NeuroStar® TMS Therapy
FDA-cleared, non-medication depression treatment
(855) 940-4867
(855) 940-4867
Greenbrook TMS Care Team Spotlight: A Conversation with Dr. Kim Cress
Daniel Hageman
What initially drew you to psychiatry and to TMS Therapy in particular?
I always had an interest in medicine and in helping others. What really drew me to psychiatry was getting the time to be with my patients and get to know them. In 2010, I was working with one particular patient who, no matter which depression medication she tried, she had side effects to everything. She was so drained by depression that she was willing to try anything. While ECT (electroconvulsive therapy) was an option, she wouldn’t consider it because of the side effects and she was afraid of the memory loss that’s associated with ECT. I knew there had to be less invasive options we should explore first, so I looked into TMS Therapy and I dug into the literature.
The more I dug into it, rather than referring this patient to TMS Therapy through another provider, I elected to start using it in my own practice. I saw the utility in being able to use it not just for individuals like my patient who had so many side effects to medications that prevented them from getting to remission but also because I had patients who weren’t able to get to remission despite being on multiple medications. I felt like TMS would have value to not just that one particular patient but to many.
What’s the difference between ECT and TMS Therapy?
Individuals treated with ECT undergo anesthesia and there are concerns with retrograde amnesia. Individuals can have problem with recall of previous events, which can be of concern to patients. For some patients who are professionals, they don’t want to put themselves at that type of risk cognitively and won’t entertain ECT as a treatment option.
I would always pick TMS Therapy over ECT except in select cases where someone is actively suicidal or catatonic because with TMS Therapy, individuals can come in, they can drive on their own, they can resume normal activities— getting back to school or work or whatever their situation may be, after receiving the TMS treatment. There’s no concerns in regard to cognitive side effects.
What’s the most common question patients have about Greenbrook TMS Therapy?
The most common question is Will this work for me? Most individuals come to me with not years of depression, but decades, and they find themselves feeling kind of hopeless. They’ve tried multiple medications and are asking Why is this going to be any different? I failed this medication and that medication, why should I have any hope that this is going to work? So then we have a conversation in the context of how TMS Therapy is different, and how it isn’t another medication.
What happens during the TMS Therapy consultation?
Once someone has contacted us either through the website or called 855-940-4867, we’ll schedule the consultation to learn about the individual’s history and background. We love to have family in on the consultation because they provide such pivotal information. Oftentimes individuals who are depressed don’t see the value or the struggles, because they tend to minimize it or they’re better but not where they need to be.
I have a patient who I’ve known for a very long time, who had completed a treatment course years and years ago with me. She said she was “okay,” but her definition of okay was having one shower a week and getting up in the morning but going back to bed for a couple hours. To her it was okay because she wasn’t suicidal or in the very depths of depression like she had been in times past. So oftentimes, individuals can’t discern that there’s still dysfunction and a loved one can see that, and help them identify that Hey, you’re really still struggling and really have to force yourself to do things, and there’s really not the joy in life that there used to be.
What’s the first Greenbrook TMS Therapy treatment session like?
During the first TMS Therapy session, the psychiatrist is assessing, prescribing and administering the initial treatment protocol. It’s also the longest session because we’re setting up treatment that is specific for that patient. The treatment course is established with putting the chair to their height to get them comfortable, we work to identify the intensity of the magnetic field we need to treat them, and then the localization of where we are treating. We spend that time to tailor each treatment to the individual. It’s important to educate patients and let them know what to expect.
What does the treatment feel like?
My very first patient said the treatment feels like Woody Woodpecker-- they describe it as a tapping sensation, as if I’m tapping on your leg. You’ll get to a point where you desensitize and you’re able to ignore it. And you’ll find yourself able to watch TV, talk, to listen to music, and be very comfortable and not find yourself in any type of discomfort or pain during the course of treatment.
How long does it take to know that TMS Therapy is working?
After a couple of weeks patients have more energy, they’re sleeping better. They’ll mention running errands or meeting with a friend for lunch—going out and doing things which were challenging for them before. We’ll see the smiles and the changes within them—they’re engaging in conversation more readily rather than coming in and being quiet during treatment, they’re taking initiative in conversation.
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You may feel isolated and alone when you have clinical depression, and depression also affects your relationships with family and friends. While the primary focus of your treatment is to improve your mental health, it’s also essential to understand your loved ones may experience their own issues as they try to support you. An understanding of how depression affects relationships can help everyone maintain healthy connections and navigate problems. Here are some of the ways depression may affect the people in your support network.
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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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