Summary
Dr. Martha Koo, who runs 11 TMS centers across California and is immediate past president of the Clinical TMS Society, shares her pioneering journey from purchasing one of the first commercial TMS devices in 2009. She discusses how early adoption of unproven technology helped rewrite psychiatry's playbook, revealing that she offered patients a money-back guarantee and never had to honor it. Koo describes the evolution from skepticism to mainstream acceptance, the insurance billing strategies that helped fund early adoption, and the three major developments ahead: accelerated protocols including one-day treatments with AMPA augmentation, device mobility for broader clinical settings, and vagal nerve stimulation integration. The episode captures the transformation of psychiatry from a purely pharmacotherapy field to one embracing neuromodulation.
Key Points
- Dr. Koo bought one of the first commercial TMS devices in 2009 and now runs 11 centers across California
- She offered a money-back guarantee to early patients and never had to honor it
- The original five-day-a-week protocol was chosen because the researcher's wife wanted him home on weekends
- Accelerated protocols, particularly one-day treatments with AMPA augmentation, are a major upcoming breakthrough
- Device mobility will enable TMS in more treatment settings beyond dedicated clinics
- TMS combined with vagal nerve stimulation represents a promising sequential treatment approach
- Insurance coverage has evolved from requiring out-of-pocket payment with appeals to more routine coverage
- The future of psychiatry involves neuromodulation alongside pharmacotherapy, not medication alone
Key Moments
Early adoption of TMS when it was considered crazy
The episode introduces Dr. Martha Koo who spent $100,000 on one of the first commercial TMS devices in 2009 when most psychiatrists considered it crazy talk, and now runs 11 centers across California.
"In 2009, most psychiatrists operated with overhead consisting of like a phone and maybe two rooms. Spending $100,000 on a magnetic brain stimulation device? That was crazy talk. Dr. Martha Koo bought one anyway."
Three major TMS breakthroughs ahead
Dr. Koo identifies accelerated protocols with AMPA augmentation, device mobility for broader clinical settings, and integration with other neuromodulation treatments as the three biggest upcoming developments in TMS.
"I do think, you know, mentioning as I did earlier, these accelerated protocols, particularly this, you know, the one day protocol that's come out recently with AMPA, I think that's huge."
The future of psychiatry beyond medication alone
Dr. Koo challenges the paradigm of treating depression as a chronic illness requiring lifelong medication, suggesting that neuromodulation treatments achieving true remission could fundamentally change the approach.
"The idea that we start people on medications and we tell them, oh, we think of this as a chronic illness. That whole concept could be blown out of the water if there's a treatment that actually gets you into true remission."
