Transcranial Magnetic Stimulation (TMS)
Series of magnetic pulses stimulate the brain
FDA cleared for the treatment of MDD
Requires no anesthesia and does not cause memory loss
Free from common antidepressant side effects
Patients can resume daily activities immediately after treatment
Performed in our office
What is TMS?
TMS Therapy is different from treatment with traditional antidepressant medications, and even other alternative treatments like ECT (electroshock or electroconvulsive therapy) in that it is:
Non-invasive, meaning that it does not involve surgery and does not require any anesthesia or
sedation. Patients remain fully awake and alert during TMS therapy sessions.
Non-systemic, meaning that it does not enter the bloodstream nor affect other areas of the body like
How Does TMS Work?
TMS refers to a medical treatment which is delivered by a device that generates changing magnetic fields. Through a treatment coil, the TMS Therapy system generates highly concentrated magnetic fields which are rapidly switched on and off. These magnetic fields do not directly affect the whole brain; they only reach about 2-3 centimeters into the brain, directly beneath the treatment coil.
The device is positioned over the prefrontal cortex - the area of the brain which is being targeted when treating depression. These magnetic fields can create electrical activity in the nerve cells. It is well accepted by researchers and clinicians that the magnetic stimulation affects not only the targeted area (e.g. the prefrontal cortex), but also other areas of the brain connected to the prefrontal cortex, including the cingulate, hypothalamus, and thalamus.
There are many devices which can be used by clinicians. In this office, we utilize several different devices, including the Neurostar Advanced Therapy System, the Magstim Rapid2 Therapy System, and the MagVenture Express TMS System.
Are there side effects?
The most common side effects of TMS include dizziness, headache, and minor scalp pain.
There is a risk of seizure with the use of Transcranial Magnetic Stimulation. Patients who have had a seizure or who have a medical condition which could increase the risk of having a seizure should share that information with Dr. St. John at their initial consultation.
TMS treatment systems create a magnetic field that could cause metal objects near the stimulation coil to move or heat up. Patients with non-removable magnetic-sensitive metals or metallic devices implanted in their head or in body parts near the stimulation coil could experience adverse effects from the treatment and should not receive TMS therapy.
How well does it work?
Current literature indicates that approximately 50% of all treated patients who meet criteria for TMS (i.e. are considered treatment-resistant) respond to the treatment by bettering their score on a standardized rating scale by 50% or more. Approximately one-third of treated patients are so-called remitters, bettering their scores so much that they are considered depression-free.
To put these statistics in perspective, it is important to note that the patient population undergoing treatment with TMS Therapy is often excluded from new antidepressant development research studies.
In addition, the STAR*D study demonstrated that patients are likely to experience a poorer response to each new medication tried following successive treatment failures. For example, after the first medication attempt, about 30% of patients achieve remission. By the time the patient has attempted 3 different medications without improvement, the likelihood of the 4th medication leading to remission falls below 10%.
Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006;163:1905-191
Carpenter LL, Janicak PG, Aaronson ST, et al. Transcranial Magnetic Stimulation (TMS) for Major Depression: A Multisite, Naturalistic, Observational Study of Acute Treatment Outcomes in Clinical Practice. Depress Anxiety 2012; 29: 587-596.
Theta Burst TMS
Newest FDA approved form of TMS
Ultra Fast: Treatment complete in only 3-4 minutes
Efficacy comparable to traditional 37.5 and 19-minute TMS protocol
In 2018, MagVenture became the first company to obtain FDA clearance to market a 3-minute TBS (theta burst) protocol for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode. The treatment has been demonstrated to be just as safe and effective for the treatment of major depressive disorder as standard TMS protocols.
Telepsychiatry appointments are available on a limited basis to existing patients of Dr. St. John’s only, for whom traveling to our office presents a hardship. Dr. St. John must determine that telepsychiatry appointments are appropriate for patients desiring to be seen via telepsychiatry. Please inquire with front office staff about scheduling a telepsychiatry appointment and to verify insurance coverage of telepsychiatry. Patients receiving telepsychiatry services in our office are required to be seen in person at least once or twice a year, depending on the frequency of their appointments.
Video visits link: https://doctorstjohn.video-visits.com
Ketamine Infusion Therapy
Alternative treatment option for patients with treatment-resistant depression
Can result in rapid relief of depression and/or suicidal thoughts within hours or days
Performed on an outpatient basis in our office
Involves 6 administrations of ketamine via an IV over a 2-3-week period
Effects of ketamine therapy do wear off
Not covered by insurance and not FDA-approved for the treatment of depression
Dr. St. John began providing outpatient ketamine infusion services in early 2017 with the aim of further improving the lives of patients who suffer from treatment-resistant depression and who have found no relief of their symptoms with FDA-approved treatments like medications, psychotherapy, TMS, or even ECT.
Will ketamine therapy help my treatment-resistant depression?
Based on published research data, and in our experience, up to 70% of all patients can expect to have responded by the time they have received 6 infusions.
Do I need to be referred by a psychiatrist?
If you are not currently a patient of Dr. St. John’s, she will meet with you for a consultation to discuss your psychiatric condition and history. She may want to obtain medical records and/or discuss your diagnosis and treatment history with other doctors whom you have been receiving treatment from.
Patients who are currently receiving psychiatric treatment from Dr. St. John will work with her to determine appropriateness for ketamine infusion therapy during a routinely scheduled appointment or may schedule an additional office visit to discuss the treatment option.
Where is the treatment performed?
All treatments are performed within our existing outpatient offices.
How many ketamine infusions will I receive?
Most responsive patients receive an initial series of 6 (six) infusions. This is generally referred to as acute phase treatment or induction treatment.
Some patients will choose to stop receiving IV ketamine therapy after 6 infusions and rely on another form of treatment instead to maintain or sustain improvement in their mood. These patients view ketamine infusions as a “stop-gap” treatment to bring about a rapid improvement in mood while they are also planning a change in medication or planning to start another treatment like TMS therapy or ECT – all treatments which take more time for patients to experience results.
Other patients choose to obtain IV ketamine therapy on a longer-term basis. These patients may instead return to the office at various intervals for booster or maintenance infusions - generally when they begin to feel the initial series wearing off.
Patients who do not experience an improvement in mood by the 3rd or 4th ketamine infusion during the acute phase may opt to discontinue IV ketamine therapy and try a different treatment instead.
If ketamine therapy works for me how soon will I begin to feel better?
Some patients will begin to feel better within several hours of the first infusion. Patients with thoughts of self-harm often notice those thoughts dissipating first. Other patients may not notice any mood improvement until the next day. Some patients will require a second (or even a third) infusion before feeling better.
Are there any long-term side effects with ketamine therapy?
Ketamine therapy results in no clear long-term side effects, though irritative and inflammatory urinary tract and bladder symptoms including cystitis have been reported in individuals with a history of chronic ketamine use or abuse.
I have bipolar disorder. Will ketamine make me hypomanic?
Hypomania has not been reported following ketamine therapy.
What medical conditions could keep me from receiving ketamine?
There are very few psychiatric contraindications. Dr. St John will discuss contraindications with you before you receive your first infusion. Patients with significant elevations of blood pressure may require treatment of their hypertension prior to beginning ketamine infusion therapy.
Are ketamine infusions addictive?
Ketamine has been reported being used as a drug of abuse.
All patients are screened for substance use disorders. A thorough discussion including the risks and benefits of trying Ketamine Infusion therapy will take place between all patients and Dr. St. John, especially those with a history of a substance use disorder.
Patients are required to follow clinic policies and will be dismissed if any evidence arises indicating that the patient has obtained oral, IV, or nasally inhaled ketamine from another source or provider.
Ketamine dependence and tolerance are possible following prolonged administration.
Will my current psychiatric medications interfere with ketamine therapy?
Anti-depressant medications (SSRIs, SNRIs, TCAs, etc.) do not interfere with ketamine, and there is no need to stop them. Ketamine infusions can provide relief during the time it takes antidepressant medications to begin working.
Important: You should not decrease or stop taking any prescribed medication without first consulting with your prescribing physician.
What should I expect during ketamine therapy?
Ketamine is administered over a period of 40 or more minutes. The dose is determined by your weight. The amount of ketamine administered is not enough to cause a loss of consciousness, so you will remain awake. During the infusion, some patients experience odd perceptions—like seeing bright colors. Some report what is referred to as a “dissociative” or “out of body” experience. Most commonly, patients describe experiencing a pleasant dream-like state. Once the infusion is complete, the dissociative effects of the drug rapidly dissipate. There are no delayed “flashbacks,” and patients generally leave the office within 30 minutes of the infusion feeling quite normal.
Are there other side effects that I would experience during or after my therapy?
Occasionally patients experience some nausea or dizziness during an infusion. More rarely, a patient may experience a transient headache. Patients can expect to be tired following the infusion. Increases in blood pressure and heart rate are also not uncommon. Your vital signs will be measured at intervals to ensure your safety. Rarely, patients have exhibited movements resembling a seizure. If you have a seizure disorder, please be sure to share that information with Dr. St John prior to receiving ketamine therapy.
Do I need to bring someone with me?
You do not need to have someone bring you or accompany you during the infusion, but we request that you have someone drive you home. We advise you not to drive a car until the morning following your infusion.
Can I eat or drink before my appointment?
You cannot eat for the 4 hours prior to your scheduled appointment. You may have clear liquids up until 2 hours before your appointment.
What happens after my series of ketamine infusions?
Following the initial series of infusions, most patients will work with Dr. St John to begin a maintenance program, returning for a single infusion intermittently. The interval between maintenance infusions varies from patient to patient.
Will my insurance company pay for ketamine therapy?
Yes and no. We are “in network” with many insurance plans and can bill any required psychiatric evaluations and assessments directly to the insurance companies.
However, because ketamine infusion therapy for mood and anxiety disorders are non-FDA approved indications, insurance companies view it as experimental and/or investigational and DO NOT provide reimbursement for the infusions.
Murrough, JW et al.: Rapid and Longer-Term Antidepressant Effects of Repeated Ketamine Infusions in Treatment-Resistant Major Depression: Biol Psychiatry. 2013 August; 74(4): 250-256
Sanacora, Gerard et al.: A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders: JAMA Psychiatry. 2017 March; pp E1-E6
Our providers will develop an individualized treatment plan based on your needs, work with you to set goals, and monitor your progress.
Follow-up appointments are typically scheduled at 30–90-day intervals and last 20–30 minutes, depending on the level of complexity dictated by the visit.
Second Opinion Evaluations
A 60–75-minute comprehensive evaluation by a psychiatrist
Differential diagnosis assessment
Referral for additional testing, as needed (e.g. lab work, neuropsychological testing)
Communication with the patient’s existing psychiatrist
Recommendations for treatment
Dr. St. John provides second opinion assessments to those who suffer from severe mental illness and who have not responded to previous treatments. Once considered treatment-resistant or treatment refractory, patients often feel lost, hopeless, or lose confidence in the field of psychiatry. The goal of a second opinion evaluation is usually to clarify or confirm a patient’s diagnosis, to obtain a better understanding of the patient’s current symptoms and/or behaviors, and/or to provide new or additional recommendations for treatment.
Dr. St John also offers several alternative treatment options in her practice for patients who qualify, including TMS Therapy and Ketamine Infusion therapy. When those treatments are recommended as part of the second opinion evaluation, they can be prescribed by Dr. St John and then performed in our same office subsequent to the consultation.
Qb Testing for ADD/ADHD
QbTest is an FDA-cleared test used as an aid in establishing a diagnosis of adult ADD/ADHD and in the evaluating of the effectiveness of specific ADD/ADHD treatments
What Is QbTest?
Qb Test is an FDA cleared and widely used objective test that measures a patient’s activity, attention, and impulsivity. It is a computer-based test that combines attention measures with an activity analysis based on a motion tracking system. The test results are instantly analyzed and presented in a report that compares your results with a group of people of the same age and gender who do not have ADHD.
How is QbTest performed?
The test is performed in front of a laptop computer in our office. During the test, a number of symbols are shown on a computer screen. The task requires patients to push the responder button when a certain symbol appears on the screen.
How long does a QbTest take?
The test takes about 30 minutes to complete.
What is the benefit of obtaining QbTest?
Clinicians are able to make more accurate diagnoses of ADD and ADHD when data is available from a combination of sources. Objective testing with QbTest is an important part of the diagnostic triangle which also includes a thorough clinical interview and rating scales, such as the ASRS (Adult ADHD Self-Report Scale). Furthermore, the QbTest can be performed repeatedly, comparing a patient’s performance after taking a certain medication or dosage of medication against the baseline test or subsequent test(s). This allows the clinician to prescribe the optimal medication and dosage faster and more efficiently as compared to the traditional trial and error method.
Psychotropic Genetic Testing
Often referred to as personalized medicine, genetic testing assays look at genes that affect your body’s ability to respond to medication. Genetic testing can ideally be utilized to reduce the time needed to find the right medication for you as compared to the traditional trial and error method.
The test panel evaluates two general types of genes, genes that indicate what effect a medication or class of medications may have on your body, and genes that indicate what effect your body will have on medication (e.g. they determine how fast your body will metabolize a medication). The faster or slower your body processes a medication determines the dose that will be needed to be effective and safe.
A saliva sample is collected by swabbing the inside of your check with a cotton swab in our office. The sample is mailed to the lab and results are typically available within 2–3 weeks.
Aroma Freedom Technique (AFT)
AFT combines work with essential oils and principals drawn from CBT and EMDR to help patients achieve goals which may have previously been blocked by negative thoughts and memories.
The Aroma Freedom Technique (AFT) uses the power of inhaling specific scents to gently shift negative thoughts, feelings, and memories towards a positive outlook and attitude. This technique results in greater confidence and inner freedom from negativity. In addition, this process focuses on finding solutions to help achieve long-awaited goals that may have been blocked by negative thoughts and memories.
AFT was created by clinical psychologist, Dr. Benjamin Perkus. He integrated 20 years of clinical experience with 15 years of work with essential oils into a technique that is easy to use by almost anyone. He created this technique combining several psychological principals such as Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR).
Liz Grizzaffi, PA-C is a certified Aroma Freedom Technique practitioner. She offers one-hour sessions using essential oils combined with the AFT process to yield mind, body and emotional wellness.
*Appointments can be scheduled via the office receptionist. Please note that this is service is not covered by insurance companies.