any psychiatrist should be interested in anything that is new and can help our patients.
Does medication work for everyone with depression?
If a person feels very depressed and the antidepressants work even a little bit, they are initially pleased with that because it is better than where they were. Over the course of months, some people will realize that it’s just not enough. Some people may feel somewhat better with the medication and get used to that and accept that this is their new normal, but it doesn’t necessarily have to be. They will say they’re fine, but we know from a clinical standpoint, there can be further improvement. We want them to be better than fine.
Do people have to stop taking their medication before starting Greenbrook TMS therapy?
Generally, we keep people on the same medications they were on prior to starting TMS therapy unless they were having a particular side effect and want to be off a medication. In general if a person does well with TMS and gets a good response, I recommend they wait a few months to see things are remaining as they want them to be. Then, if they want to try decreasing their medication, that is a perfectly okay time to talk with their doctor about it.
What happens when Greenbrook TMS Therapy begins working?
People will notice the patient looks a little brighter or less weighed down. Once the treatment starts working, when someone walks into the office, we can get a sense that things are starting to turn around. Throughout the course of treatment, the physical manifestations of depression will start to change: a patient’s sleep will improve, their energy and motivation will pick up. And they will start to feel relief from their sadness or hopelessness.
What’s the most rewarding part of your work?
Seeing the changes in patients. I had a patient just last month who had tried many different antidepressants over the course of years and hadn’t had much success with any of them. Once he went through TMS Therapy, he was like a different person. A very happy, new person. He was bright, excited, and he recognized that he felt completely different and much better. His family saw it, too.
What are patients often surprised by?
Many people find it a little daunting that treatments are five days a week for several weeks. Then they are surprised when they find themselves looking forward to TMS sessions each day. Patients like taking a break from their day and having time where outside stressors can’t get to them. During treatment they can reliably get away from everything and they don’t mind it as much as they thought they would. The sessions are fairly quick, patients can drive themselves, and they can get in and out efficiently.
How can depression affect a person’s family life or career?
Depression can certainly affect everything in a negative way. I see patients who end up just spending their time after work in their bedroom instead of hanging out with their kids. It can diminish relationships between parents and kids and can cause strain between spouses. Depression is great at facilitating distance between people. At work, depression can decrease a person’s productivity to the point where managers might notice. I’ve seen patients with depression become less able to tolerate stressors, so they’re getting irritable or snappy at a coworker when normally, if they weren’t depressed, they would be able to handle the stress and brush it off. All those little micro-insults are so much harder to handle if you’re depressed.
If you think someone you know is depressed, how do you bring it up?
If you notice a friend or family member isn’t wanting to hang out as much, if they aren’t as social or if they are isolating, those are signs something is going on with them and maybe they are struggling. If they look more disheveled or are having major changes with their sleep or their weight, those can be more obvious signs. But socially and emotionally, if they seem like they aren’t themselves that’s enough to warrant concern. If you’re worried about someone, you can start by asking how that person is doing. You might have to persist a little bit in asking. Sometimes you have to risk having an awkward conversation or feeling a little uncomfortable to pull it out of a person. Maybe they’re okay, or maybe it’s something else, but it’s worth double checking.
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Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for your nasal esketamine treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT), so nasal esketamine is probably a new treatment experience for you. If you're wondering what it's like to start nasal esketamine and get ready for your first session, keep reading. Getting Started with the Nasal Esketamine Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether nasal esketamine is a good fit for you. Alternatively, you can schedule your esketamine nasal spray consultation with a treatment center (such as Greenbrook) that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS). At Greenbrook's REMS-certified nasal esketamine treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine provider before beginning treatment. If the medication is deemed a good fit, you’ll receive your prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard (oral) antidepressant along with your nasal esketamine treatment. There are two important regulations to note when it comes to preparing for treatment: Each treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your treatment schedule. In addition, if you’re wondering what to bring for the treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During Nasal Esketamine Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real nasal esketamine sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each treatment session. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of Spravato esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook's Care Team is readily available if you need assistance. How to Prepare for after your Nasal Esketamine Treatment Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after nasal esketamine treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll have treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine patients begin feeling relief from depression symptoms within hours of their treatment. Other Tips in Preparing for Your Nasal Esketamine Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for each treatment session. Schedule A Free Consultation To get started with nasal esketamine, schedule your free consultation today.
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