Summary
Dr. Craig Heacock interviews Dr. Elizabeth Fenstermacher, founder of the TMS Clinic at CU Anschutz medical school, in an episode inspired by the late Nolan Williams' pioneering work. They provide a comprehensive comparison of TMS, ketamine, and psilocybin as psychiatric interventions. The conversation reveals that standard TMS achieves about 50% response rates which jump to 56% remission when combined with psychotherapy, while the SAINT protocol uses neuro-navigation, intermittent theta burst, and intensive scheduling to achieve superior results in just five days. A key insight is that ketamine and TMS may be complementary rather than competing: ketamine provides rapid crisis intervention while TMS produces more durable remission. The episode includes a moving tribute to Dr. Nolan Williams who passed away unexpectedly.
Key Points
- Standard TMS achieves about 50% response rate, jumping to 56% remission when combined with psychotherapy
- Nolan Williams' SAINT protocol combined shorter theta burst patterns, multiple daily treatments, and fMRI neuro-navigation as the special sauce
- Ketamine and TMS may be complementary: ketamine for rapid crisis intervention, TMS for durable long-term remission
- Accelerated TMS may sacrifice some durability compared to the standard six-week protocol
- TMS for OCD shows about 30% improvement in Y-BOCS scores with broader coil patterns
- The standard protocol of 30 sessions over six weeks, while burdensome, may produce more durable results
- Dr. Fenstermacher's clinic combines behavioral activation goals with TMS treatment for better outcomes
- Nolan Williams passed away unexpectedly, leaving a profound legacy in the field of brain stimulation
Key Moments
Nolan Williams' legacy and the SAINT protocol
Dr. Heacock opens by honoring the late Nolan Williams as a leading light of psychiatry who pioneered the accelerated SAINT protocol for TMS at Stanford.
"Today's episode, I would say, was inspired by the work of Nolan Williams. He was really a leading light of psychiatry, psychiatrist at Stanford, and a pioneer, not just of TMS, transcranial magnetic stimulation, but an accelerated form called SAINT."
How neuro-navigation made SAINT protocol so effective
The discussion identifies fMRI-guided neuro-navigation as the special sauce that made the SAINT protocol dramatically more effective than previous accelerated approaches.
"Nolan Williams, when he did Saint, he put many different things together. So they used shorter protocol in intermittent theta bursts. They combined it with many, many, many treatments a day."
Ketamine and TMS as complementary rather than competing treatments
Dr. Fenstermacher suggests ketamine and TMS serve different roles: ketamine for rapid crisis stabilization, then TMS for producing durable remission, forming a sequential treatment strategy.
"I wonder if maybe we're asking the wrong question. It might be that they actually serve different purposes. Ketamine is the thing that rapidly helps someone who is acutely hopeless, suicidal, and we're using ketamine to pull them out of the hole quickly."
Durability tradeoff between accelerated and standard TMS
Dr. Fenstermacher reveals that accelerated TMS protocols may sacrifice some durability compared to the standard six-week course, which was actually one of the motivations for developing accelerated protocols in the first place.
"I should comment on the durability of the accelerated protocols. That was actually the reason the accelerated protocols were developed was to try to address the fact that so many patients were dropping out."
