Hey Dr. Harvey, how are you doing?
Hey, doing good. How are you doing Dr. Wolfsburg?
I'm doing good. I'm super excited about the topic today. This is one of the episodes I was looking forward to doing.
Yeah, likewise. Yeah, me too. I think this is one that we really don't talk about enough.
Yeah, and the topic will be TMS for OCD. Okay.
Yes, exactly. Yeah, yeah. And I think that's, I'm kind of surprised we haven't done this topic before, you know? But, you know, because we're so used to thinking about TMS as being something to treat treatment-resistant depression that, you know, sometimes we don't talk enough about using TMS for OCD. You know, when But when I talk to people about TMS, you know, and of course a lot of people haven't heard of it or don't know anything about it and they ask what it's for, you know, I usually say, you know, TMS is for, I usually say, well, it's for depression and some other stuff too.
And when I say and other stuff too, I mostly mean OCD. That's really the main thing. I mean, because I think OCD is the second most common thing that we use TMS for. So yeah, so it's definitely time that we talk about that.
Yeah, yeah, I'm excited. Now, I guess I'm the balancer here. So if anyone's excited about something, I say it's bad. And if anyone's not excited about something, I say they're wrong and that they should be excited. So as naturally, I will be the balancer today.
Balance is good. I'm a big fan of balance. And I think especially for OCD, you know, there's certainly reason to have that balance. So that totally makes sense for this topic.
Yeah, I think one person would say balance, another person would say nuisance. It's all perspective, I guess.
Exactly right. Yeah.
So yeah, I guess let's jump right into it. Talk to me a little bit about OCD. Okay.
Yeah, yeah. So, yeah, so treatment for OCD with TMS, you know, it's been around for a long time. You know, it was actually FDA cleared in 2018, which is time flies. That was eight years ago. And, you know, I think at the time when it was FDA cleared in 2018, I think the other thing is that, you know, By 2018, insurance companies were being pretty good about covering TMS for depression.
So, you know, in 2018, I thought, oh, you know, insurance companies, they'll be covering TMS for, they'll be doing a pretty good job of covering TMS for OCD by, you know, 2019, 2020, something like that. And Here we are in 2026 and still waiting. I mean, there is some coverage, maybe roughly half the insurance companies are covering it, but it's not. Yeah, it's kind of hit and miss for the insurance coverage.
And that's what I see. I've seen insurances that just flat out say like, oh, we don't do that. We don't do TMS for OCD. And one thing I want to emphasize just from the start is when we say TMS for OCD, not all TMS is the exact same thing. So I bring this up because I think before I was in TMS, I thought like TMS was one thing that everyone gets the same thing.
And it's like, oh, and it also works for OCD. Whereas The FDA clearance is on a particular protocol and a particular device. So the device most commonly or one of the more commonly used devices for OCD is the H7 helmet. So the thing I want to emphasize is that it's targeting different areas of the brain than when we're using it for depression. And then also it's a particular protocol that's being used.
In practice, you know, for OCD, there are, you know, medications work well for I think more than half the people generally and also psychotherapy especially exposure with response prevention or ERP that also works well for more than half the people and of course if one of those works well then there's no use doing TMS so I think right now TMS is something people consider as a backup plan if the other things don't work and it's really not Currently, it's really not being used or considered as a first-line treatment.
It's more of a backup plan.
All right. Maybe we should just dive a little bit more into OCD. So how common is OCD?
Yeah, so OCD, and of course you'll see different numbers if you look at different places, but it's somewhere in the ballpark of 2% of the population. About 2% of humans have obsessive compulsive disorder, and of course for some of those it's sort of mild and not a Relatively mild and not a huge problem, but for some of the people who have OCD, it's just devastating and life-altering and something that really,
really needs a lot of attention. But yeah,
it's about 2%, which puts it at substantially less than the number of people who have major depressive disorder.
One thing I think that is probably underappreciated by the general public is that OCD traits are actually incredibly common. So people having a symptom of OCD, it's something like a quarter to a third of the population have a symptom at one point in their life. There's a big difference. Just having a symptom or an intrusive thought isn't the diagnosis in itself. So there is a separation between having the symptoms and the disorder proper.
Yeah, exactly. Yeah, yeah. And I think I think in medicine we have to be careful to not pathologize personality quirks or isolated symptoms.
Yeah, as a clinician, just because we hear a person has a symptom, we have to do a deeper dive and look at the way it impacts the person, how much it impacts the person, how much time it spends their day. Because if someone reports an odd symptom, and it's a one-off, it doesn't really impact their life, OCD might not be the right diagnosis. And then pursuing the OCD treatment might not be appropriate, or it might, you know, maybe treating the mood disorder might take precedence.
So I just say that, just because you hear an OCD-type behavior or symptom, That doesn't mean instantly you go to OCD treatment.
Absolutely. Absolutely. Yeah. Yeah. So I think sometimes people have isolated symptoms and there's also obsessive compulsive personality traits or obsessive compulsive personality. People can have obsessive personalities where maybe that makes them good at their job. We don't necessarily have to fix it or change it.
Yeah. What do you think is the reason that people aren't getting the TMS for OCD?
Oh, good question. Yeah. So I think, yeah. So to start with, there certainly are a lot of people who should get TMS for OCD. A lot of people would be way better off if they did. So I think the reason that a lot of people are not, one of them is... One of them is that lack of insurance coverage. I think nationwide, maybe roughly, this is just a wild guess, but I think maybe roughly half of us have insurance that would cover treatment for OCD by TMS.
So that's part of it, is just the lack of insurance coverage. I think also just a general lack of awareness of TMS and even more of a lack of awareness of TMS or OCD. It's just something people don't think about, people don't know about. And yeah, so it's just something people don't think much about. And I think another reason, another reason that it's not as widely used is just in general, you know, TMS for depression will sometimes give amazing, impressive results.
But if you give TMS for OCD, it's a lot less common to see that amazing, impressive result. You know, TMS for OCD, it definitely works. It's definitely better than placebo. It's definitely worth doing sometimes. But it's not as impressive. It's not as amazing as TMS for depression. At least currently, it's not.
Yeah, I want you to go into a little bit more detail there. Yeah. How would you say it compares to medications? Clinically, what do you see? Like what do patients report? Yeah, give me a better idea of how helpful TMS is for OCD.
Yeah, yeah. And I can tell, and I'm actually... You know, in full disclosure, I'm co-author of one of the papers that looked at the post-marketing data for TMS, for OCD. But that was a long time ago, so I don't necessarily remember a lot of stuff about that. But But yeah, I think for the currently FDA cleared, and I want to start by making the distinction between the currently cleared protocol for OCD and some of the newer protocols.
So for the older protocols that are FDA cleared, roughly what we saw is that, you know, half or a little more than half the people who got treated had some response. And when we say a response, we mean, you know, maybe 20, 30, 40% improvement in their scale scores. So when people would get TMS or OCD, if the treatment worked, the patient would say, yeah, you know, I'm definitely less bad.
This is definitely better. You know, with that improvement, maybe they could start driving their car again or, you know, maybe they, you know, maybe they spent We didn't see that with OCD. We didn't see that with OCD. Preston Pyshenko
What do you see with the patient? So let's say if you, you know, I'm assuming you've treated a whole bunch, those half that didn't get help, were they like, that didn't help at all? I feel the exact same. Did I see improvements in other areas? I guess, what did you see in the patients outside of the data?
Yeah, yeah. So one thing I saw outside of the data, and later on there was data to show this, but one thing I saw anecdotally, which was later shown by the actual evidence, but one thing I saw anecdotally is a lot of patients came to me with both OCD and depression, and we were aiming to treat their OCD, but And for some of those people, when we're finished with treatment, the patient would say, you know, oh my gosh, my mood is a lot better.
I'm a lot less depressed. My OCD is still terrible, but my mood is better, is what some of those patients would tell me. So I think early on we knew that the OCD treatment also works for depression. So if people have both, They can, you know, the treatment's particularly good in people who have both conditions. So that's one thing we saw. But yeah, you know, a lot of people had the very severe OCD and it was kind of tragic to see some of them who had bad OCD and the TMS didn't work.
Now, when you were using the treatment, were you using the brains by age seven?
Yes, yeah, we were using the Brainsway H7, yeah,
yeah Would you say a helpful way of thinking about it is it's hitting a broad area, it's almost similar to SSRIs, and that SSRIs we know help treat depression, help treat OCD, when I say it's similar, I mean we do see it help in other areas outside of specifically OCD, outside, like it seems that the H7 coil has a broader, it helps with a lot of different things in some sense
Yeah. In that way, it is analogous. Yeah. It's kind of like an SSRI, which seems to work for both OCD and depression. Yeah.
So how is the TMS different for OCD?
Yeah. So with the TMS for OCD... The main thing is that we're simply targeting a different part of the brain. For depression, we're treating dorsolateral prefrontal cortex. We're usually targeting dorsolateral prefrontal cortex because that's starting to change. But for OCD, we're targeting the dorsomedial prefrontal cortex, or more specifically, we're And I'll explain what those are in a little bit. But we're targeting dorsomedial prefrontal cortex and also anterior cingulate cortex, which is just kind of like a little bit down from the medial part.
So it's the part in the midline, the part in the center, the part kind of where the sulcus is, sort of toward the front or at least sort of a little bit anterior to the apex of the head.
Yeah.
The vertex. Yeah.
And in my understanding, so you mentioned, you know, the big difference between this and the depression target is dorsomedial versus dorsolateral. So we're hitting more of that, the midline, when I say midline, I mean, like, you know, where your nose is. Yeah. Now, my understanding is that you actually map the motor cortex with a foot instead.
Correct. Yeah. Yeah. Good point. Yeah. Yeah. So we're, you know, and this, the When we map people for depression, we kind of find out, you know, find the, well, you know, different people do mapping different ways, actually, but one way to do mapping is to find the hotspot. If it's depression, to find the hotspot for the hand on the motor cortex. But when we're treating OCD, we can, one way to map is to find the hotspot for the foot because the motor cortex for the foot is sort of, is in the midline.
You might remember from neuroanatomy, you know, the homunculus, you know, the homunculus kind of has his or her legs dangling into the sulcus. So that's, yeah, that's one way to think of it.
Yeah. And one other thing that I think is super important to emphasize is that with the FDA-approved protocol, symptom provocation, could you talk a little bit about that?
Right. Yeah, that part's very important. So they think that the treatment works better if we provoke the patient's symptoms during the treatment. So for each patient, we sort of individualize it and we talk through with the patient, you know, what can we do to make your symptoms flare up during the treatment? Because for whatever reason, we believe that, you know, if the patient is is moderately triggered by their OCD symptoms during the TMS treatment that the treatment seems to work better.
So that can take a lot of forms, but just one example is if a patient has an extreme fear of germs and contamination, then just as an example, we might ask them to wipe their hand on the carpet and And so we asked the patient, you know, how much is this bothering you? How distressed are you? And we are aiming for a moderate level of discomfort during the treatment.
Yeah, so my understanding is that, Jay, basically just be repeating what you said, you know, three to five minutes before you start the treatment, you're aiming for a four to seven out of 10 of distress for symptom provocation. And then once the treatment's running, you know, trying to pay attention to that trigger so that you have the symptoms provoked.
Yeah.
I also actually, I made a little guide for patients. So I'll link that in the show notes. Yeah. because I think it's important because I think I do see this missed a lot of clinics and that they don't do this symptom provocation and it's part of the FDA cleared protocol.
Exactly. Yeah. Yeah. And we think it matters. So we should be doing it. Yeah. Yeah. But it does kind of put us in an interesting situation where, you know, we're trying to help the patient feel better. But then right before the treatment, we're having a conversation with the patient and basically asking, what can I do to make you feel bad? Yeah.
Well, I think things get worse before they get better. That's something I live by.
Patients don't like it, but it's... Yeah, that's a good way to look at it. But it is kind of a point of amusement. Sometimes the patient kind of chuckles at that, like, oh, the doctor wants to know how to make me feel bad. Great.
We can get our holistic impulses out.
Exactly, exactly. Yeah, but all in good humor.
Can you talk about the different FDA-cleared coils?
Oh, yeah, yeah. So there's sort of a story behind that. But originally, the cleared coil was the H7 coil by Brainsway, which is basically kind of like a large figure-eight coil that's bent in kind of a butterfly kind of way, which gives a large volume of stimulation and also deep stimulation. and we think that you might need that broad, deep stimulation to get the stimulation that we want, especially in order to actually reach that anterior cingulate cortex.
So that was the original FDA clearance. Later on, a A MagVenture coil got the same clearance, and that was a 510k clearance, which, long story behind that, but basically they claimed equivalence, and I think there is a reasonable argument for equivalence, even though that coil was not as deeply penetrating. but they made a claim of equivalence. And then later on, one of the standard figure eight coils also made a claim of equivalence, but that one was even less similar to the H7 coil.
But now that one and some other ones also have FDA clearance for treatment for OCD. And I think- Oh, I was just going to say, as far as I know, the best data or the only data that's really cleared through the FDA is stimulation with the H7 coil. The others are all based on a claim of equivalence.
What are these coils? You mentioned it's targeting the dorsomedial prefrontal cortex and the anterior cingulate. What's the reason we target those spots?
Yeah, so we actually know more about the neurology of OCD than we do about the neurology of depression. For OCD, we know it has something to do with those midline structures and the CSTC loop, you know, the corticostriado-thalamocortical loop.
You got it.
Yeah, I got it. Boom. Yeah. So it's that loop. And we know that loop is overactive in OCD. And we know that when people get better, it's less overactive. So, yeah, so we stimulate that area to make stimulating that area. That's the area that was being aimed for in some of the earlier studies. And for many people, it works.
Yeah, I liked in one of the previous podcasts you mentioned the mechanism of TMS is that when we stimulate in that area it gets better, which is, I really enjoyed that. What do you feel like is in the future for TMS for OCD?
Yeah, you know, I'm optimistic that, I mean, you know, the treatment's pretty good now, but I'm optimistic that it's going to get better in the near future. There was a different protocol that there was a published study for like a year, year and a half ago, something like that. and that protocol used D-cycloserine and also used Thetaburst, still at the midline, and it seemed to get much better results.
Now, of course, it's only one study. As far as I know, it has not been replicated. I've heard anecdotes of other people using that and of it working well. So I think that this is going to be borne out by additional research. So anyway, the point being, I think that TMS for OCD is going to be a lot better in the near future. At least I'm hopeful for that.
I mentioned I'm going to balance. I see we're running close to time. The one thing that I see that I want to warn clinicians about, this is my big warning, is I'm seeing now providers because they want to use their OCD machine will start calling symptoms that are better thought of. formulated through a different lens, for example, a personality disorder or just generalized anxiety and they'll force it into OCD.
And I want to warn patients and providers the danger of providing a formulation that doesn't fit so that patients get treatment that might not be the most appropriate thing for them. And I think that's going to be on the rise. So I always worry about making similar mistakes over and over again.
Good point. Yeah, yeah. You don't want to be like, you know, like sometimes if there's a guy with a hammer, they think everything's a nail, you know?
Yeah. And, you know, I'm seeing patients with borderline personality disorder that they got TMS for intrusive thoughts that probably would be better thought of as abandonment fears. But maybe that's for another day.
Yeah. Yeah. Let's do that one another day.
Yeah.
All right.
Great job.
All right. Yeah. But hey, thanks everyone for being here. Glad we could talk to you about TMS for OCD. Hope you enjoyed the show. And if not, then okie dokie then.
Have a good one, Dr. Harvey.
You too, Dr. Milford. Talk to you later.