All right. Good morning, Dr. Harvey.
Good morning, Dr. Maltzberg. How are you doing?
So I'm acknowledging that this is a podcast and the audience can't see, but I feel obliged to point out that Dr. Harvey is currently wearing a helmet on the Zoom.
A helmet? Oh, yeah.
Yeah, I don't think it's normal for you to be wearing a helmet. And I get the sense that you want me to ask, why are you wearing a helmet? Sure.
Oh, you mean this helmet? You mean the helmet that I'm wearing on my head right now? The bike helmet?
That's correct.
Yeah, yeah, and I actually drove a car, so you might be wondering why I'm wearing this bike helmet, and so yeah, so I'm really glad you asked why I'm wearing this helmet. I'm wearing this helmet because I was thinking today about safety, and so this is just to remind me that the topic today is safety. Safety first.
Now, you know, I agree safety is important. Are we talking about safety about safety? This podcast, I believe, and correct me if I'm wrong, is about TMS?
Correct. The last time I checked. But yes, that's correct. Yeah, yeah.
So, you know, isn't TMS typically considered pretty safe?
Yeah, it is. You know, it is considered pretty safe. I mean, I think sometimes when people Google, you know, check TMS on Google, it's like, oh, there's no side effects. But that's a lie. You know, there are side effects and there are safety risks. The safety risks are small. I mean, it's really a small safety risk compared to other things we do in psychiatry. But the safety risks are greater than zero.
So, yes, they're well worth talking about.
Yeah, I certainly get annoyed when people are like, oh, there's no side effects and it's completely safe. Right. But the flip side is, you know, when we're comparing it to something like, you know, when someone is coming in for treatment-resistant depression, chances are they're on, you know, the heavy hitter medications, which those medications come with a lot more safety risks.
Yeah.
But, yeah, let's talk about the safety risks of TMS.
Yeah. Yeah, let's do that. And just so we can paint a picture here, One thing I didn't think of when we started the podcast is how hard it is to have a helmet and headphones on at the same time. So I had to take off the helmet. I think that's reasonable. Yeah, kept knocking off my headphones. I still have my helmet right by my side here to remind me about safety.
But yeah, you know, it's true. It's true that TMS is very safe, especially in comparison to other things We do in psychiatry, but there are a few things that's very, very important to be aware of. So I think the main things, the main safety topics we want to talk about are number one is acoustic injury. You know, the possibility of damaging hearing. The second one is seizures, which can occasionally be induced by TMS.
And the last one is the risks of metal, the risks of metal being near the magnetic field. And those are Those really are the main safety risks. One thing I want to mention, kind of as an honorable mention, I want to give honorable mention to scalp discomfort. Scalp discomfort is probably the main side effect of TMS, but it's not really a safety risk. It's just something that can sometimes make it uncomfortable, but it's not really a safety risk.
So we're going to skip over the subject of scalp discomfort today and probably go back to that topic at a with a future podcast. But for right now, acoustic injury, seizures, and risks of metal.
Yeah, whenever, you know, with medications, devices, I always kind of break, you know, I think side effects is the big category. And I always break it up into, you know, the common side effects. And then there's the rare but serious effects. So I guess these, like you mentioned, these are the, I guess I would categorize them as relatively rare but serious safety risks. And We'll superficially talk about the minor side effects, but this one we're really talking about, like you said, I would say rare but serious safety risks.
Yeah, exactly. Right. Yeah, yeah. Rare, but serious. Yeah, it's funny that it kind of turns out that way with both medicines and TMS, that the relatively minor, not serious side effects are real common, and the scary bad ones are very rare. So we're lucky it works out that way.
I think that's by design. I don't think the very unsafe ones get pushed forward. Yeah. All right. Which one would you want to start with?
Yeah. Let's start with acoustic injury. I think that one's probably the easiest one to talk about. So yeah, let's talk about acoustic injury. Yeah, yeah. So acoustic injury is basically, you know, loud noises can sometimes damage hearing. You know, like if somebody, you know, somebody like, you know, mows the lawn all the time without earplugs. If they go to loud rock concerts all the time, that can damage their hearing.
And similarly, TMS can be sort of loud. And so there have been actual cases, you know, it's not just hypothetical, there have been actual cases of people having decreased ability to hear after doing TMS, right?
Yeah, it's one of those, you know, I'm thinking of, I like to go to a lot of concerts. And, you know, when I first started, I was like, I thought you were a baby if you had ear protection in. But anyone who goes to any concerts with any regularity has ear protection. Like, it's a serious thing. That's one of those things, you don't notice it in the moment.
I mean, maybe you get that weird ringing in the ear the next day, but it goes away pretty quickly. But it's an accumulative damage if you kind of keep hearing loud things over and over and over. Like I said, it's subtle because you don't, it's not, You don't get it the next day You get it years down the line You don't hear things
Oh, exactly, right Yeah, yeah It can be subtle And people can have damage to their hearing And just kind of get used to it So they don't notice it, you know And then they go to a couple more rock concerts And that makes their hearing just a little bit worse And next thing you know, they're like What? What'd you say? What'd you say? What'd you say? And then they've got a serious problem.
But probably one of the first things I want to point out about acoustic injury with TMS, first of all, machines are not as loud now as they used to be. So I think the risk is less. But also, you know, we give earplugs and we give people earplugs to wear during TMS. And with earplugs, as far as I know, the risk is just zero if you're wearing earplugs.
I mean, there's zero risk at all so long as people wear the earplugs that they're supposed to wear during TMS.
Yeah, I think, you know, the You talked about this to us earlier and it really hammers in the point that it's not one of those, you know, to me it shouldn't be a negotiable. Like it's a serious risk and we have a way to seriously mitigate that risk. So I think the big message is for providers, like enforce the earplugs. Patients follow the lead of the doctor.
If you say during the intake offhand, like, oh, and you can wear earplugs if you want. I'm not going to get followed, but if you build into your clinic structure or talk to your techs in terms of emphasizing the importance, every patient should just be wearing earplugs.
Oh, absolutely. Yeah. Yeah. And I think part of the problem is some providers might not be aware that the risk is real. I mean, it's an actual risk. So yeah, if a patient comes in, my way of looking at it is no earplugs, no TMS. If you want TMS, wear the earplugs.
Now, when you talk about the risk, do you have any sort of numbers offhand?
Yeah, we don't have any numbers. I mean, I think the acoustic injury is something that almost never happens anymore because we give people earplugs, you know. There have just been some case reports early on of people having, you know, very early on in the early days of TMS. But it happens so rarely now that we don't really have percentages or anything like that. So we don't know how common it would be if we were doing the bad things.
Yeah, yeah, yeah. But yeah, I think the noise is kind of like a pecking sound, depending on which protocol you're using, but it sounds kind of like a loud woodpecker. And the noise comes from the fact that very large amounts of electricity are going through those electromagnetic coils. And that creates a very strong magnetic field. So there's deformation of the coils. The coils are physically vibrating because of the strong magnetic field.
And that's where the noise comes from. That's why it creates that noise. And I guess another part of it is when you're in the TMS room and you hear the machine, Most people, including me, when I hear that, it's like, it's kind of loud, but not that loud. So it's sort of understandable for people to think, maybe it's not that big of a deal. I hear noises louder than that without wearing earplugs.
But the other thing to remember is that... You know the patient getting treated by TMS you know for one thing the coil is very close to their ear so there's that but also there's an actual physical vibration of the coil and the coil is resting directly on the patient's head so that more noise so that that same vibration is actually being carried through the bone directly to their inner ear And it would be synchronous with the noise.
So you have those two things added together. You have the noise and you also have the physical vibration. And those things can cause the physical damage that go along with acoustic injury.
You mentioned that reminds me, have you seen those cool headphones that you put on like your outer ear and then it just vibrates the bone?
Oh, yeah.
Those are so cool.
I've heard of that, right, right. I've never tried it out. I haven't either, yeah, but some people with hearing problems use those, and apparently it's a big help, which is kind of cool.
So what's going on, what's the mechanism of the hearing loss?
Oh, yeah, that's a great question. So, yeah, the hearing, I mean, just in the big picture, the hearing system itself is just fascinating. I mean, we could spend years studying how hearing works. And, of course, some audiologists do that. They spend years studying it. There's a lot to it. But the part that we can focus on today is the inner ear or the cochlea. And the cochlea contains thousands of these cells called hair cells.
And that's these very special cells that have these finger-like projections called cilia or stereocilia. And fun fact, we have about 16,000 hair cells. And each hair cell has a whole bunch of those stereocilia on them. So what happens is if the cochlea encounters a noise that's too strong or too loud, it can physically break those cilia or physically damage the cilia. And once that cilia is damaged, it doesn't grow back.
You cannot grow new hair cells. You can't grow new cilia. That cilia are not going to heal. You're born with a certain number of hair cells with those cilia. And when you break them, you lose them. You get what you get. You get what you're born with. You don't get any more.
It's actually helpful. I never thought about the actual number, but it's less than I would have guessed. Like knowing there's only 16,000, like I got to protect those babies.
Right. Right. Exactly. Right. Yeah. Yeah. If I say something loud, you might lose five or six. Yeah. Your number goes down. Right. Yeah. Yeah. Yeah.
My understanding is it tends to be in the higher frequency that kind of gets destroyed. Yeah.
I think so, yeah, yeah. I don't know a whole lot about that part of it. And for TMS, the noises are more in the lower range. But yeah, I'm not really sure about the frequencies. Yeah, yeah, yeah. But yeah, I think that there's a lot of other things in the human body where there's a... Because when you think about the brain or talking about cells, you expect it to be like millions, like 10 million hair cells or something.
But yeah, Yeah, it's like 16,000, which is a weirdly small number for something that important. But yeah, another thing to know about that is we do have some spares. You know, we're born with spares. So they say that you can lose about 30% of your hair cells without any problems with your hearing. But then when you lose more than 30%, then you can start to have trouble.
Gotcha. So you get a little bit of reserve, but...
Yeah, yeah, yeah, yeah. But really, probably the most important thing to remember, again, is just wear earplugs. Have the patients wear earplugs. If they've got earplugs, the risk goes down to zero.
Awesome. Let's move on to our next big risk. I think we're talking about seizures.
Oh, yeah. Yeah, yeah, yeah. Let's talk about seizures. So, you know, seizures are something that's very rarely induced by a TMS treatment. The risk of seizures with TMS is only a risk during the treatment itself. It's not like you're going to go home and have a seizure. There's not an increased risk between treatments. It's only during the treatment. But during a TMS treatment, we are stimulating the brain.
And in very rare cases, that brain stimulation has led to people having a seizure, like, you know, just a regular, you know, generalized tonic-clonic seizure.
That's not the sort of thing. It doesn't, you know, quote-unquote cause epilepsy, but a patient can get an induced seizure because of the TMS.
Correct, yeah, they can get an induced seizure from TMS. So yeah, you cannot induce a seizure disorder, but it's possible to induce a seizure.
What's the risk typically?
Fortunately, the risk is really, really small. And again, this is another kind of thing where it's something that's so rare, it's hard to get good data on it. But the very best data set we have was taken from members of the Clinical TMS Society who went through this long process where there's a survey and All the respondents had their answers scrutinized very carefully to make sure we had good data.
But what that came up with was somewhat less than one out of a thousand patients. I think it was around 7. So around 7 out of a thousand patients would have a seizure during their treatment.
And I guess what makes it difficult, sorry, I'll let you finish.
Oh yeah, yeah. I just thought I should point out that that is in the same ballpark as the risk of seizures with an antidepressant medication. So if someone takes Welbutrin, Cymbalta, Prozac, whatever, that also carries a risk of a seizure and that risk is in the same ballpark as the risk from TMS.
You mentioned the one thing that makes it hard to give an exact number for seizure risk is not all TMS is the exact same thing. There's different targets, there's H-coils, there's deeper TMS. I would imagine different protocols and different targets have different statistics. Which is, you know, not to say that the number is useless. It's actually a very helpful number to give a global idea. But I think that's why it's hard to find an exact number.
But I like the 71 out of 1,000 patients.
Yeah, yeah, yeah. The risk is very low. Yeah.
You mentioned it is the same because I do see sometimes say it's like the same as some of the commonly used antidepressants. I do feel like I need to be a little annoying and say, you know, it's probably similar to the, you know, bupropion, but The bupropion statistics were based on very, very high doses. I think when bupropion first came out, they would recommend titrating to much higher doses than we do today.
And they adjusted that number because after they started using it more commonly, more patients had seizures. So it's probably equal to our higher risk seizure medications used at the higher doses is probably how I would think about it. I'm not sure if that's how you think about it.
I think, yeah, once I kind of did a deep dive to try to find some percentages from the medications, and it was hard. It was hard to get good percentages because they just, even like the official FDA labeling, you know, the seizures were rare enough that they couldn't, it was really hard to get good numbers. But yeah, but the gist of what you're saying is true, I think.
When Welbutrin first came out, it was not the extended release, it was the immediate release, and it was also at higher doses. So when people were using that, that had a risk that was It was several times higher than the risk for TMS. But now that people use the extended release, it's smoother, people have lower doses. I think with those changes, yeah, I think the risk is about the same as the TMS risk.
And the reason I bring that up is, as we kind of said at the beginning, I never like when people just say like, oh, it's completely safe. Right. And I want to, so when patients say like, oh, it's the same as, it's the exact same as our antidepressants, you know, there's a nugget of truth in that, in that it's the same as our high risk antidepressants used at high doses.
But I just bring that up because like, you know, when I prescribe something like, you know, Zoloft, I don't see most providers talking about seizure risk. And there is some logic into it in that it's probably lower than TMS, but it's still... Right, yeah, yeah, yeah, you know, the risk is definitely there and the risk is definitely greater than zero. Yeah. Yeah, yeah, yeah. And, you know, in terms of how I think about it, I don't think if someone doesn't have any risk factors for seizure, you know, the risk of seizure to me isn't worth not doing it as a result of, you know, the fact that they don't have risks.
But what it does inform me is that when patients have a lot of risk for seizures, have previous risks for seizures, it's going to change the risk benefit profile of TMS.
Absolutely, right. Yeah, yeah. And that's something important to take in mind with a patient. If they have some history of past seizures or a history of a head injury or if they're on medications that might increase the risk of seizures, then it's not at all a deal breaker, but it is something else that you have to take into account. And also you want to mitigate the risk by making sure that the staff is trained to handle a seizure.
And even though quite a few seizures have happened, just as overall physicians doing TMS for decades, there have been a pretty good number of seizures that have happened total. You know, nobody's been hurt by that or nobody's been, nobody's had any permanent consequences ever, as far as I know. But still, still, you definitely want to make sure that the staff knows how to handle it and use Usually it means a call to 911 to make sure the patient's okay and to kind of monitor the patient through their seizure, which is usually brief and self-limited, but you want to make sure your staff knows how to identify a seizure and knows how to handle it if it happens.
If you wouldn't mind, could you kind of walk us through the general principles of handling a seizure? And, you know, legal disclaimer, this podcast should not be the only thing you listen to. This is not medical advice. All that good stuff. Just give us an overview without every clinician should use their own judgment and practice and not rely on this.
And I will second that because I'm talking off the top of my head right now. So, yeah, yeah.
This is not a replacement for anything.
Exactly, yeah. So you can listen to me, but then get more advice after listening to me, because I'm probably going to leave out something really important.
We promise.
Yeah, we promise we're leaving out something really important, so do your own research after you listen to this. Consider this a starting point. Yeah, so the first part is to make sure that people know how to identify a seizure. And so if a seizure happens, the very, very first thing that the technician should do, of course, is to turn off the machine. You know, turn the machine off right away.
You know, take it off of the patient's head. And also call for help, whether it's other staff who are nearby or calling 911. And at the same time, depending on the physical situation of the patient, you want to make sure the patient does not fall off of the chair. You want to make sure you kind of, if possible, either let the patient stay in the chair or kind of gently guide them toward the floor while they're having the seizure.
And if possible, you want to kind of turn them to their side in order to help protect their airway so that secretions don't go down their airway. You do not want to try to physically restrain people. You do not want to put stuff in their mouth. You certainly do not want to say, hey, drink some water. No, nothing goes in their mouth. You want to protect their airway.
And so basically what you're doing is calling for help and keeping the patient safe while they're having the seizure. The Almost certainly last less than 60 seconds. And then you just wait, wait for the, you know, you stand guard while they recover. And probably they ought to, if this, especially if this is a new, if they're the first seizure they've had in their life, it's probably worth it for them to Go to the ER and get an evaluation because maybe part of the reason they were vulnerable to seizures is there's some other undiscovered condition that they have.
So usually a trip to the ER is warranted when that happens.
That's super helpful. One other topic I wanted to touch on regarding seizures. What are... For patients, what are things that lower the seizure threshold that would make it so maybe you would pause treatment or wouldn't do treatment that day as a result of, you know,
yeah. Right. Yeah, yeah. There's a lot of things. So one thing is that alcohol use can cause unpredictable fluctuations in the stimulus threshold. Like if someone has just mild withdrawal, then that could... Dr. Justin Marchegiani Wellbutrin, especially higher doses. Clozapine, I mean, we don't have a whole lot of Patients getting TMS who are also on clozapine, but clozapine at higher doses can increase the risk of seizures.
And also, of course, someone with a pre-existing seizure disorder. I mean, a lot of times if someone has a seizure disorder to start with, we might hold off on TMS in the first place, but sometimes we wouldn't. Sometimes we would move ahead and treat. So that patient would also have an increased risk of seizures.
So I guess another big thing, and I think we typically recommend patients don't make medication changes during their TMS, especially ones that could, like you said, you don't want to be jacking up the dose of bupropion while you're doing TMS and lowering the seizure threshold even more.
Right, yeah, yeah. At least in my clinic, we always prefer, if possible, we prefer for people to not monkey with their medicines during their TMS course to kind of minimize any of those changes.
Yeah, and as you said, alcohol and benzodiazepines are big hitters in that. Yeah, yeah. For coming down on those especially. Yeah. Anything else about seizures before we move on to our last one?
Oh, yeah, I guess just the other thing is, you know, we think that sometimes coil placement matters. Sometimes if the coil is placed too far to the rear, too far posteriorly, that that might increase the risk of seizures. So make sure you're doing the right thing with coil placement. The motor cortex might be more epileptogenic. I love saying that word. It has a lot of syllables. It makes me sound smart.
That's why we do this. That's exactly why we do this. You want to have the coil in the right place and make sure you're not placing the coil too far posterior, assuming you're aiming for the left dorsolateral prefrontal cortex, which you usually are, but not always. Yeah.
And then an additional, my understanding is Brainsway has a higher risk, which makes sense if it's, you know, a little bit deeper.
Yeah, there is some data suggesting that. Yeah, I mean, I think Brainsway would disagree, and I think the evidence is mixed. But possibly, yes. Possibly, yes. I mean, I'm a fan of Brainsway, but yeah, that could be true. I do, too. Yeah, yeah, I do, really. But yeah, the risk could be a little higher with those devices. All right.
All right, let's move on to our last risk that we're talking about today, metal.
Yeah, metal, yeah. So, you know, magnetic fields and metal, it's not too hard to make a connection with that one, you know. So, with a TMS device, of course, we have a very powerful pulsatile magnet. magnetic field coming out of the machine and metal can interact with that magnetic field. And there's two different ways that the metal can interact with the magnetic field. The obvious one that everybody would think of off the top of their head is that with a magnetic field, you can be tugging on the metal, you can be pulling on it or jostling the metal.
So those are all things you want to think about. And the other thing is that with the pulsatile magnetic field, you're also creating an electrical field. And metal conducts electricity. And of course, different metals are different. Some metals do not get tugged by a magnetic field at all, and others do. And similarly with electrical conduction, some metals are very good electrical conductors like copper and others are not good electrical conductors like titanium.
So that's really the main thing to keep in mind. So, and it turns out that this comes up in all sorts of things. So after I started doing TMS, I learned that a lot of my patients have intracranial metal in places that I never dreamed of or I never thought of. And I think one example is, you know, I had a patient come in for TMS. She seemed like a perfect, perfect candidate for TMS.
And And it turned out, you know, as I got her full medical history, I found out that she actually has metal stents in her lacrimal ducts. You know, so her tear ducts right there in her eyes. So she... So yeah, she was not able to do TMS because we were afraid of conducting electricity right there in her lacrimal ducts. And some of the other metal things that people have, some people have had a head injury and they might have a titanium plate somewhere in their skull or from some kind of reconstructive surgery.
Some people have cochlear implants and we would usually not do TMS for anyone with a cochlear implant. Something less common is a deep brain stimulator. Those we would almost never give TMS to someone who has a deep brain stimulator. And also aneurysm clips. If someone has a cerebral aneurysm, they might have a clip there. The clip is probably the And of course the titanium is a lower risk than other metals, but the risk is still greater than zero.
Titanium does conduct electricity. It's not a good conductor, but it still conducts electricity. So we think there's some risk there also. And then there's other metal that's near the head. People have vagal nerve stimulators. Those are not in the head, but there's a lead kind of up to the neck, so it's close to the head. Sometimes people have had surgery on their spine, which if it's the upper part of the spine, it's kind of close to the head.
Another metal thing that people worry about sometimes is metal tooth fillings because a lot of people have gold or silver in their teeth. Now that one, that one you do not have to worry about at all. The risk from the magnetic coil is absolutely zero for that kind of dental work. You don't have to worry about that one at all. And so a lot of times, you know, other physicians I work with will come and ask me, you know, with all these different types of metal that people have and all the different TMS protocols and ever-changing guidance, you know, if you read something now about what's safe and what's not safe, it's a little different than what you read a year or two ago.
The thinking on that is evolving. So, you know, so if people ask me, you know, which metal is safe and which metal is not safe, there's really not a good way to just to write down the rules for exactly what's safe and what isn't safe. But what I can say, what I can say is with anyone who has metal in their head, the things you want to look at, you know, first of all, what's the location of that metal?
You know, exactly where is it? and you want to look at what kind of metal is it? You know, is it a metal that is attracted by, is it ferromagnetic or not? And also, does it conduct electricity or not? And those are the two main things. So really, I think the strategy is to find out as much as you can about the metal and then kind of pause and think about it.
Think, you know, Don't even decide during the appointment with the patient. Stop. Talk to other providers. You want to think it through. You want to think through that metal with other providers. Look up the literature. And really take your time before making a decision of whether or not to treat that patient who has metal. Mm-hmm.
That was great, Dr. Harvey. I'm curious, do you know of anybody who's been hurt or affected by intracranial metal and TMS?
Fortunately, no. I've never seen that happen, partly because I'm pretty careful, but I've never seen that happen. I've never heard of it happening with anyone else's patient. I don't know of any cases in the literature with somebody getting hurt by TMS with intracranial metal. Metal I think the most dramatic story I've heard and I want to say ahead of time the patient was not hurt by this but the most dramatic story I heard is someone who started getting TMS who had hair extensions and I think the technicians did not realize the patient had hair extensions and so there's some metal in that so the patient had metal on their scalp and the patient started getting TMS and the patient's like, ouch, ouch, ouch.
And they stopped the TMS. Yeah, yeah. But the patient's hair did not catch on fire, nothing like that. You never want to have a patient's hair catch on fire. That's a general rule of psychiatry. At a general rule of psychiatry, if a patient's hair catches on fire, that's a bad thing. So that's a bad thing. I learned that one in medical school. So, yeah. So the patient was fine.
And I think I heard for that particular patient, the patient wanted their hair extensions so badly that they didn't do TMS, which kind of makes me think, how depressed were they if their hair extensions were more important than... But anyway... Life's all about values.
It's all, you know...
Right, exactly, exactly. And really, that's the closest thing I've heard to anyone getting hurt by metal. There have been cases in the literature that I hope I'm remembering the details of it right, but it's not a TMS coil, but an MRI where I think, if I remember right, I think it was someone who was actually an NFL football player who had an MRI and they had a tattoo and the tattoo had been something that they had done overseas.
So it had metal in it. and had metal that could interact with the MRI scanner. and that caused some kind of superficial skin burn. So we worry about that with TMS also. So if I have a TMS with tattoos on their face, then I always ask, did you get those tattoos here in America or did you get it overseas? Because they don't do metal in tattoos here, or I don't know, maybe prison tattoos do, I don't know.
But mostly tattoos are You know, free of that kind of metal here in the S. But elsewhere, they're not. So if they were tattoos that they got from somewhere else, then that could be a worry. But I should say, you know, a magnetic field from an MRI and a magnetic field from TMS are different, you know. And I've heard some people say, oh, if it's MRI safe, it's TMS safe and vice versa.
And I've heard, What I can say is the magnetic field for an MRI scanner and a magnetic field for a TMS machine are quite different from each other. So they are not at all identical. And for a TMS machine, that magnetic field is optimized to create electricity at a distance. So that's different than an MRI. So they're certainly not equivalent.
Any other closing comments on metal?
I don't think so, no. Actually, I do have a closing comment. I think that our thinking about metal is something that is evolving. The very latest literature I've seen really emphasizes the fact that, hey, we should So I think that will be coming in the future. Right now, we're just kind of doing our best and trying to be cautious. But I think there will be better standards in the future.
Moving on, more of a broader question What have you heard is the most serious, like have there been any serious injuries from TMS that you've heard of across any of the major risks we've talked about?
Yeah, there have not No, I've heard of zero people dying from TMS Zero people having serious major injuries I think the closest thing we've had to a major injury is in the early days of TMS TMS
So there have been seizures. There have been people with hearing loss. There's been some close calls with the metal, but it seems like there's been no horrific cases, at least that's been documented.
Right, yeah. And I think if there had been a horrific case, I think it would have been documented somewhere. But yeah, as far as I know, there haven't been.
Yeah. All right. I think that wraps up our serious risks of TMS talk.
Alright and we'll probably have more episodes going over some of this in more detail later on and going over other side effects like scalp discomfort but yeah I think that wraps things up but yeah I really enjoyed being here really enjoyed talking to y'all and I just want to thank the audience for being here hope you enjoyed the show and if you didn't then you know not all about you Alright thank
you so much Dr.
Harvey You're welcome Thank you.