A recent study has found that repetitive Transcranial Magnetic Stimulation (rTMS) is effective in treating depression. The results showed that the majority of patients experienced a significant reduction in symptoms, with some even achieving complete remission. Read More.

Interview with our Psych NP Mark Garretson

Mark and Nick talk about ketamine, TMS, and strategies to avoid needing either of them. Transcript below.

hello and welcome to the Ascend Health show
I’m Nick Angeles I’m one of the owners of

the Ascend Health Center and I’m here with
Mark Garretson my co-worker and friend he’s

a psychiatric nurse practitioner then and
we’ve now done this might be the 29th or 30th

show and never before have I invited anyone
who works with me because it’s a terrible

terrible idea but it’s also gonna be a lot
of fun so welcome to the show thank you glad

to be here Nick and I have we were a runner-up
for one of our shows so I will feature this

prominently and refer to it at least 20 or
30 times yes well congratulations Nick thank

you it was all the guests who brought a smoothie
I just drank the Smoothie during the show

it was great but today instead of smoothies
although that would be a wonderful topic of

conversation I assume we should talk about
Psychiatry since that’s what you do at Ascent

Health Center where psychiatric mental health
facility but we both used to work at Cleveland

Clinic as cardiothoracic ICU nurses so why
are we both here because we’re used to the

oh someone’s dying quick grab the crash cart
and now we’re more in the field of like well

someone’s depressed and let’s slowly get them
better yeah yeah well I ask myself that every

day but why am I here um well I ended up here
uh both of us have a critical care background

uh I did that for a number of years and then
I ended up in the emergency room and had the

opportunity to interact with people that were
having psychiatric mental health issues a

lot and uh got experience dealing with them
there and saw how things were kind of handled

and the emergency department and that there
was a real need for help and that’s kind of

what inspired me to no that makes sense because
I had the same experience where we’d put them

in a room and then every hour or two we’d
open up the door hey do you want to hurt yourself

you want to hurt anybody else okay thanks
and then that was like the care that we’d

provide in the ER for mental health yeah so
and even like especially before covet at our

Clinic I would tell patients oh well just
come and hang out in our lobby for a while

until you feel better if you’re not quite
serious enough to go to the hostel because

that was the experience where you go there
and they’d stare at you and maybe lock you

up for a little bit so it didn’t really make
you feel that much better about your mental

health yeah and that’s kind of the experience
that I had the emergency room is not designed

to address people that are having severe psychiatric
issues and crises and in the doctors you know

uh are not trained as psychiatrists they they
do the best they can but there’s a real need

and uh that’s that’s how I ended up here and
uh glad to be here well what about the opposite

approach so if we’re saying that the ER is
a miserable place to go if you have a mental

health issue and obviously you still have
to go there sometimes what about people who

think they can Google themselves to Wellness
and I should say as a disclaimer that uh Mark

and I very much care about patients but when
we do talk to each other we’re very plain

spoken so you may this is a little bit of
a inside look of how things actually work

so so if a patient says okay here’s exactly
what I need to get better why do I need to

see a nurse practitioner psychiatrist in the
first place like how do you usually respond

well you know online resources can can be
very helpful for many things um but the information

that’s available is often uh inaccurate uh
you don’t know what the training and background

of the people they’re providing the advice
oftentimes it’s other you know patience on

message boards those sorts of things they’re
talking about mental health issues that they

have and those folks don’t necessarily have
all the training and experience that the psychiatrist

or a psychiatric mental health nurse practitioner
has as far as understanding the appropriate

treatments the appropriate medications that
sort of thing so you’re also talking about

reviews of different treatments if you look
at to see what patients have said yeah absolutely

I mean it’s you know again um online resources
you know trying to to help yourself is great

um and it can be helpful sometimes it can
get somebody pointed in the right direction

but um you know it also it’s it’s it can be
um it can be confusing for patients it can

create problems again there’s lots of resources
available online sometimes they aren’t the

most reliable right and uh so it might not
be like the first line you’re saying like

maybe come to us see what kind of medication
might work or what the next step is and then

you can take it upon yourself to even go further
since we we do tell patients that often that

okay you can come see us a lot more often
or you can start exercising or eating right

or some of these other things that can at
least slow down the amount of time you have

to visit a professional yeah because a lot
of times for reviews I often tell patients

well think of your dishwasher like no one
reviews their dishwasher unless it destroys

their dishes or absolutely doesn’t do anything
right so obviously any sort of review you

see on a treatment or medication that’s for
like the Destroyer dishwasher type of approach

where it was a rare reaction that really affected
someone yeah and then they’re still really

fascinating to read but as far as gospel truth
it might be a and and I think we’ve seen that

especially with um with TMS or transcranial
magnetic stimulation yeah where it’s a fairly

innocent therapy meaning that the side effects
are almost nothing especially compared to

psychiatric drugs but then when you start
reading reports it could be challenging I

mean especially because the type of patients
who will qualify from an insurance standpoint

for that already have tried multiple drugs
and had some issues so we’re already talking

about a subset of patients who their bodies
already kind of react differently than most

people yeah and and and that’s one of the
things I mean that we have at Ascend that

kind of sets us apart we we have some treatment
modalities we’ve got TMS which is transcranial

magnetic stimulation we’ve got spervato and
and ketamine these are treatments that aren’t

available everywhere it’s a specialized you
know we really do try to specialize in in

helping folks that have been struggling with
depression usually for many you know for many

years and uh and they’re used to taking the
medications and again um you know online resources

are great the first thing that anybody does
when we prescribe a medication now you know

most these folks go and Google the medication
to see what you know potential side effects

there are um that sort of thing uh and and
that’s that’s okay we understand that’s part

of the process but um you know as I’ve told
you many times the mind you know I I tell

patients all the time your mind is more powerful
than any drug that I can give you and sometimes

you know they may go and look up medications
and see all these horrible uh you know potential

side effects I mean everybody’s seen the advertisements
on TV where you know every medication they’re

talking they’ve got somebody smiling and you
know playing with their dog and in the background

you hear you know that it may cause death
or blindness or absolutely the whole multitude

of issues so um you know it’s it’s just important
um to remember that if we prescribe something

whether it be Dr Molina or I uh that we know
the medications pretty well we’ve studied

them and if we’re concerned about side effects
we’re going to tell you about it unfortunately

a lot of people take the Medicaid you know
get the medications and then they have problems

yeah um but sometimes it’s the power of the
mind if you think you’re going to have problems

it’s certainly increases the uh potential
for that sounds like you’re saying too that

it’s an individualized approach where right
here’s the possible side effects but for each

patient who said they might have a side effect
you have to see okay what were your side effects

to the last medication you had right how many
medications have we tried before and what

were the effects so because I know both of
us have told patients before well you know

you’ve tried and failed seven other medications
this is a mild side effect you just need to

push through and in other cases like look
we’ve got five other really good ideas that’s

fine stop taking this one come in and we’ll
come up with something else yeah yeah you’re

right I mean it’s uh you know and and fortunately
medications patients can have side effects

from medications but oftentimes um you know
they’re they’re they’re limited uh right they

may just take some time to adjust and one
of the things that we really focus on is uh

being conservative in our approach and our
treatment and starting people out with with

low doses absolutely medications because we
know that in most cases side effects or dose

dependent or dose related and if you start
somebody out at a high dose you might have

you know you might have problems and the the
problem there is that the medication may be

a perfectly good medication and may actually
help the patient but if they’re started it

too high of a dose and their body doesn’t
have a chance to adjust and they have side

effects right or problems they’re not going
to take it and a lot of times when I’ve told

patients that their response humorous enough
is I’m sorry aren’t you the guys that prescribe

ketamine infusions where the patient says
oh I might feel like I’m in outer space what

do you mean you’re conservative but I think
that’s why we are conservative because we

have these tools that work rapidly and can
make great changes in the brain very quickly

so there’s not this urge to take the same
approach with medications or prescribe love

benzodiazepines or stimulants or some of these
medications that traditionally in Psychiatry

you know you only look at if all these other
classes have failed because as we mentioned

often there’s a lot of great short-term solutions
that will be terrible for people in the long

term right no you’re right not to get you
on our usual Soap Box about benzodiazepines

because obviously for some patients they are
appropriate absolutely but absolutely but

we you know again the the treatments having
kind of a more holistic approach um a conservative

approach is you know I I think is a way to
go because it uh it minimizes the chance the

patients are going to have problems with medications
and treatments and um that increases the chances

that they’ll actually be compliant and take
the medications and and get the benefits that

we’re hoping for right well I think it also
depends on the approach of uh where someone

decides to go for the mental health care because
there is the idea of like a more aggressive

let’s do this drug let’s not talk to you for
a few months let’s see how it does with us

sometimes it does have to be a bit more fine-tuned
where the patients are calling and Reporting

back how that worked do we need to increase
this decrease this um so sometimes it does

require more appointments and more fine-tuning
but uh usually that’s not a complaint of the

American Health Care system that people are
paying too much attention to me you know it’s

usually the opposite that everything’s falling
through the cracks and I can’t get an appointment

and that sort of thing right so so that makes
sense a more conservative approach allows

us to gradually uh fine-tune where we’re trying
to go whether it’s avoiding Mania while preventing

depression or depending on the situation yeah
definitely okay so I did have a question where

um how do you respond to criticism uh about
psychomedications in general or antidepressants

and honestly some of this criticism comes
from me as your co-worker because I’m a nurse

anesthetist so my whole mindset is like oh
let’s fix someone quickly like sometimes I’ve

even said like oh you know those psych meds
don’t work as well as they should and rather

than taking this antidepressant waiting for
a month why don’t you just do supervato or

a ketamine infusion or TMS where within days
we’ll get some sort of results but a lot of

times that’s not fair and it kind of minimizes
the work you do and everything that you know

you’ve learned in your years of study so what’s
like a better response to that rather than

when I you know try to encourage everyone
that all the answers are these quick fixes

so to speak yeah well I’m used to being minimized
but um this is actually a therapy session

for Mark that’s why we’ve gathered here today
but uh the trauma of working with me yeah

um well you know

um I’m not a big fan of a lot of psychiatric
medications either I mean we know that in

particular with depression the standard treatments
the ssris the snris Wellbutrin those medications

really um don’t benefit a lot of people that
have depression and they make you more depressed

if you’re like what’s wrong with me that this
standard treatment isn’t working and they

have side effects uh you know whether it be
weight gain other issues uh they can have

an impact on sleep

um you know there again there aren’t very
many medications that you can take that ultimately

don’t have some side effects um and and obviously
we’d prefer uh you know in a perfect world

not not to have to medicate folks that uh
that’s why we’re so uh keen on therapy and

getting counseling because we know that a
combination of therapy and medication if needed

we know that that’s what produces the best
results from right there’s very few side effects

from talking to someone that’s true that is
true absolutely so you know it’s one of those

things um you know or the medications uh that
that we use you know well for example um you

know sprovado it’s a powerful medication uh
and it helps people that haven’t benefited

from the traditional treatments for depression
like ssris and snris

but it you know it it doesn’t work for everybody
right um uh but it can be very helpful and

a lot of times it can help us get people off
of other traditional medications or at least

lower the doses so which is a good thing and
of course TMS is doesn’t involve medication

at all right which is another if there’s a
history of Eating Disorders or substance abuse

or fixations about pills in general something
that’s a cleaner way to just treat depression

it is it is a cleaner way to do it um you
know it’s uh uh it’s a good good alternative

particularly for people that don’t you know
don’t want to take medications there are some

you know have been some recent uh recent developments
medication wise that uh we’re excited about

um to help people with depression that work
faster and uh you know we’re currently evaluating

those but it is tough when somebody comes
in and they’re you know they’re profoundly

depressed and you tell them that you know
we’re going to start you on this medication

but you might not feel good for six to eight
weeks right um if at all I mean it because

again they don’t work for everybody well and
sometimes if meds work right away the it’s

short-lived where after a few more weeks somehow
the brain finds another way almost the ways

people will start on a diet and they’ll lose
some weight and then the brain’s like actually

my homeostasis is 10 pounds heavier than this
sorry about it buddy so it’s not always a

bad thing if it takes a little while because
many times it took several different traumatic

experiences in life to make someone depressed
you know there’s new data that maybe it’s

not this serotonin deficiency that you can
only treat with Prozac maybe sad things happen

to you and now you’re sad about it and it’s
that simple yeah so so that makes sense and

and I should say to be fair that I have the
same view of anesthesia that’s like you’re

saying where some of these psychiatric drugs
don’t help everyone you know I I really like

all of the anesthesia drugs but if someone
tells me oh I’m going to have anesthesia usually

my first approach my first is that’s a terrible
idea you should avoid these poisons whenever

possible yeah and honestly that’s um it’s
probably a healthy approach for both of us

rather than thinking like no these are wonderful
things that everybody should partake in yeah

I mean ideally if we don’t you know we can
get somebody in therapy and get them moving

in the right direction and help them with
coping skills that sort of thing and avoid

medications altogether that that’s the best
case right you know scenario I mean that’s

something that we really you know it makes
us happy we don’t want to prescribe medications

or do treatments just for the sake of right
prescribing or doing treatments because that

is the thing that often uh people don’t think
about this but you do get locked into the

system because once you prescribe a medicine
then that person needs to come back they need

to talk to you about it and then you adjust
it and they need to come back again right

whenever possible we do try to tell patients
okay is there a way that we can do this where

can come in for a checkup because you’re like
oh let’s see how I’m doing but not because

you’re locked in which again is our issue
with some of the drugs that can be more addictive

or that your body responds to in such a way
that it’s no longer making those chemicals

itself sure so and we’ve seen that a lot with
substance abuse too where the medication-assisted

therapy you can end up on Suboxone for the
rest of your life or methadone and yeah obviously

there’s a time and a place but it is a pretty
chilling business model at times as well well

yeah and sometimes it involves picking the
lesser of evils and uh you know again uh I

think that uh the approach that that we take
uh is uh very helpful for patients um and

it’s the way that I certainly you know and
you’re probably the same way if if you go

in um to a doctor’s office and somebody just
starts prescribing a whole bunch of different

medications for you and throwing a whole bunch
of things at you um you know sometimes we

kind of recoil a bit just because of our experience
in uh in medicine and in nursing so yeah you

end up like what kind of box of Lucky Charms
is this there’s a funny colored marshmallows

everywhere and I mean that’s a good point
too where um both of us feel that because

at Ascend we have different therapies not
available other places we don’t need to take

over everything for patients they can stay
with their psychiatrists we won’t touch any

of their medications and just simply do the
treatment because and this is a fault of Mind

once you start tinkering with multiple receptor
sites and multiple medications it’s hard to

tell what worked what was the secret formula
that made you feel better right and we can’t

tell if we’re altering too many things at
once yeah yeah it’s you know what variable

what what variable produced the the result
or was it a combination of all yeah that makes

it tough um but you know I think that you’re
you know it’s a good point that when we’re

treating people with uh treatment resistant
depression um you know most of those folks

have a psychiatrist that you know may well
have referred them to us because we’re again

kind of a have kind of a specialty Focus um

but we can collaborate with their psychiatrist
and and it’s important to try to maintain

a dialogue

but it uh it gives us you know kind of a sharpened
focus and lets us really you know uh kind

of drill down on whether it be ketamine infusions
or sprovata or TMS we can really focus specifically

on that and uh and hopefully adjust things
and right personalize it helps too because

in that way it’s a limited role and oftentimes
it’s limited in time too which you know no

one wants to be dragged into a lifetime of
psychiatric care if there’s other options

and I should mention too for anyone watching
or listening that uh the normal disclaimers

about unless we send you a bill this isn’t
medical advice you need to go to a doctor

as we said about there’s plenty of resources
online but they’re not personalized for your

specific case so you may hear some things
that sound exactly like what you need but

it helps to work with someone to hone in on
okay what therapy is going to work the best

because especially if there’s been failures
in the past it’s important not to go down

a road where it’s unlikely that it’s going
to be beneficial right and that’s something

that we are very passionate about like that’s
you know most of the patients that we see

they’ve taken some wrong turns in their journey
to getting better last thing we want is to

send them down another dead end well and you’re
right and and we’re not giving you know uh

medical advice here we’re just brilliant advice
but not medical advice great well true but

um you know the important thing is to have
you know have a good psychiatrist work with

them and follow their advice and be compliant

we do have some things at Ascend that can
help people that aren’t uh you know they’re

they’re a little different they’re outside
the box uh and uh we’re always happy to talk

with uh uh psychiatrists uh who may be interested
in uh trying to help patients that that haven’t

benefited from traditional treatments absolutely
and uh so if anyone has any questions you

can always go to ascend healthcenter.com because
we haven’t had enough time today to really

Define the difference between like bravado
and TMS and ketamine but that’s what our website’s

for because if we start explaining it then
the 22 seconds left in the show will go very

quickly but yes thanks for joining us and
I’m glad that we got to hang out today yeah

that was great it’s always good to talk with
one of uh one of my buddies from the trenches

that’s right at the clinic so uh really enjoyed
it and uh hoped to have a chance to make it

back here again and we can talk more specifically
about yes some of the treatments thanks for

joining us everyone thank you

Powered by Paranoid Hosting™. 'Cause you never know...