Dr. Martha Koo bought her first TMS machine in 2009 when colleagues thought she was "crazy," and now runs 11 centers as immediate past president of the Clinical TMS Society. Her insights reveal why TMS doesn't require patient belief, how early billing accidentally funded research, and where neuromodulation is headed with accelerated protocols and implantable devices.
Dr. Martha Koo bought her first TMS machine in 2009 when colleagues thought she was "crazy"—now she runs 11 centers across California as immediate past president of the Clinical TMS Society. Her biggest revelation came when longtime therapy patients said "I'm good, but I'm not my true full self," showing how psychiatrists often settle for partial recovery. Unlike medications, TMS doesn't require patient belief to work—as one skeptical patient discovered when he achieved complete remission despite thinking the treatment was "silly." Early billing operated in a regulatory gray zone where insurers accidentally processed TMS sessions like MRIs, inadvertently funding the field's growth. She envisions a future with accelerated one-day protocols, mobile devices in oncology and OB-GYN settings, and implantable brain stimulators. Her blunt advice to hesitant colleagues: "The cat's out of the bag—I don't see a world in future psychiatry that's just medicine and therapy."
Timestamped Show Notes:
[08:09] The $100K gamble and early TMS adoption[
13:25] Insurance loopholes and money-back guarantees
[15:57] "Not my true full self": what patients really want
[19:44] Santa's sleigh and the belief problem
[22:50] Military medicine and the polypharmacy solution
[25:05] Why TMS is five days a week (blame Dr. George's wife)
[28:33] Accelerated, mobile, implantable: what's next
[34:05] VNS comeback and combination approaches[37:21] Interventional psychiatry as evolution, not revolution
[48:09] Advice for hesitant psychiatrists
Will Sauvé, MD (00:02.892)
Doctor, so nice to talk to you.
Martha Koo, MD (00:05.528)
You too, well, thank you so much for inviting me on this Osmoine Webinar. It's thrilling.
Will Sauvé, MD (00:09.794)
Well, wait until the end and then we'll see if you're still glad, But then, mean, first things first, it's almost like housekeeping, but one thing I wanted to bring up is as the immediate past president, that's what you told me is the official title. What thoughts do you have about the most recent clinical TMS Society meeting where we both were in San Diego, what feels like 30 seconds ago, but.
It's already been a couple of months.
Martha Koo, MD (00:40.856)
crazy how that time flies. And thank you so much for joining the meeting. I always think they're amazing. And yeah, it was great. It was our 13th annual meeting and a really special one because it's my home state. So it was very nice to have the meeting when I was president at the time in California. And like I said, it was also a repeat of where we had our very first one. So that was super cool. And it was an exceptional turnout.
We had, I think, over almost 690 total attendees, of which 580 or so of those were members and clinicians. The rest were sponsors. We also had the most sponsors that we've had. We expanded sponsorships and included things outside of just CMS, which I think was really incredible for people, EHR systems and stuff like that. I thought it was. Yeah.
Will Sauvé, MD (01:35.468)
The HR systems, yes.
Martha Koo, MD (01:38.608)
I think, know, also technology for therapy and, you know, evidence-based therapy too. So was great, but I thought the turnout was amazing. It's always a great time. San Diego was an amazing city. We had some really new, right? We had, as you know, you were there. I think the AMPA innovation and demonstration was incredible.
Will Sauvé, MD (01:59.277)
Right?
Martha Koo, MD (02:02.426)
was just great. I love being president. It's probably will go down as one of my favorite years. It's just the people that I worked with were incredible. It was really a fun year, a lot of hours. And so that's when you say, wow, it's only been three months. I feel pretty rested up, but it incredible.
Will Sauvé, MD (02:18.446)
Yeah, a lot of hours, but worth it.
Martha Koo, MD (02:22.672)
Very worth it. I would encourage anybody to work their way up to leadership in that society. You learn so much, you stay on the cutting edge. It's really a great way to stay informed on everything, right? Just the new technologies, the innovations, the current research, the evidence-based things, things that are going on in insurance. It's great, but mostly the people are fun. mean, you've been in bigger settings than I have. I've been in private practice or in my company and not really in...
hospital settings where I have as much opportunity to coordinate and collaborate with colleagues. And so for me, that was really fun. All the meetings and talking to so many professionals from all around the world was great.
Will Sauvé, MD (03:05.902)
I really appreciate that point though, that the private practice setting is pretty isolating.
Right? that, I mean, interestingly in that same vein, was, I was having a conversation with a friend, you know, unrelated somewhere here in Virginia and a big practice with, I my goodness, I'm, thinking of my friend's practice. She's got to have something like 15 cats and dogs working in this practice. And every one of them, when you ask them is basically lonely.
And it's like, well, it's a busy outpatient practice, predominantly med management. truth of the matter is they're all in their head down, seeing patients doing their work, but working as fast as they can. And quite commonly, any one of them will get to the end of the day and realize that they've not seen another soul that works in that particular practice. like.
Martha Koo, MD (04:04.56)
And that's really hard, right? With everything that happened COVID and so much things went telehealth. I think that's challenging, which is a nice thing about TMS, right? We let even during COVID and it was a stressful time, but we didn't close. I we had people coming in and it was, I was so happy. I had someplace to go and show up. And our doctors, we have nine at our practice. I'm at your behavioral health at TMS, our wellness bond. And we make a lot, you know, it's nice cause they're in house. Our NPs, even though
Will Sauvé, MD (04:10.807)
Right?
Martha Koo, MD (04:34.64)
90 % of their med management is virtual. We have them come in. And then there's, have the techs and we have the admin. So there is a real community feel. I think they appreciate that. We make efforts to do monthly provider meetings and I have a weekly medical director meeting. Yeah. Otherwise than that, it's pretty isolating to sit, especially behind a screen. If you're doing management or therapy all day, even if you're in a group practice, right. And you're in your little cubby hole all by yourself or you're at home.
Will Sauvé, MD (04:57.42)
right?
Martha Koo, MD (05:04.464)
be an isolating. And if you know that there was this great New York Times article, gosh, I should pull it out from like the 1960s. You know what I'm talking about? Called the Impossible Profession. You know, it's really, it's, it's, it's quite, you know, old, but it talks about all of that. But the title was the Impossible Profession and it talked about sort of the isolation. It's a cool
Will Sauvé, MD (05:18.358)
No, I don't know that one. No.
Will Sauvé, MD (05:26.958)
Mm-hmm.
Will Sauvé, MD (05:33.742)
Well, and we learned the hard way how bad it is in COVID, I agree completely. At Greenbrook, we also did not close. I was very proud of that. I love to tell people I never missed a day of work. It's like I was still, I was in the office every day, which was freaky driving on 95 from Richmond to DC with no traffic like that. Unbelievable how fast you can get to Northern Virginia when there's nobody else on the road.
Martha Koo, MD (05:48.772)
Yes?
Martha Koo, MD (06:02.704)
next
Will Sauvé, MD (06:04.366)
the clinical TMS society, the reason why it's burning my brain, the society was having an online meeting and we're all on there. And I think we were talking about events pertinent to 2020, 2021. And for the eight millionth time, for no reason, I blurted out, because no one asked me. And I said, TMS is not an elective procedure. And you know.
I heard it repeated back to me so many times over the next year. You're like, you know, it's kind of amazing when you run your mouth and then that ends up kind of being the thing that other people heard, but that I saw it that way. So it was kind of an interesting double thing. Like you never closed. We didn't close it. We have people that are very, very ill and they need their treatment. And like, frankly, a doctor runs into the fire like that kind of no matter what's going on, you have to do it.
Martha Koo, MD (06:55.258)
Yes.
Will Sauvé, MD (06:59.18)
However, it was also a really, really lucky privilege to have a reason to go out and go to work and see people and do something when so many people did not have that and were restricted from it.
Martha Koo, MD (07:12.848)
they weren't allowed, right? And we, and you probably saw this too. I mean, we had so many patients that were incredibly grateful to have someplace to go and have a human contact, particularly people, right? It's one thing if you have a family or a partner or roommates, the people that are single and live alone, you know, they just loved coming in and having face-to-face contact with somebody. was really meaningful.
Will Sauvé, MD (07:28.674)
Right?
Will Sauvé, MD (07:40.236)
Yeah, really meaningful and like so necessary. So maybe more people take that seriously now. But that's a you know, we both been in practice for a while and that was maybe kind of one of my first questions because you you open the South Bay TMS Center in 2009. When when TMS was barely one one year old, this thing comes out. So what?
Martha Koo, MD (07:59.666)
In 2009, I did indeed.
Will Sauvé, MD (08:09.196)
What was it that like possessed you to get into TMS so early on?
Martha Koo, MD (08:14.063)
That's a great question. What's interesting, I think you know this, after I finished medical school and residency, I did psychoanalytic training and then I opened my practice. So I had spent a decade really doing intensive therapy and medication management and seeing good outcomes for a lot of people and also seeing many people that were certainly only partially better or not better at all with this combination.
In the interim, I had also been tracking neural modulation techniques because when I opened my private practice and was in analytic training, I had to make some money. So I was employed at UCLA, the geriatric faculty clinic, was doing, a couple of my days, I was doing the outpatient electroconvulsive therapy. So this was 1996.
And they were talking already at that time about using magnetic energy to achieve the same results and not what came out to be magnetic seizure therapy, but what out to be TMS. And so it had just piqued my interest. was always really, I love psychiatry. love neurology. went into actually medical school thinking I was going to be a neurosurgeon. So I was always just super excited and interested about the brain as well as the mind. And so those decades
Will Sauvé, MD (09:13.634)
Right.
Martha Koo, MD (09:29.361)
that 10 years I was just tracking it and looking at the research and when NeuroStar got its FDA clearance, said, okay, I'm gonna buy a device. People did think I was a bit crazy. It was a lot of money just to dump on a device and there wasn't a lot of, think,
acceptance at the time that it was truly an efficacious and safe procedure, you so what we know now. But I was just excited to have something to offer my patients that I thought would be an added benefit to those that weren't getting like full remission.
Will Sauvé, MD (10:07.214)
Yeah, of course. It is a lot of money though, which interesting for me over the years, because I was about a year behind you on the opposite coast. We didn't know each other. We were doing these things in parallel. But I remember back then thinking about that and having conversations with people in the TMS industry about trying to get adoption.
Martha Koo, MD (10:22.193)
Thank
Will Sauvé, MD (10:33.45)
with TMS in psychiatry and the whole joke, kind of a joke, but it's not really that funny. If you tell a radiologist that a piece of equipment costs about a hundred thou, then they're like, so we're buying 10. Many medical specialties, they understand the price of equipment and they're kind of used to million dollar price tags, MRI, CTs, things like that. But you think a
Martha Koo, MD (10:49.145)
That's
Will Sauvé, MD (11:02.902)
traditional psychiatrist up until about 30 seconds ago, know, private practice, your overhead is like a phone. You got right rent, you know, but if you're really snazzy, you'll get an awkward with two rooms, you know, people can have a waiting room. So that's like, yeah, I've found that still in my opinion, that's still kind of happening. You walk up to one of our colleagues and
Martha Koo, MD (11:12.934)
I'm gonna turn this
Will Sauvé, MD (11:27.918)
suggest that they would spend something close to a hundred thou and they just about throw up. There's a whole, whole different conversation at that point. So that
Martha Koo, MD (11:32.87)
Yeah. No, it's a whole. Yeah. You're bringing up so many, I mean, memories that I remember having now, cause it was, not only putting out that kind of money to buy a device, but you know, my office was set up very much like an analytic office. I did have a waiting room. had a, it was in the back of a home actually, like a lot of analysts do in my office. had separate entrances and exits. And so I, I had a whole different office. So then I'm paying rent.
Will Sauvé, MD (11:51.309)
Right?
Martha Koo, MD (12:02.673)
at a separate place because it had a different feel. And it was the first time that I hired any staff, right? Because I had a TMS back. So sort of learning to manage a staff, it was different. So even that, I used to run back. It was literally a block away and I would have like a 10 o'clock therapy patient, 11 o'clock TMS patient, like run across the street and then I'd run back. I was really skinny in those days because I was doing a lot of running back and forth.
Will Sauvé, MD (12:05.987)
Right.
Martha Koo, MD (12:32.733)
for you after a while, I didn't even have a tech, I just did them all, you know, until I saw that it was working. but yeah, it's bringing back a lot of funny memories of that having a tech and I would do the whole treatment. And that was really where I started. Even when I had my tech, I one out of five. Yeah. Because I would do therapy during. Yeah.
Will Sauvé, MD (12:33.432)
you were getting in your step.
Will Sauvé, MD (12:47.598)
Oh, like you're, you're kind of personally doing it all. Oh, and so you, talked over you for a second there. So you, you included therapy in that. So what, okay. So bottom machine, right? So you,
Martha Koo, MD (13:00.921)
my top therapy, but I'm not like CBT or...
Will Sauvé, MD (13:05.004)
You spent all that money to buy a machine that the majority of our colleagues thought was kind of crazy, shall we say. And let's see, you included therapy as part of the experience and did all that yourself. So in that first year, do you think you had any big surprises about the good that it was doing for patients?
Martha Koo, MD (13:10.577)
Thank
Martha Koo, MD (13:25.093)
Yeah. I mean, I think that I would say two huge surprises. One, I had no trouble. Once again, granted, I live in a place where people really value healthcare and they did everything because we remember at the time there was no insurance coverage. However, it was almost easier than not now because now there's great insurance coverage and the requirements are getting close to what the FDA
Will Sauvé, MD (13:37.336)
Mm-hmm.
Will Sauvé, MD (13:40.962)
Right.
Martha Koo, MD (13:52.115)
Initial indication was which was failing one medication, right? But at the time What would happen is people would pay out of pocket and then you would appeal it and when you when you showed that they had a response or Emission based on ratings Yeah, so in the beginning I I literally once again, I was so interested I was doing it I tell people listen, I'm pretty sure and whatever but you know, if you don't get your money back, don't worry I'll give you your money back
Will Sauvé, MD (14:06.446)
yeah, you could recoup some.
Martha Koo, MD (14:20.796)
Like that's how confident I was in the process. And I never had to do that by the way. So it was actually super cool. So it was a way, it took maybe three months after completion, because it would go through the appeal process, but we always got it back. Some, I'll tell you this, well, some just shows you insurance companies would submit and the patients were getting paid every day as an MRI. They were processing. Yeah.
Will Sauvé, MD (14:26.478)
Mm-hmm.
Will Sauvé, MD (14:45.771)
Wow.
Martha Koo, MD (14:47.538)
It was the T codes at the time, right? They weren't even the CET, right? They were the T codes and they were getting back, I it was charging $3.50 a session and they were getting it back every day. they were like, like somebody thought somebody was getting 36 MRIs in nine weeks, whatever, but they were paying for it. So was really an interesting time. Um, but I didn't have trouble. And then the other thing that I think I was really most surprised at is
Will Sauvé, MD (14:49.794)
Right?
Will Sauvé, MD (15:03.724)
Mm-hmm.
Martha Koo, MD (15:15.088)
I wasn't really telling any of my personal patients about it in the beginning. I was trying it on other females patients.
Will Sauvé, MD (15:20.344)
Mm-hmm.
Will Sauvé, MD (15:24.61)
Yeah, trying to kind of fire while that, right?
Martha Koo, MD (15:27.502)
Yeah. But so eventually I'm feeling confident and I put a little brochure in my waiting room there. And then I started to have all these patients and they're well, can I do TMS? And I say to them, well, you're better, right? You know, this shows you in psychiatry, we meet somebody and they're quite depressed or they're in a hard space and you can give them meds and therapy. And as we know, you you can get them 30%, maybe 50 % better, but you lose perspective. You know, I never met those people at their 100%.
Will Sauvé, MD (15:57.293)
Mm-hmm.
Martha Koo, MD (15:57.541)
And so, you know, I'm thinking, you're doing great, right? And they're like, well, yeah, I'm good, but I'm like, I'm not my true full self. Yeah. And so that was, so then I started obviously feeling more confident. I was treating a lot of my own patients and seeing the difference. And you've seen this, like, see how people pop with TMS. No, right. You can't put words on it. It's just very different from medication.
Will Sauvé, MD (16:05.632)
Right.
Will Sauvé, MD (16:18.175)
heck yes.
Martha Koo, MD (16:23.054)
And I mean, think the therapy is always necessary regardless of the biological intervention, but they just, yeah, they come to life with so much more color in it. It's amazing. So those two things I was, I was really quite blown away with.
Will Sauvé, MD (16:34.154)
It's amazing.
Will Sauvé, MD (16:39.31)
Well, I'm with you on that. I agree about the therapy. then now getting into TMS, I was in the inpatient unit. So that was in the Navy.
Martha Koo, MD (16:49.298)
that's really interesting. Before we had the accelerated protocols or anything. Yeah.
Will Sauvé, MD (16:55.464)
right. So, but in the Navy 2010 and I was coming and you know, they, I think I've told you this before, but the, you know, the Admiral signed up to buy a TMS machine because we're the Naval Medical Center, San Diego. mean, she didn't know, she was a hematologist. She didn't know what it was, but she bought that thing and no one knew what it was. And they said it was electrical. And I'm pretty sure they said, it to Will. Like that was my rep at the Naval Medical Center.
because I was ECT guy and inpatient, but I was therefore coming from the perspective of the most severely ill depressed patients and that, you know, a really, really severe MDD patient, I mean, they are typically going to be so cognitively impaired that I'm a huge fan of therapy, but I almost regarded as cruel in that, you know, in that exact case.
Martha Koo, MD (17:26.15)
Yeah.
Martha Koo, MD (17:53.198)
stay to mind do they have the capacity to process?
Will Sauvé, MD (17:56.474)
yeah, mean, what are we gonna eat tomorrow is too hard, let alone we're gonna try to do therapy. And I think that's where, so I was coming from almost a different angle than you were, but I saw that same thing that it's like TMS can get somebody well. I think my other favorite thing about it was that I had so many patients challenge me about whether or not they believed in it.
Martha Koo, MD (18:09.235)
Mm-hmm.
Will Sauvé, MD (18:22.93)
And that and my most my most surprising outcomes. I had a I had someone who submitted to TMS just to get his wife to stop like leave him alone. know, he tells me right to my face in the eval says, I don't believe in this. I think it's silly. You know, and he used some more less appropriate words about what he thought it was. But but he also told me he's like, that's the only way I'm going to get my wife to leave me alone about it.
So I'm going to sit in your chair and we're going to do our thing. And he was completely in remission by the end of treatment. And he, and of course he tells me, I've never been so happy to be wrong. And I'm like, I should have bet you, you know, and then, then you would have been happy to like pay up on the bet. But it led to a conversation. One of my major pet peeves.
is the need for people to believe in the treatments. Like what our entire careers, we've even been telling people you kind of have to have some faith in that pill if you think it's going to do you any good. You it's like you're somehow sabotaging your treatment. And I love being able to tell people that this TMS chair is not Santa's sleigh. It does not run on belief. It's going to stimulate your brain. All you got to do is let it.
Martha Koo, MD (19:38.151)
Yes. Yes.
Martha Koo, MD (19:43.453)
do its thing.
Will Sauvé, MD (19:44.522)
and it's gonna help you or it's not, but there will never be a time when I would be telling somebody that you didn't believe enough or you didn't try hard enough. It's like, which of course I love that because I don't wanna blame people for their illness. So it, very marital experience.
Martha Koo, MD (20:00.124)
is very, how you're absolutely right. You we talk about the placebo and the nocebo effects with medication. think are truly valid in that, right? We see that in it. I don't know if it's all that or it's, you know, it's painful to take medications, right? All the side effects comes first, potentially later. And so if people are ready, you know, their personal dynamics are, you know, a bit skeptical, a paranoid, they're sure they're going to get this or that, then I think it does make it very hard.
Will Sauvé, MD (20:05.932)
Mm-hmm.
Will Sauvé, MD (20:16.301)
Right?
Martha Koo, MD (20:28.189)
for them to accept the medication, stay compliant, take it as needed and have a positive response, right? Something in their body, I think has a lot of psychological meaning. Whereas when you're going with TMS, it truly, I agree with you, it doesn't work for everybody. But it's never a matter of people come in and say, I don't believe in that, that that interferes with the outcome. I haven't seen it.
Will Sauvé, MD (20:34.638)
Mm-hmm.
Will Sauvé, MD (20:49.93)
Absolutely. It also validates your point about the necessity of the therapy, right? The whole, and whether it's TMS or if it's medication, but if you can't appreciate that therapeutic relationship, if someone, like they don't like the pill or they're excited about one thing, not something else, and think recognizing that is critical. Again, I was really, really lucky. I was in the military environment so I could just order my patients to put up with it. Serious, like I can...
Martha Koo, MD (21:18.611)
So you were using TMS with inpatients then? Like when they were inpatient or no, it would be after they were, or did it overlap?
Will Sauvé, MD (21:28.17)
It was going to be mostly after they were discharged. Now that I got out of the Navy very, very soon after. So I didn't, I did not have the opportunity to build a real program at the Naval Medical Center, San Diego. It's like, got trained, we used it. I loved it. And then, and then next thing I knew I was wearing civilian clothes and moving to Virginia, but I went to a hospital. Yes.
Martha Koo, MD (21:54.458)
Yeah.
Will Sauvé, MD (21:55.086)
But I went to work at a hospital in Virginia where we were, they hired me because it was an inpatient PTSD program. So that's like, that's why I came to Virginia. They hired me because of the uniform. You know, it's like totally took advantage of something that didn't mean anything. And they hired me for that job. Like you can create PTSD because you were in the military. It's like, it's not really how it works, but okay. And we had this, you know, 28 bed.
Martha Koo, MD (22:09.331)
Okay.
Will Sauvé, MD (22:23.182)
inpatient setting that was about 98 % active duty where our patients coming in, it was all being covered by TriCare. It was just this like magical, wonderful thing. And I brought TMS into that program. So that's where I was doing TMS in the inpatient environment for about three years. And I think of that as the first and last time in my entire life that the CEO of a hospital listened to me. But that...
Martha Koo, MD (22:40.998)
Okay.
Martha Koo, MD (22:49.139)
Exactly.
Will Sauvé, MD (22:50.254)
But in that magical moment, and in 2011, the Department of Defense was completely freaked out by polypharmacy. There's like more than one journalist that completely made their careers by writing articles about that back then in 2011, that there were active duty and veterans who are on multiple medications, are bad outcomes, and combining benzodiazepines with pain meds, right? All that, you name it.
And it was all very upsetting. And I told the CEO of the hospital, if you bring TMS and I can treat our patients without adding more drugs, it will be gold. It was like, there won't, like there won't be a base that will want to send anyone anywhere else because it's like no additional drugs that like, that's all they need to hear.
And somehow he heard that and I got my machine and we did that for three years, very, very successful. Now inpatient environment, but I had them for 28 days. So what I would do then since as you so acutely reminded me, like we didn't have accelerated protocols. Nobody had ever brought that up. I think there was like one paper about doing like three, 3000 pulse treatments in one day.
Martha Koo, MD (23:47.878)
Okay.
Martha Koo, MD (24:03.368)
Okay.
Will Sauvé, MD (24:03.534)
very small number of people and it was very equivocal and kind of like didn't really know what to make of it. But we I had him for 28 days and I actually treated him seven days a week because it was an inpatient setting. So you know I shrugged my shoulders and so they only made it Monday through Friday because they assume people take the weekends off. So here we are in the inpatient setting. I have techs. I have the patients. I got everybody. So you know we just did we would do 28 treatments all in a row.
Martha Koo, MD (24:09.565)
Right.
Martha Koo, MD (24:15.796)
Okay.
Will Sauvé, MD (24:33.516)
while they were in house and I was only hoping to make the depression better. But I did find over that time and now there's kind of the data in retrospect to back it up, but all of my PTSD patients were pretty much getting better across the board. So depression was improving, the symptoms of depression were improving, but I mean, their PCL5s, their CAPs, they were getting better.
which we were doing, of course, kitchen sink therapy. So there's some of that too. But again, combining TMF with therapy, that was a huge winner.
Martha Koo, MD (25:05.022)
Yeah, well that five days a week the lore on that I mean you could ask Mark George, but I think you know this to do you the story on that when you Okay, well the story the way the story goes the Lord goes is you know He was working on all this stuff a lot like I think even in the garage I think of like Apple and how that came out but he was all excited about it and when they were setting up the protocols and determining
Will Sauvé, MD (25:12.095)
I know.
Will Sauvé, MD (25:22.957)
Yeah.
Martha Koo, MD (25:28.5)
protocols and what they wanted to use. The idea is wife told him that if he didn't come home on the weekends, she was out of there. So the only reason it was five days and not seven or six, which I think is he was shooting for is because his wife said, I need you at home sometime.
Will Sauvé, MD (25:47.34)
Right? Well, you know, I can sympathize. Like, that's the thing.
Martha Koo, MD (25:51.38)
Yeah, yeah, we used to we are we used to have our states open Mondays through Saturdays patients loved to have Saturdays mean as we expanded we that just got challenging in terms of having an admin always there and the proper doctor coverage and everything but I Love when we had Saturday is it I think it really helped patients Holidays and stuff right or vacations sort of overlap
Will Sauvé, MD (26:10.434)
Well, you know, that's it.
Will Sauvé, MD (26:16.91)
Heck yes. And I think people don't think about that. Like it's very pertinent to when, when you think about once you started scaling, you know, right up into like eventually what nine centers and Oh, wonderful. Congratulations. And you know, we all know how big, you know, Greenbrook got at its peak and it's there. I also think it's part of the therapeutic consideration to think about how a treatment fits into someone's life.
Martha Koo, MD (26:30.132)
We have 11 now.
Martha Koo, MD (26:37.044)
Yes.
Will Sauvé, MD (26:45.622)
So like, yeah, maybe the ability to come in and have a TMS treatment on a Saturday, that's gonna be pure gold to certain patients. These days, being able to maybe have a Spravato treatment at six o'clock in the evening. I think there are quite a few people out there that they would give anything to be able to pop in after work.
Martha Koo, MD (27:02.696)
Yes.
Will Sauvé, MD (27:11.298)
have a treatment, get a ride home, go to bed. That would be wonderful for them. And well, some people can do it, some people can't.
Martha Koo, MD (27:18.42)
Yeah. Well, and I think it's it's people really have to be mindful of this now with the adolescent FDA clearances for TMS, which I mean, I'd love we we've all been waiting, right? We've all known, I think felt very deeply that this is safe and efficacious and a really good option for teens. And so exciting to have have that. But we are, you know, we're pretty much open seven to seven. But I'm telling some people, you know, can't teens that go to high school, right? They have after school activities.
Will Sauvé, MD (27:34.488)
Mm-hmm.
Martha Koo, MD (27:47.829)
you're really going to need to be prepared to have longer hours. we don't, in any of our work, if it's bed management therapy, even our IOPs, they're set up to not disrupt school if feasible. they're feeling well enough that they're attending school, you don't want to interrupt their academics and their social life.
Will Sauvé, MD (28:00.173)
Right.
Will Sauvé, MD (28:05.592)
Well, no, I that's just the thing they tried to teach. At least people our age, they tried to teach us that in the first year of medical school, right? Like you can the best treatment in the world. if you wreck someone's life, you're doing it. It's like, congratulations, we've cured your depression. It's like, yeah, but I failed out of school. Well, OK. That's always going to be a problem. With that in mind.
Martha Koo, MD (28:17.84)
Doing it!
Martha Koo, MD (28:27.771)
I know.
Will Sauvé, MD (28:33.272)
Cause it, cause I kind of have something in mind, but what do you, what do you think is maybe the biggest breakthrough we have ahead of us in our field of interventional? Those doesn't even have to be TMS, but just thinking of interventional things in general, since we're both pioneers, apparently.
Martha Koo, MD (28:43.765)
goodness. That is such a great, yeah, no, that is a great question. Well, maybe I'll choose to cheat a little bit and not pick one biggest breakthrough, but a couple. 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 the input that I know there's more research to acquire in terms of...
Will Sauvé, MD (28:56.782)
Wonderful.
Martha Koo, MD (29:11.317)
not safety, but efficacy and durability. think that's a huge breakthrough because as we're talking about it, think people having to come every day for six weeks and then the taper, that's a burden on a lot of people schedule-wise, transportation-wise interrupting. Obviously, much less burdensome than ECT. When people had to be on disability, they couldn't work, but it's still a factor. So I think the same accelerated protocol coming out and having
Will Sauvé, MD (29:25.827)
Yeah.
Martha Koo, MD (29:40.694)
something to do as you're referencing for inpatients that actually work. Just like what happens, right? We send these patients that aren't doing well in outpatient with meds and therapy to the hospital and there's nothing else we give them that works any faster currently in containment. So I think the accelerated protocols are a huge breakthrough and looking forward to what science is gonna show in terms of how many pulses you really need and what kind of schedule, right? And the durability of that, I think that's huge. I also think
Will Sauvé, MD (29:44.248)
Mm-hmm.
Will Sauvé, MD (29:53.653)
Exactly.
Martha Koo, MD (30:09.087)
this concept of the more mobile devices and potentials of treating people at home or in different settings. It's been frustrating for me. I'm really interdisciplinary and I get so upset. Why don't oncologists have TMS centers there to support? So many people really struggle with depression around mortality and death. Why don't OB-GYNs have it for their
Will Sauvé, MD (30:25.816)
Right?
Martha Koo, MD (30:36.703)
postpartum or I would say even any perinatal, because I do feel it safe when monitored correctly in pregnancy. So I think the mobility of the device to be able to spread it to different treatment settings, I think is going to be massively huge. And then you were at the FACT-TMS, for people I don't know, Foundation for Advancement of Clinical TMS, the nonprofit arm of the Clinical TMS Society. Nolan Williams was talking about
Will Sauvé, MD (31:01.613)
Yes.
Martha Koo, MD (31:04.949)
So this brings mobility to a whole other level, implantable little TMS stimulators within the brain. so I think that's huge. Yeah, like almost sci-fi process. But I would list those three things probably as the biggest in terms of TMS. And I know you said it doesn't even have to just be TMS, but I think those are huge.
Will Sauvé, MD (31:14.198)
Yes. I remember him talking about that.
Martha Koo, MD (31:33.75)
I've been excited to hear about, know, VNS making the show, you know, come back again. Maybe that's not the fairest way to say it, but I'm really excited that they're getting so much more of the FDA approvals and they're getting out there and they're, you know, those recovered trial outcomes are incredible for difficult to treat depressions. And I think it's a pretty well tolerated, I mean, it's invasive, but I think we're gonna find more and more stuff with the...
The vagus system, maybe the gut, the brain, gut, and the microbiome, I think there's a lot of innovative work that can happen with that area of the body and the mind as well as probably inflammation. So I think if I were to list either things outside of just brain stimulation, right, it's gonna be the gut and the vagus nerve system.
Will Sauvé, MD (32:19.95)
Yeah.
Will Sauvé, MD (32:23.448)
Well, you listed the majority of my favorite things. So you got it. Well, boy, I don't even know where to start because that's all just so great. But vagus nerve, how many times in the years that you've been doing TMS have you had a patient get woozy, barfy, right? And the whole thing. And then we had to tell them what, which it surprises me how infrequently it happens.
Martha Koo, MD (32:31.965)
You
Will Sauvé, MD (32:53.442)
But when you stimulate the prefrontal cortex, that tracks back to the vagus nerve. So it's like, are stimulating the vagus nerves of our TMS patients. We have been the entire time. I think that's an amazing fun fact. And then to your point about recover, like that has led me to think that VNS,
Martha Koo, MD (32:57.289)
Yes.
Martha Koo, MD (33:03.637)
Mm-hmm.
Will Sauvé, MD (33:14.466)
which will say, it's invasive, but there's invasive and there's invasive, right? We're talking about a pacemaker-y kind of device that's going to go in the neck. It's wonderful. But the fact that the benefit is huge, but it comes on kind of late has made me think that TMS and VNS are sort of a match made in heaven.
Martha Koo, MD (33:37.799)
That's what I think. Top down and bottom up, type of approach, right? With the vagus nerve. Yeah.
Will Sauvé, MD (33:42.892)
Yeah. Well, and then it kind of speaks to like going back to going back to the old days when we were starting and you're just about afraid to have metal in the room when you're doing TMS. now like years and years of trial and error. You know, I did TMS on a guy with a cochlear implant once. That was. He was.
Martha Koo, MD (33:53.877)
I
Martha Koo, MD (34:05.928)
is fine, right? Before we said everything but cochlear implants.
Will Sauvé, MD (34:09.774)
It might have been one of my greatest cowboy moves, that, and the reason it kind of came about is that he felt that the cochlear implant never worked.
So he showed me the implant. had been enough years and I'd seen the paper clip against the coil trick. And I wasn't concerned that something was going to come flying out of the poor guy's head. But that's the way I put it to him. Like, well, the worst possible outcome is that it is a sensitive electronic. It's going to break your implant. And he shrugged his shoulders. He's like, it never did anything. I don't care. It's like, well, can I get you to sign something to that? You're not going to be mad at me.
Martha Koo, MD (34:19.495)
Jesus.
Martha Koo, MD (34:32.66)
Right, right.
Martha Koo, MD (34:41.846)
you
Martha Koo, MD (34:46.058)
Yeah, absolutely.
Will Sauvé, MD (34:49.188)
And I actually got some help from a physicist at the device manufacturer. So we even had some documentation about the decay of the field. And I was pretty confident. And so therefore, nothing happened. But then that's led me to the VNS point that I'm really not concerned about doing TMS on someone that's got an implant in their neck. So I would love, I don't know when I'm going to get a chance to do it, but I would love it if someone got their VNS implanted.
and then started a course of TMS. And then we could potentially get them like maybe even into remission sort of right on time for the vagal nerve implant to be really doing its thing.
Martha Koo, MD (35:21.494)
Yeah.
Martha Koo, MD (35:29.11)
Yeah, well, that's our plan. starting to, haven't quite rolled it out, but we're ready to roll out VNS pretty soon. And the idea is, give patients an opportunity to.
get the implantable device, but do TMS while they're waiting for those six months and then have it and have any little breakthroughs if you can't adjust it on the VNS device, then hopefully, you know, sort of augment with TMS. think it's a great, or allow them to reduce polypharmacy, right? Which is always helpful, right? It could work right as a placement. Yeah, the scariest.
Will Sauvé, MD (36:02.371)
Exactly.
Martha Koo, MD (36:07.51)
time that I had, which is heaven for it. didn't have my own heart attack. I think I got a lot of gray hairs is I treated somebody with a pacemaker who I had to turn, you know, put that big magnet on to turn off their pacemaker during TMS. Oh, well I like, did it once. was very, luckily he had a great response. Everything turned out fine, but literally every time, and that was still a 37 and a half minute protocol. So, I mean, now I might be smart and be like, Oh, let's just do the three minutes.
Will Sauvé, MD (36:16.183)
Yeah, yeah.
Will Sauvé, MD (36:20.515)
Mm-hmm.
Will Sauvé, MD (36:32.78)
man.
Martha Koo, MD (36:35.71)
intermittent theta-burst, right? But literally for almost like 40 minutes, I'm like, you don't dare have a cardiac event now. Because I have turned your pacemaker off. It was stressful, but all's good that ends well.
Will Sauvé, MD (36:42.954)
That's right, don't do this to me!
Will Sauvé, MD (36:51.67)
It was stressful, it really brings back the whole concept of interventional psychiatry, right? It's like that. You're really having to do the doctor thing in that moment. And of course now, like Spravato has brought us back into, know, pay attention to the hemodynamics and the blood pressure. And there's a greater than zero chance that, you know, there's someone getting Spravato that might require some kind of physician's intervention and you're the doctor.
Martha Koo, MD (37:02.57)
Right. Right.
Martha Koo, MD (37:21.312)
Yes.
Will Sauvé, MD (37:21.71)
Like you're gonna be a part of that and then our IV ketamine colleagues are potentially placing IVs. So it's a real, like real return, right, to the full world of medicine.
Martha Koo, MD (37:34.732)
Yeah, no, it's exciting. It's exciting time for psychiatry. What do you think? I'm curious about the whole idea of the name, I don't want to say name or nomenclature around interventional psychiatry and the concept of should that truly be a different field or require
My worry a little bit about it, I mean, I guess I'm leading you with my sort of bent is a little worried about, right? A requirement of more education, which is going to defer, you know, deter access and things in terms of training. But I'm curious, right? Because it's, it's, everybody's talking about, interventional psychiatry and some, and I know there's a lot of neuromodulation fellowships that are coming up, but I'm just curious about thought about that and the importance of that or.
Will Sauvé, MD (38:13.282)
Right.
Will Sauvé, MD (38:17.496)
Well, one of my answers is ask again later, because this is still trying to flesh it out, right? It's like, I'm thinking about that, you're thinking about that. Historically, I've always been more of a lumper than a splitter.
So I do, I appreciate the notion of fellowships. I appreciate the notion of training. I appreciate recognizing things as maybe being their own kind of special thing. But at the same time, I can't think of a single thing in interventional psychiatry that a doctor shouldn't be able to do.
And so it strikes me, ultimately at the end of the day, the qualification to do all these things is my medical license. And then I do worry about this kind artificial exclusivity. Once you start parsing things off and something's a subspecialty, what does that become other than an excuse for insurance not to pay? Nothing.
Martha Koo, MD (39:04.629)
Right, the specialty license, yeah.
Martha Koo, MD (39:21.793)
Good point.
Will Sauvé, MD (39:22.86)
Like nothing's really stopping a doctor from doing a lot of different procedures except that they don't have a particular fellowship, so insurance won't pay them to do it, which then effectively kills that pain.
Martha Koo, MD (39:32.722)
right? Malpractice coverage. was never a problem with me. And I don't know what you had, but I remember when TMS was coming out, my insurance malpractice, I told them like, now I'm doing TMS, right? Same thing now I'm doing IV ketamine when I was doing it. And it was no problem. Some people's malpractice carriers wouldn't or, and I don't know, then special certifications. I mean, to be devil's advocate though, because I'm also like sort of the slip side of my feeling of I don't really like this whole interventional thing.
It's been a problem in our field to monitor appropriate training of doctors and technicians. We don't really have any formalized system. And I think we would all say, now we have opportunities. We have PULTZ's courses. We have other courses for training. But the hands-on part is really, it's like, well, the device people are happy to drop off a device, and they'll give you their couple days, three days training, and then you're on your
there really hasn't been good regulation in terms of doctor or tech training. mean, it's sort of like, do your best. We trust each other to get our hours in before we're, you know, just lying.
Will Sauvé, MD (40:40.738)
Yeah, agree. the word regulation always makes me grit my teeth, but I hear you. Also, to support that point, I've met more than one colleague in the last 10 years that they know how to do TMS, but they don't know how to use a H-coil. And then that well, because they were trained by the manufacturer of the device they bought, and they know how to use that device.
Martha Koo, MD (40:46.005)
I guess.
Will Sauvé, MD (41:07.278)
And then by extension, they might know how to use devices that are similar, but then if there's a device out there that, as we know, that's kind of a completely different thing, it's like, well, no, they never learned to use it. They're kind of afraid of it. It looks funny to them, so they don't want to. So someone might go two decades without ever picking up a really critical tool in the toolbox.
Martha Koo, MD (41:07.319)
device.
Will Sauvé, MD (41:31.022)
if you think you're gonna be a neuromodulation person, and then how much of that is because there aren't any real formalized standards. That's completely fair. I suppose that just means someone should set the standard. And I think pulses is possibly a good candidate for that.
Martha Koo, MD (41:53.785)
So much of the education and they have a good hands on component for MP. And then there's just the hours and hours that, you know, I would argue anybody needs to start, which honestly I didn't have in the beginning, right? I mean, I had a full week and then I, the manufacturer was really good. was, you know, not a star at the time, but they were, I called them often and they came out.
You know, their trainees were really good. And if I had any questions or like make sure I'm in the right spot or what's his MT, they would be, they were coming out. Right. But that was the only resource you had. I didn't have other doctors to go hang out in their clinics. You know, like now we have our doctors good two months, 60 days, right. Doing lots with somebody who's trained. didn't, you we didn't have that. Right.
Will Sauvé, MD (42:34.958)
Yeah, exactly.
Will Sauvé, MD (42:40.152)
Well, and it goes back to the isolating thing, but it's, recently you brought up malpractice and recently, actually at the last meeting I heard in San Diego, I was hearing more than one of our colleagues talk about they're interested in maybe certain off-label ways of doing TMS, but then the first thing they brought up is they're afraid of their malpractice. And you know.
My experience was the opposite with malpractice. That's why that's particularly interesting to me, because my favorite case, it's like my cowboyest case might've been the cochlear implant, but my favorite, favorite case over the years was a little boy, nine years old, his dad brought him in wanting me to treat his Tourette's disorder.
Martha Koo, MD (43:27.096)
Okay.
Will Sauvé, MD (43:27.594)
And that this was one of those magical times when the this gentleman slides a piece of paper across the desk with a mysterious protocol written on it. If I would consider he had actually gotten that in an email from Dr. Mantovani, but who was studying Columbia at the time, because I'd read those papers and I'm looking at this protocol and like this is not what's in the published paper. You got it from him. Yeah, did. Wow. So he the hook up.
Martha Koo, MD (43:51.529)
Hahaha!
Yeah.
Will Sauvé, MD (43:56.014)
But first thing I did, it's like I got a nine year old boy and this is maybe 2014, know, 2015.
And we're thinking about doing TMS, not just off label because he's a kid, but off label because it's Tourette's disorder. I call it malpractice. Like, do you do to me if I do this? And they, interestingly, they came back at me and the gentleman said, are you a psychiatrist? Yes. was like, have you had the relevant education? Like you're not job medallist and trained, but you're, you've, you've still done your rotations. Yes, I did. Is TMS a procedure? Yes. He says, well, what's the problem?
Like, he's like, you're doing medicine on a kid. Like, we're really not that concerned about it. Like, Roger that. And it took, you know, we had to sit him on like three phone books. We were running around the office grabbing random things to put under the forked butt to like get his head up to the coil. But I'll be darned if we didn't make the ticks go away completely. We did maintenance on him for maybe two years.
Martha Koo, MD (44:35.256)
Great.
Martha Koo, MD (44:45.976)
I get the call.
Will Sauvé, MD (45:02.102)
and then he spontaneously resolved. was one of the lucky ones that one day the ticks kind of stopped coming back.
Martha Koo, MD (45:10.21)
do you know that wasn't due to the fact of the early intervention of the TMS? We'll never know. But that's, mean, these are all these fascinating things, you know, and questions I think about all the time. First of all, yeah, I think with the adolescent FDA clearance, we're going to get younger and younger ages. And I always wonder the earlier we treat...
Will Sauvé, MD (45:14.562)
You will never know.
Martha Koo, MD (45:30.572)
What, how is that going to change your understanding of the course of let's just stick with depression, right? Let alone when can we get FDA authorization for adolescents for OCD and Tourette's and all, or adults for Tourette's even. The idea that we start people on medications and we tell them, we think of this as a chronic illness, right? Sort of like cancer though, we want it in remission and then we do all these things to keep it there. You know, that whole concept could be blown out of the water if, if there's a treatment perhaps like TMS that
Will Sauvé, MD (45:48.718)
Mm-hmm.
Martha Koo, MD (46:00.185)
first episode we get in there or we treat and you sort of retrain their brain to fire a different way. It's curious, will they ever have another episode? Will they have it only under extreme stress? Will they anyway, but would there be fewer? I think those are things that would be great for somebody to be able to do a study on just first episode, young adult or teen depression and follow them over the next 20 years.
and see the outcomes, think that would be just amazing.
Will Sauvé, MD (46:33.196)
Music to my ears. mean, just the, well, the notion that if you could do that, right, in the converse of my typical TMS patient is usually about 30 years depressed and about eight drug trials in, been that way for a decade and a half. But imagine the years of life you can get for someone if you could get them well when they were 22. And then hypothetically, maybe they even don't get ill again.
Martha Koo, MD (47:01.718)
Yeah. And how, if they're truly in remission, how does that change certain things? We don't know. mean, it goes back to sort of the Nolan putting, you know, the Dr. Williams putting in simulators in their brain and us talking even at that gala dinner about, is that broaching on personality change or what is that? But I think of this, like how many 20, 30 year olds maybe would have picked, chosen a different career if they were field?
Maybe they would have chosen a different partner if they were feeling better. Like all these choices in life we make based on our mood and our energy and our, you know, what we, our self-esteem, it's, it's, it's really could be drastically different.
Will Sauvé, MD (47:44.098)
Concur. So with all of that wonderful future in mind, and let's say three minutes or less, I want to respect your time.
Martha Koo, MD (47:54.224)
Talk forever with you, particular.
Will Sauvé, MD (47:57.006)
Goodness, thank you. What would you tell a psychiatrist today who was hesitating to add interventional treatments into their practice? So we're 100 % what?
Martha Koo, MD (48:09.313)
Wait.
in a nice way? Just by what we're talking about, I probably don't want to say. You've got to be kidding. Yeah, I would say it's that you have to do it. I mean, I don't know what else to say. I don't know how you can perceive a future in the field of psychiatry without integrating. And if you can't do it yourself, making sure you're collaborating with a place that offers it.
Will Sauvé, MD (48:13.966)
It's me, you don't have to hold back, give me that.
Martha Koo, MD (48:39.225)
Because I don't see a world in future psychiatry that is going to just be medicine therapy. I really don't. I just don't see how it could be. When we know what we know about TMS, as well as all these other things we're talking about. I mean, even ECT and VNS and, you know, like CTS and all that. I mean, there's so many. just, I think that it's more like the can is open and we don't think that maybe the ideal way anymore to treat
psychiatric diagnoses or brain disorders, however you want to call it, is pharmacotherapy and therapy alone. I think the cat's out of the bag on that one.
Will Sauvé, MD (49:16.472)
Right?
Will Sauvé, MD (49:24.512)
It is. Well, I love the imperative, right? You got to be able to use all the tools. I'm with you on that. think going back to the concept of interventional psychiatry, what if we also started reminding ourselves that it's actually called psychiatric medicine, what we do, right? Like, I love interventional.
Martha Koo, MD (49:27.16)
Bye!
Martha Koo, MD (49:41.303)
There you go. like that. I like that. Like I just want psychiatrist. Like that's why I sort of hate the interventional psychiatry because I'm with you. I'm a lumper and I think it is psychiatry and stay up with the times. To me, it's no different than I could be deciding I'm putting every single one of my patients on Prozac. Right? And to side, I'm going to be in the eighties and that was the SOSRI and I'm going to have not even paid attention to, you know,
Will Sauvé, MD (50:01.623)
Right?
Martha Koo, MD (50:09.419)
Selexa and Lexapro and Paxil and all the ones that came after. To me, it's sort of the same idea. You you don't want to just be practicing medicine in the olden days. You need to stay up with the times and the times are different interventions besides just using medications and therapy.
Will Sauvé, MD (50:15.214)
Mm-hmm.
Will Sauvé, MD (50:28.632)
I love it. Wonderful. Thanks for all the time today.
Martha Koo, MD (50:34.413)
Very welcome. Thanks for the awesome discussion.
Will Sauvé, MD (50:42.574)
Okay.