Podcast Transcript

Episode 22: Alternative Therapies and Eating Disorders

[Bouncy theme music plays.]

Sam: Hey, I’m Sam!

Ashley: Hi, I’m Ashley and you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level. 

Sam: We believe that all bodies and all foods are welcome, we would love for you to join us on this journey. Let’s learn together.

Ashley: Hello everybody, and welcome again to another episode of All Bodies. All Foods. Sam and Ashley are here today, and we are joined by a special guest, Dr. Martha Koo. We’re gonna talk about alternative treatments and therapies today when working with clients with mental health issues, disordered eating, and some eating disorders. So, we’re excited for this, we hope that you all are as well! So, Dr. Martha Koo is double board certified in Psychiatry and Addiction Medicine. She is also certified in Psychedelic Assisted Therapy, and an adherence rater for MAPS psychedelic research. For over 25 years, Dr. Koo has enjoyed her private practice providing outpatient psychotherapy, psychoanalysis, and pharmacological treatment for individuals, couples, and families. A pioneer in the development and application of Transcranial Magnetic Stimulation, Dr. Koo is the founder of Neuro Wellness Spa, where she offers TMS, Magnetic e-Resonance Therapy, IV Ketamine, Spravato, IV nutrition, and Photobiomodulation as novel interventions for treatment-resistant mental illness. Dr. Koo is also the Medical Director at Clear Recovery Center, a residential detox and intensive outpatient treatment centers for individuals struggling with mental health, addiction, and dual diagnosis. Dr. Koo, thank you so much for being with us today!

Dr. Koo: Thank you very much, Sam and Ashley. I’m excited to be here, I love your podcast and all the mental health awareness that you do to get out there.

Ashley: Thank you so much!

Sam: Oh, thank you! We love hearing that.

Ashley: Yeah! So, we would love to just start today, Dr. Koo, with maybe— could you share with us and our listeners just a little bit of what kind of got you on this path of working with alternative treatment and alternative therapies?

Dr. Koo: Yes, I’d love to! I think that it’s no surprise, right, the vast majority of people that struggle with mental health issues, and I think that medicine has done a wonderful job in trying to tackle the issue and come up with new interventions, but I think, like, there’s really two big areas that I noticed in my years of practice, just in my private practice individually providing both, you know, medications and intensive therapy, that we miss. And I think one is that, it’s well known but hard to address, that many, many, many individuals don’t respond to just medications and therapy alone. And when people are investing that much time and energy to feeling well, and I was in that process, obviously, it’s sad and frustrating, and I wanted to be able to do more for those patients. I also think the other area is, and I’ve always tried to emphasize this philosophically, that, you know, mental wellness is more than just the absence of illness, or the absence of disease. And I think having treatments, right, that can really improve quality of life is super important. And a lot of the medic— you know, in terms of medications that we use, they have their own list of side effects that really impinge on that quality of life. So even with people that are lucky, that do respond let’s say to an antidepressant, anti-anxiety agent, they think they’re often left, perhaps not with complete wellness due to side effects. And so, it was really, you know, just working with people over two decades and seeing these people really investing in therapy and medications and not achieving full wellness that had me really interested in alternative therapies.

Sam: Oh, that’s so interesting. You know, you hear a lot of, you know, when people start medications, they sort of say, “I know I have to give it time, I don’t know if this is working.” I’m just curious at, like, at what point do you feel like, can we say officially, like, “This is a resistant case?”

Dr. Koo: That’s a really great question. So typically, from the medical side, we look at an adequate drug trial, meaning that the person has reached a therapeutic dose, to be at least four weeks, sometimes six weeks. And so, it can take a couple of weeks to get up to what we consider a therapeutic dose, and then you want the individual to be on the medication, you know, four to six weeks after that. So it’s, you know, a fairly significant amount of time when someone’s not feeling well. And you’ll see some of these alternative treatments, some of the benefits are the rapidity of response and efficacy, as well as the tolerability. But I also think that we look at resistance as a tricky word. In medicine, we’re trying to, you know, change that up, which I think is great. I think sometimes patients feel badly when we say like, “a treatment resistant illness” or “treatment refractory.” Which also doesn’t instill a lot of hope.

Ashley: Yeah!

Dr. Koo: Now it’s like, “difficult to treat.” So, I prefer to say, right, like, you know, “We don’t do well with one medication or two, it’s difficult to treat.” But it’s the vast majority, I think people are surprised to hear that. You know, there’s a famous, you guys probably know about it, the famous STAR*D trial, which is old now, but it was the largest study by NIMH. And they show that, really with one antidepressant trial, we only capture about 30% of patients with depression that get into remission. After two trials, then maybe 50%. And that’s really, like, 10 people, you say five of them are still severely depressed, and this is after we’re looking at maybe 8 to 12 weeks, right, of treatment. And that’s— those aren’t great outcomes.

Sam: No. This is such an important episode because as we know, we talk a lot about eating disorders obviously on this podcast, but eating disorder so rarely travel alone. And it’s so common to see an eating disorder, and depression, and anxiety. So, I think it can give a lot of hope, for people out there who are struggling with those things, to know that there are other paths to recovery. And I’m curious if— so do you, would you suggest that people sort of try the medication and therapy first before? Or is this something someone can try right away? Or how, what are your recommendations around that?

Dr. Koo: I think there’s two ways to look at that. I think it’s reasonable, obviously, to try one medication, right, in terms of cost and maybe ease of treatment. I think if someone has depression— and yeah, we should really bring it back, obviously, to eating disorders. So, Sam, I’m so glad you said that. I mean, I think we know depression is highly comorbid with eating disorders as well as anxiety, OCD. So even though I’m maybe talking about some of these treatments specifically for depression, they’re very applicable in people struggling with disordered eating. And some actually— there was a real recent trial, we can talk about it later, of TMS specifically looking at Anorexia. So that was interesting, it just came out. But I think trying a medication is very reasonable, right? Some people, you know, you may be in that 30%, you may tolerate it really well, it may work. I mean, the odds aren’t great for that, but it does happen. And I look at sort of accessibility and cost as really important parts of treatment. However, there’s also the piece of if TMS, we’ll talk about Transcranial Magnetic Stimulation, that’s clearly— it’s currently indicated for someone who has tried and failed one medication. But when you look at the robust response and how people feel, if I had my choice, yeah, that would be first line treatment. Mainly just efficacy of outcomes, tolerability, it’s really hard to beat. And so, it would be nice if that could be first line. But currently, I think to answer your question fairly, on an academic and clinical level, that yeah, somebody— we would recommend clearly a trial, an antidepressant first.

Sam: Mhm, got it.

Ashley: Dr. Koo, I’m curious, can we kind of, like, go down a list of treatments and therapies that you provide at Neuro Wellness Spa and really simply educate us all on what these different forms of treatment are?

Dr. Koo: That would be great! I would love to.

Ashley: Okay. So, I’m curious, could you first talk a little bit about TMS or MeRT? And am I saying that correctly? MeRT?

Dr. Koo: You’re saying that absolutely correctly.

Ashley: Okay!

Dr. Koo: So, TMS stands for Transcranial Magnetic Stimulation. And it was FDA approved in 2008 for Major Depressive Episode reoccurring. It’s currently FDA approved also for OCD, actually cigarette cessation, and migraine with aura. So, it has a bunch of indications. It’s highly effective, though, across a lot of illnesses we know, really good for anxiety disorders, also could be used in bipolar disorder. There’s a lot of efficacy for addiction and, as I was just mentioning, eating disorders. And it’s covered by insurance, which a lot of people don’t know.

Ashley: Yes.

Dr. Koo: What the technology is, is it’s a neuromodulation technique. So, it uses a high intensity magnet, like an MRI strength magnet, and we focally stimulate specific neurons in the brain that we know aren’t functioning well in whatever illness we’re targeting. So, quick way I like to say it for people, is a little bit like physical therapy for the brain.

Ashley: Okay.

Dr. Koo: People don’t think of neurons that way, but they are! And so it just involves placing a coil, a magnetic coil, on an individual’s head. And we calibrate the device specifically to the individual, based on placement and intensity, and the process involves somebody coming to the office five days a week for about six weeks. And then there’s the next three weeks, there’s a bit of a taper. So, you know, about five sessions during that time. And it’s a really tolerable treatment. They’re in and out in about a half hour, drive themselves to and from, there’s absolutely no anesthesia, right, there’s no cognitive impairment, there’s no seizure. Sometimes people confuse TMS with ECT, which is Electroconvulsive therapy. Very different. And the beauty of TMS is not only is it covered by insurances, the vast majority of insurances, it’s— people start feeling better within two weeks. The vast majority of people—

Ashley: Oh, wow!

Dr. Koo: Yeah, by about session 10— are feeling not for remission, but they’re feeling better! You know, if we compare to a medication where usually by two weeks you’re barely getting up to what would be considered a first therapeutic dose. And so, then that’s sort of the start. And so that is so helpful, I think, for patients to have that response quickly, especially when they’ve struggled, often for quite a while. What else would I say about it? And there’s a whole other support system that comes around with that, right? As we were talking about wellness, at least at Neuro Wellness Spa, we have— usually match the TMS tech with the patient, and so there’s a rapport building and a relationship there over nine weeks, and we’re helping them with nutrition, and exercise, and social engagement. And there’s just a structure around that. And so, I think that also, right, is incredibly helpful and just offers a level of support that, for most just biological outpatient treatments, patients don’t get.

Ashley: Yeah!

Sam: That’s so true.

Ashley: Is this something that patients can do simultaneously with maybe therapy, you know, if they’re seeing a weekly therapist? Or if they’re even—so at Renfrew, we have an IOP/PHP/ residential— if they’re even in like an IOP or PHP, can they do these at the same time?

Dr. Koo: Oh, the most excellent!

Ashley: Okay!

Dr. Koo: We typically, I mean, I’m very blessed, the area I live in southern California, the vast majority of patients we work with do have therapists. People are very aware and there’s good accessibility. But anybody who comes who doesn’t have a therapist, believe me, they have one by the end of the treatment. We really think that that’s an incredibly important component of the whole process. And as you mentioned in the start, in my bio, I’m Medical Director at Clear Recovery and we see the best responses when we can treat patients that are in their PHP/IOP and then doing the TMS. You know, sometimes we wait those first two or three weeks of the PHP.

Ashley: Sure.

Dr. Koo: So much going on and a lot to adjust to, and to just add. But then we coordinate it to make it very easy for patients. So, we’ll schedule their appointment either right before or right after their IOP, which makes it really convenient for them. But, yeah, those— when you combine and collaborate in that manner, it’s really beneficial to the patients.

Ashley: Awesome.

Sam: Wow! I’m so glad you brought up ECT because I have to admit, when I first heard about TMS, that was my first thought! I would, you know, all those scary, like, movie clips of people, you know, getting the ECT treatment. And I’m so glad we’re doing this episode because I hope we’re breaking down some of the fear around these interventions that could be really helpful. But I have to ask, I’m so curious, do you know what it feels like physically? Like, what is— you have this thing hooked on your head, like, what does it feel like? You know, have you tried it?

Dr. Koo: Yeah, I pretty much try everything! I don’t feel— well, I guess I should take it back, I haven’t tried all the medications out there. But in terms of TMS or MeRT, and we’ll talk about the other ones, absolutely. I think it really helps, right, when you’re trying to describe a process to a patient, if you have some personal experience. But yeah, the TMS coil is, when we’re treating depression, let’s say, it’s sort of on your left frontal forehead there. OCD centrally. And you actually feel a tapping on your head during the active treatment. There’s nothing really tapping there, but there is, because of the magnetic force of the energy, it feels as if there’s something tapping. That’s not continuous, the whole treatment is about 20 minutes and the tapping is intermittent. So, on for 10 seconds off about 40 seconds, right? So, there’s these little breaks. And it’s really tolerable. Some people actually like the feeling, I’d say it just feels like a tap. In the very beginning, I could say it’s a little uncomfortable. Some people get a headache day one, easily treatable with Tylenol or Motrin before you start, and then that’s usually the end of it. But you feel this tapping sensation, but other than that, you’re alert and you’re awake, you can talk to the tech, you can meditate, you can, you know, read a book, you can do homework if you’re a student, watch television. It’s really a very tolerable all over treatment, and you’re sitting in a chair that, for lack of a better description, a little bit like a lounge chair, or dental chair even, with a nice head support system. Sort of a pillow around that. There’s a little noise to the process, right, you think of an MRI. But when you have, you have this pillow around your head and the head support system, that blocks that out. So, it’s really a comfortable— I’ve had a lot of, well, to be gender biased, a lot of female-identified patients being like, “Oh, I should get a mani pedi,” you know, during the process! They start feeling really good by the end, you know, that’s fun. They come in and like, yeah, not a lot going on there, enjoying by the end they’re like, “Hey, you should offer mani pedis at the end.”

Sam: A full spa experience.

Ashley: Right.

Dr. Koo: A spa, yeah!

Ashley: Yeah. Is that something, Dr. Koo, so, like, at the end of it, can a client kind of just get up and walk out? Do they have to take a minute to recalibrate, or resettle, or—?

Dr. Koo: Oh, absolutely. It’s just up and out.

Ashley: Oh, wow!

Dr. Koo: Up and out right then. Yeah, in the car driving wherever, and that’s the biggest— and I’m glad Sam, you asked, I mean, people really with ECT, you know, there’s a seizure, and there’s cognitive impairment, and there’s anesthesia, and you certainly can’t drive, and you really have to be on disability because you really can’t work, right, and do ECT simultaneously. Whereas with TMS, no, it’s— people come on their lunch breaks from work, you know, before school, after school, and it really does not interrupt any activities of daily living that people are committed to or need to need to do.

Sam: Wow, this is fascinating! The brain is so complex, I’m just curious, I mean, we don’t really know how medication works exactly… do you know how this works? Or is there just sort of theories around it? Or how much do we know about what it’s actually doing to the brain?

Dr. Koo: Well, we know a lot about what it’s doing, and I think your question raises really the truth for all psychiatric interventions, right? We sort of know what they do in a petri dish, or what they do to the neuron, or we’ll talk about TMS, what they do to maybe a neurocircuit or a connectome. But how that translates to, right, what really happens, I think that’s anybody’s guess still. But we’ve really moved from that model of, right, neurotransmission, which is the, which is really how we thought of depression, all the way to neurocircuits, which is what TMS focuses on, to now what we call, like, really the connectome, right? And we think it’s the interplay of different neurocircuits in the brain that really is modulating these changes that we see, whether it’s medication, you know, psychedelics, ketamine, and, you know, all the way down. So, a combination of like neuroplasticity and neuromodulation. What the TMS is doing, if we look at depression, that’s maybe the, you know, the one FDA indication, it’s targeting the dorsolateral prefrontal cortex. So, like I said, sort of your left frontal part of your head, and it stimulates that circuit down to the anterior cingulate gyrus, the amygdala— most people know the emotional seat of the brain, and then back up to the prefrontal cortex. And we know that circuit is really not functioning well in depression. So, if somebody has depression and they went and had a SPECT scan or, you know, a functional MRI, we would see that that circuit isn’t bright yellows and oranges and reds, right, as it should be. By the end of TMS, we also have evidence that that has changed in people that aren’t depressed, that that left sided performance of that circuit sort of equals the right side. But that would be true, right, whether they got better with medication, or therapy alone, or another strategy. So, we do know what it’s doing, I think that the magic or the mysticism is how that really translates to, obviously, to the well-being.

Ashley: Dr. Koo, how long has TMS been around? And when did it become kind of, you know, our topic is “alternative therapies” as I’m air quoting, but like, it feels— you know, I’ve heard of T MS before and I’ve actually had a client that’s engaged in it while we were working together, and so, I’m just curious, like, when did it finally become something that insurance even took over and said, “We will cover this,” you know?

Dr. Koo: Yeah, it’s a long time. And so, it’s sort of sad that it’s still— so many people are unaware of it as a service. So, mid 1980s is really when it came around, and Tony Barker is credited for it. It was really developed as a brain mapping, right, to figure out sort of which parts of the brain were responsible for which activities. And then we had in the 1990s more really focused research on the utilization of TMS for depression. Mark George credited with that, Johnny O’Reardon, a lot of those people, but the first sort of— the FDA approval was 2008. So, as you see, like, it’s been 15 years.

Ashley: Yeah.

Dr. Koo: It was on insurances pretty broadly around 2016/17.

Ashley: Okay, okay.

Dr. Koo: So, it did take a while. That was actually very quick, I think it was one of the fastest sort of device manufacturers to get on insurances, it usually takes quite a while. So, that just changed everything, it had been pretty much cash pay before. And it’s, and the coverage is getting better and better. So, I can clarify that the FDA indication is just trying one medication and either not tolerating it or it not working. So, it could be even two weeks, “I didn’t tolerate it.” Most insurances require two, and some four, trials. So, they’re a little bit different but they’ve, it’s gotten better and better as time has gone on. And even though there’s a lot of data in adolescence and really good efficacy, it’s— the insurance usually is 18 and above still.

Ashley: Gotcha. Okay. Thank you so much! I would love to kind of move on just because there are so many more that we want to ask you about. But could you quickly touch on MeRT and explain that to us?

Dr. Koo: Sure! And MeRT will be fast because it’s really like a more personalized or individualized TMS.

Ashley: Okay.

Dr. Koo: So, same exact device, same exact technology, right? In terms of neuromodulation, targeting certain neurocircuits in the brain. And the difference with the MeRT is that we took, we do an EEG of the individual’s brain first, and then we send that off to a lab, and then we get a protocol that’s really individualized by the hertz, which is the frequency at which we’re treating, and then also the placement. So, with basic TMS, everybody gets a 10 hertz treatment. With the MeRT we, you know, we all run a little different in terms of what our baseline hertz should be, and so we can individualize that specifically. And then the placement depends on also their EEG, and we’re looking at really synchronicity across the brain. MeRT is really indicated for traumatic brain injury, PTSD, really, really good; cognitive impairment, dementia, peak performance, right, and ADHD. So, I think illnesses that we think of… a little bit more globally, right, involve the brain, versus things that have maybe more specific circuits, OCD, anxiety, and depression, are really applicable for MeRT. And so, when you say which have I done, TMS I’ve sat in the chair and tried. The MeRT, I do, I’ve done several times. I do, like, really for peak performance and, yeah, it’s amazing. You sleep better, I feel my mind just works faster. It’s a really good anti-aging, right? We all know that as we get older, right, we do, you know, every part of our body tends to slowly, slowly decline. And so, I’ve used it for that. And same thing, my staff, somebody jokes, they cut me off because I start doing it and I come in with all these ideas I want to do! They’re like, “Okay, Martha, we’re cutting you off the MERT machine!”

Ashley: So how—

Sam: Better slow her down!

Ashley: How long do people— is that like a once, a daily thing as well for six weeks?

Dr. Koo: Perfect. We do that really in two weeks stints, right? Most people end up doing 20 to 30 sessions, that’s pretty typical. But we go, we do an EEG every two weeks, we look at the changes in the brain that are occurring, we obviously coordinate that with how the patients feeling subjectively, whether then we go ahead and do two more weeks. The huge indication I left off, I don’t treat tons of children, but it’s amazing for Autism. So, we’ve treated some children, they actually regained language, they’ll sleep through the night.

Sam/Ashley: Wow!

Dr. Koo: It’s incredible for Autism, people on the spectrum. And with that, we tend to do a series of about 30, and then maybe every year the individual will come back for, you know, the kids come back in the summer or winter break and do it again.

Ashley: Wow, that’s incredible!

Sam: Wow, that’s amazing!

Dr. Koo: Yeah, it’s awesome.

Sam: We have… next on the list, IV Ketamine, which is… I have so many questions. Could you tell us a little bit about that, Dr. Koo? And what Ketamine used to be used for, or just how it sort of evolved through the years?

Dr. Koo: Absolutely! So, Ketamine is actually an FDA approved anesthetic and it’s a really, really safe medication. Sometimes people know of it as a really— an anesthetic used a lot in veterinary medicine. And the reason is because it’s so safe, right? Most times when we’re worried about anesthesia, it’s worried about, like, respiratory depression, right? Somebody’s breathing. And so, the lovely thing about Ketamine is it actually doesn’t cause any respiratory depression. It’s an NMDA receptor antagonist, that’s sort of the molecular use of it. I don’t know if that has a lot of meaning to people, but what’s important about that is, as an antidepressant, it works on a whole different system than what we’re talking about when we talk about antidepressants, with the serotonin and norepinephrine and dopamine, it really works on the glutamate system. And that was what was so novel about it, it was really… came on the scene around 2000 in terms of its antidepressant efficacy, and it’s taken off since then. It can be used in many ways, Ketamine, in terms of how it’s administered, right? At our site, I do IV, which is intravenous. And so, obviously, that’s putting a needle in somebody’s arm and giving them the IV Ketamine that way. But people, you know, there’s an FDA approved now medication, right, called Spravato or Esketamine. So that’s a nasal application, and then certain sites do oral or intramuscular, which is a shot in a muscle, in terms of the availability. So, the process can really change, if someone’s interested in ketamine, they really need to understand where they’re going, how it’s administered, really what we call the set and setting of the process, because it’s a really important part of the treatment.

Sam: What’s the difference between glutamate compared to… I mean, when we typically talk about depression, we talk about, “Oh, I need a boost of serotonin. Oh, I need a boost of dopamine.” But what’s the difference for our listeners? How would you sort of describe the two?

Dr. Koo: Right, glutamate is the most prominent excitatory neurotransmitter in the brain. So, that’s one way to think about it. And it’s usually contrasted with gaba, which is the most prominent inhibitory one. And this raises just questions of how much we don’t understand what, you know, depression is. If we want to really stick— we could be talking about eating disorders, or depression, or bipolar disorder, but the concept of, you know… we think now in medicine of depression as a quite heterogeneous illness. And, you know, we know there’s factors of neurotransmitters, we know there’s factors of how neurons communicate, we think there’s important things about inflammation, right? There’s important things about the hypothalamic pituitary axis. And so— and there’s important things about glutamate and gaba inbalance. And so, I think as researchers, we’re trying to really figure out, and it’s probably more than one thing, I think, you know, it’s a conclusion. But it’s sort of, they’re just really different systems. So, I think I can’t compare necessarily, like, a serotonin with a glutamate, but just say it is another neurotransmitter in the brain that’s really important and really prominent. And when we modulate it, we see changes in mood.

Sam: Wow, so interesting. Yeah. Okay, and Spravato is really Ketamine just administered differently?

Dr. Koo: Yes, correct.

Sam: Got it. OK. OK.

Dr. Koo: So, the thing about Ketamine, I can talk about maybe those two processes, it’s important to know, again, when we talk about accessibility and cost, you know, IV Ketamine therapies are pretty much cash pay procedures at this point. Spravato is on insurance and can be billed, and so I think that that’s a beauty of that. I am a little bit more bent towards the IV process, and that’s because the bioavailability we know is 100%, right? When we give someone the IV. And I come from a very psychoanalytic background, and so we do know modulating glutamate is important for mood in general, but I think that there’s also this process of using it as a dissociative anesthetic which happens at the, you know, sort of the IV, and it’s about going in with a intention and in a certain set and setting, and having this 40 minute infusion, and being left alone, usually with curated music, and an eye mask on, and having this experience. And then, really importantly, like, journaling and then going to therapy and processing that, and I feel like that’s a really, really important and efficacious part of the procedure. The Spravato is also coming into an office, there’s a set routine twice a week for four weeks and weekly for four weeks. And it does have to be administered on site, observed, you know, patients, we can’t call the medication in for patients to do this in the privacy of their own home. And so, people will have a bit of a dissociative experience, too. So, but it’s just a different framing. There was a recent paper that came out that showed actually fairly good efficacy comparing the Spravato the IV. The differences were people responded much quicker with the IV intervention than with the Spravato. But at the end of the eight weeks was pretty equivalent to maybe at the end of the two weeks for the IV. So, I think there are some advantages in terms of the rapidity of response. They’re both, you know, Spravato is FDA indicated for treatment resistant depression, failing two medications. And then it’s also approved for depression with suicidality. And with IV, we see really good effects with depression, PTSD, anxiety, eating disorders. I mean, we haven’t really focused— they say that the beauty of TMS, for me, with patients struggling with disordered eating is, you know, there’s often a lot of anxieties about taking a medication. I think dependency fears, we see sometimes in that population. And I love the message, because we’re really showing them that the healing is coming from within and they’re not broken, there’s nothing defective about them. They just need a little boost. And so, I think a lot of people when they take an antidepressant, they have that concern or that framing that, “There’s really something wrong with me and I need this,” or “I’m dependent on this.” And I think that’s very helpful for that population. But the IV Ketamine, you know, we look at eating disorders sometimes a little bit in terms of like addictions, where there’s a lot of emotional avoidance— or there can be, I don’t wanna grossly generalize. With some people, there can be emotional avoidance and sort of more rigidity, and the tolerability of feeling and letting go. And I think that’s the beauty of the IV Ketamine process, when we can treat these patients, or what I’ve seen is, is they’re just able to, like, feel their feelings and process them on a much deeper level. Their sense of self, right, really gets to be worked with, they think there’s a lot of identity wrapped up sometimes with disordered eating and, “Who am I if I’m not struggling with, you know, my food, or my weight, or my body image.” And the Ketamine is really uniquely poised to look at those issues, which I think is really just a nice process. And like we’re saying, like the importance of the therapeutic component of any biological treatment

Sam: To have that relationship with someone to really process your experience. This isn’t a, you know, I imagine this isn’t a situation where you kind of go into the office and it’s like, “Fix me,” and you leave. It’s sort of like you’re having an emotional experience and it’s helpful to talk about that with someone.

Dr. Koo: Yeah, absolutely.

Ashley: I was just curious if you could maybe break down just a little bit for our listeners that maybe haven’t experienced something like this before. But— so, when you say, like, a “dissociative episode” with the Ketamine, like, what exactly does that mean? Can you break that down? Thank you.

Dr. Koo: Yeah. And that’s, and I really appreciate you asking because sometimes we look at disassociation as a symptom, and this is a dissociative anesthetic, but it’s really a little bit more like a psychedelic. And so, the process is we really wanna frame the set and setting— set is, like, how the patient comes in with what’s on their mind, and what their beliefs are, as well as maybe their past and their personality, that’s all part of set. And setting, obviously, is where the process is taking place. And then we help them with an intention of something important that they maybe want to focus on. And then we put in the IV in their arm and there’s, we also premedicate with medication so there’s not nausea. That would be the main common side effect of Ketamine. And then they’re just laid down, they usually have a nice blanket if they want, if they’re comfortable then they can put an eye mask on, and they have earphones, and then we just let them start the process. What it feels like is really a little bit psychedelic, right? Everyone’s a little different in terms of what happens, and every session is different, but you could see colors, you could even have something that’s a little bit more linear. It’s sort of like a dream that would come through. Sometimes there’s really more of a sense of a feeling. And the infusion is about 40 minutes, and the other beauty of Ketamine is it’s pretty quick in, quick out, right, when we do it IV. And so, recovery is very fast. People aren’t left, you’re not left groggy all day. You know, we usually take about 20 minutes to recover.

Ashley: Okay.

Dr. Koo: As I said before, they do need a ride home. So, it’s a real, like, a bit of a psychedelic experience and it’s, as anybody knows when they talk about that, it’s a little hard to put in words, right?

Ashley: Right.

Dr. Koo: We [inaudible], right? But there’s a sense of, like, there’s just a noetic quality, or a little bit of a mystical sometimes experience or a feeling of, that there’s hope, and there’s more, there’s a world, you know, you’re part of something and the world has meaning and purpose. And I think that’s part of the healing process. There also can be, like you say, really visual and maybe somatic even experiences, like a dream where people work through trauma, they work through really challenging things. But there’s enough space with the Ketamine on board for them to be able to process those. So, I would remind patients it’s, you know, with Ketamine, you often get what you need, it’s not necessarily what you want. But— because there can be challenging infusions, but, you know, your brain and body is really smart and it’s not gonna show you anything you’re not ready to handle. But, right, there’s beautiful, beautiful experiences people have. And then there’s challenging ones that are equally therapeutic, and really important. And I think the main thing is then taking the time to process them, and put the right meaning on them, and understand how they impact you in your life.

Sam: Incorporating these experiences into your work. Ashley, what were you gonna say?

Ashley: Oh, I was just gonna say, so definitely you would recommend, like, having a therapist and doing this work in addition— you know, kind of processing through the experience?

Dr. Koo: Absolutely. Yeah, we have, we let, you know, we have extra rooms if therapists wanna come, and some patients want to have a therapy session right after. Most don’t, but we certainly do that because we really, like I say, emphasize that a lot in terms of the necessity of being in therapy. The research shows that, you know, the there’s a lot of sort of opening and neuroplasticity in the brain within the next 48 hours. And so, we do try to have someone see their therapist the next day or two days after. It’s really ideal to process as well as journal that night, as much as they can remember of their experience.

Sam: Hmm, to really, like, take advantage of that window of opportunity. Yeah. I’m curious, is there anyone you would say that this would be contraindicated? Where you would say, “You know what, this probably isn’t a good idea.” I’m just curious, or is this really for anyone?

Dr. Koo: No, it’s a really good question. There, I mean, there is some literature of using ketamine, you know, in people struggling with addiction. My view is, is if somebody is in active addiction, that would certainly be not where we would go, you know?

Sam: Right.

Dr. Koo: Certainly fine if they have a history of, and now they have a period of sobriety, and they’re in a good recovery support system, then I think IV Ketamine is very safe. But I think that would be somebody that we would say, “It’s really probably not the time.” And it doesn’t really matter the intervention, it’s also if that’s going on, then I think it’s hard to know what’s what, right? And so, sort of important to have a baseline, you know, of recovery from that before adding any biological, you know, even we’re talking about medication. But that’s really it. I mean, everybody else is fine. TMS, I didn’t cover that but it’s, you know, it’s like an MRI, you have to think of it. So, if you have any ferromagnetic material, cardiac pacemaker, you know, an aneurysm clip, then unfortunately you can’t do TMS.

Ashley: Gotcha.

Sam: Good to know, yeah.

Ashley: Could I ask, I’ve got kind of a quick tangent question. Just about, thinking about support systems for our clients that are experiencing these. Is there anybody that, like, the support— or anything that the supporter needs to know, or the family members need to know, when their loved one is engaging in one of these forms of therapy?

Dr. Koo: I think, I mean— wow, it’s a whole other—

Ashley: I know!

Dr. Koo: Yes. Yes, yes, and yes. I mean, I’m a very family systems person, right?

Ashley: Yes.

Dr. Koo: And I feel like we all know the idea of the identified patient. I really feel, right, it’s hard pressed for any of us if we have a loved one with a mental struggle that, you know, it doesn’t impact the entire family or the entire family dynamics isn’t involved. And so, I think that to really get somebody into wellness, you know, if we have our ideal situation, yes, the whole family is involved. For the Ketamine, we rely on family and/or supports a little bit more because, like you said, the person really needs a ride home every time. And so, that’s a bit of a demand on the family. We definitely educate them so that they’re comfortable, you know, they’re picking up their loved one. With TMS, we see less family action involved. People are welcome to come any time. They’re welcome, you know, I’ve had a lot of parents, and siblings, and even children, adult children that have come, or even a bunch of little children. We treat women, like, you know, postpartum a lot. And so, our staff love it, “Oh, bring your baby, we hold ‘em!” But regardless, that wasn’t really for support. So, they’re always welcome. Like, we’re very open and welcome now because I think the more education there can be, it’s helpful. But other than that, there’s no specific demands on family. I think them being educated on the process and then, you know, people are different when they come out of depression.

Ashley: Yes.

Dr. Koo: Sometimes they’re less passive, right? Or they want to go do more, their energy is better, they’re more interested, and I think that’s an adjustment for any couple or family system, to really realize that there’s going to be those positive changes. But those can be challenging in of themselves.

Sam: Sure. Mhm.

Ashley: So, what do you think about moving us on to psychedelics, Dr. Koo?

Dr. Koo: Let’s move on!

Ashley: Share with us all about that. I’m so interested to hear what you have to say.

Dr. Koo: Well, this is a really, really, as you guys know, very hot topic now, and I think excitingly so. You know, the psychedelics really started having some really good research in the 1970s, particularly LSD and psylocibin, and really showing great, you know, some great efficacy for two things that actually we’re not focused on so much now, but end of life distress in cancer and alcoholism. And then they were pretty much shut down. I think nothing really to do with the LSD or psylocibin, but really more political movements and sort of the times. And in the background for all these years, certain researchers, and I would credit MAPS, which is a big organization working really hard to get psychedelics back on the scene. And so, we’re in a really exciting time, I think, for mental health with the psychedelics. We’re looking at hopefully having MDMA FDA approved, probably for just PTSD, perhaps this year, but by 2024. And psylocibin hopefully shortly after. And once again, just the data looks really amazing in terms of these processes, and just adds another, you know, way, which is, I think back to what we’re saying, you know, the sad thing about depression is how many people don’t respond, even to any of these. You know, TMS doesn’t work for everybody, IV Ketamine doesn’t work for everybody either. And having just a, you know, a lot of choices for people. So, yeah, I think the psychedelics are gonna be huge and I think we’re gonna see a lot of great efficacy for them. And people are really doing great due diligence to assure safety and sort of set protocols.

Ashley: Can you explain to us kind of what the process looks like? If some, you know, when someone comes in and they let you know that they’re interested?

Dr. Koo: Sure!

Ashley: What is that like for them?

Dr. Koo: Yeah. So obviously, right, legally now we can’t, I can’t do, you know, offer psylocibin or offer MDMA. There are research sites, a lot of facilities, so people listening are interested, I mean, MAPS has tons, Johns Hopkins, NYU, UCL A. So, but currently, really the only legal accessibility in California is with the research protocols. But what it looks like really, looking at either MDMA or psylocibin, is a little bit like we talked about the IV Ketamine. I mean, you want to be connected with a really good therapist who understands what your issues are and can help you with intentions and framings and make sure you’re in a really safe space. And then typically the administration of the medicine would happen orally, obviously. And then there’s either like a four or eight hour process, right, that somebody has a journey on their psychedelic. And they are never left alone, right, they’re there. And the way that most FDA trials are set up, there’s two clinicians in there, so maybe a psychiatrist and a therapist, maybe two therapists, usually different gender identities, and the patient. And so, there’s a lot of really care that goes along with the process. And in that, there’s times where there’s really patients going very inside, you know, eye mask on, listening to music, a very internal process, alternating with times when they’re coming out, and they’re engaging in conversations with the therapist and processing. Most of the studies, like with MDMA, have been with trauma, processing that. And the outcomes are amazing. You know, they’ve already published a lot of those in terms of the FDA trials, and really the PTSD for MDMA outcomes are pretty spectacular. So really, it involves, I think this gets to how it’s gonna get translated with FDA approval and how the things will be set up. But ideally, right, it’s really a process that’s heavily therapeutic with a lot of processing, you know, during this journey and then several weeks in between where there’s just more deep work done, deep therapeutic work, before there may be then another journey.

Ashley: And when someone is kind of taking these medicines, MDMA and “silocin”?

Dr. Koo: Psylocibin. Well, that’s actually the active, you got it, that’s the active ingredient when it gets digested! But psylocibin, yeah.

Ashley: Psylocibin. So, when they’re taking these, so it is an extensive process. This will be, I mean, when this does get FDA approval and you all are able to provide this, I mean, your clients will be there for hours.

Dr. Koo: Yes.

Ashley: Is that—?

Dr. Koo: Yes.

Ashley: Okay.

Dr. Koo: It will be a several hour process. I mean, people are looking at other substances, like DMT is a very quick and rapid thing, but, like, they really aren’t— that’s not where the FDA is looking right now. And I think that another a whole pool of things that are happening, right— it’s sort of tricky, like, when they happen, what are studies— are microdosing. So that’s a little different and does involve, right, people are microdoing psylocibin, let’s just say, and that can be a daily process done in the privacy of your own home. That’s not, there’s not an FDA approved, you know, microdose of psylocibin at this point, that’s not something that doctors can do, prescribe, or recommend. But as a process, since you’re asking, that is another way, right, that people are incorporating these alternative medicines into their life. And these, you know, the plant medicines have been around for thousands and thousands of years, right?

Ashley: Right, right.

Dr. Koo: Not in the US culture, but, you know, obviously in other countries, and we know there’s a lot of validity in their healing powers. And I think it’s about using them, right, once you say, in the right set and setting and in a therapeutic modality, right? It’s not about just taking them to have to have a certain feeling, right? It has to be embedded in a therapeutic process with intention.

Ashley: Yeah.

Sam: Mhm. I know we’re just about out of time, but this was fascinating. Thank you so much, Dr. Koo, for talking about all of this today. And hopefully it’s been really informative.

Dr. Koo: Thank you very much! It was really my pleasure. I’m happy to, you know, talk about these to anybody, any time. They’re really exciting. It’s great for psychiatry.

Ashley: Dr. Koo, real quick— any thoughts on where you see mental health moving with these alternative forms of therapy?

Dr. Koo: Oh, wow, great question! I definitely hope we’re moving in a direction where we’re able to figure out faster for people what they’ll respond to. So, I think more personalized medicine, and I think we’re trying, right? I think the sad thing when we look at a lot of these illnesses we treat, eating disorders, depression, anxiety, OCD, is people go through— they feel a little bit like guinea pigs, right? So, I think if we can get better on our— I would love to see a process where we would look at somebody’s brain scan or blood draw, whatever that means, and say, “Oh, you should be on Prozac,” or “You should do TMS,” right? “You should do Spravato.” And I just think, I love that there’s so much more awareness and less stigma around mental health. So, I do think, like, in 10 years, right, there’s a lot more hopefully emphasis on wellness. And, you know, it’s sad that you sort of have to have a disease to get an ICD code to get a treatment, when so many of these treatments, right, would be really great preventatively. So, if I had my ideal world, like, you know, in the next decade we would see, you know, just like women have, you know, we go for pap smears and you know, mammograms, like it would be great that people could get therapy covered before they had a diagnosis, right?

Sam/Ashley: Yeah!

Dr. Koo: Intervention to prevent illness if we know there’s a big genetic propensity, versus waiting to get sick and then get treatment. So, those would be, I think that that would be my dream.

Ashley: Awesome.

Sam: I love it!

Ashley: Thank you so much.

Dr. Koo: You’re welcome!

Sam: Thank you for listening to All Bodies. All Foods. I hope you enjoyed this episode with Dr. Koo. If you loved this episode, you can support us by subscribing, rating, leaving a review, or sharing with others. And if you want more, you can follow us on Facebook, Instagram, Twitter and TikTok, our handle is at @RenfrewCenter. For free education, events, trainings, webinars, resources and blogs, head over to our website, www.renfrewcenter.com. And if you have any comments or questions you’d like us to answer in a future episode, be sure to email them to [email protected]. I hope you join us next time on All Bodies. All Foods.

Ashley: Thank you for listening with us today on All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

[Bouncy theme music plays.]