Nadia Bening, MD - Psychiatrist in Austin, Texas

Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision, and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There's no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. Welcome back to Meet the Doctor. My guest today is Dr. Nadia Bening, and she's a board certified psychiatrist in Burnett, Texas, which is west of Austin just a little bit. Nice to meet you. Welcome.

Dr. Bening (00:41):
Thank you. Thank you for having me. I'm excited to be here and talk about TMS.

Eva Sheie (00:45):
I am too. So TMS is something you specialize in, and I had not heard of it until I was introduced to you, and I'm very excited to hear more about what it is. So what does it stand for and tell us about what that specialty looks like.

Dr. Bening (00:59):
Sure. TMS stands for transcranial magnetic stimulation, and it says it is pretty much we are stimulating the brain specifically in the area of the prefrontal cortex through the skull, transcranial magnetic stimulation, and it uses magnetic energy, so it's simulation using magnetic energy through the skull. And we're doing multiple things as far as mechanism of action when it comes to primarily treatment of depression, specifically treatment resistant depression, when people have tried medications and therapy and have not seen relief of symptoms.

Eva Sheie (01:39):
When someone finally discovers TMS, what kinds of things have they tried first?

Dr. Bening (01:46):
So typically they have tried antidepressants. There's lots of different antidepressants out there. And then they've also usually tried some talk therapy, whether that's a specific cognitive behavioral therapy or a dialectical behavioral therapy or acceptance commitment therapy. There's all sorts of different types of therapy. And so a lot of people have tried both of those things. And I think most of the mindset is like, okay, it's those two things, or it's ECT, which is shock therapy. Electro convulsive therapy is shock therapy where people are inpatient, induced under anesthesia, and seizures are induced in order to rewire networks, but we really don't really know how it works. And so a lot of people hear TMS and think, oh my gosh, is that shock therapy? But it is not. And so it is amazing to have something now in between the two that is accessible as an office-based procedure and quick and no downtime and no activity restrictions and typically covered by insurance.

Eva Sheie (03:00):
Do you find people have also tried things that maybe are less conventional like psilocybin or mushrooms?

Dr. Bening (03:08):
So yeah, a lot of the psychedelic stuff is out there. It's not legal. We're not prescribing those things as practitioners. Now, the one that is the ketamine. So ketamine has gotten a lot of attention, and I've certainly heard amazing transformative stories with it, but then I've also heard other stories of, yeah, I felt better while I was doing it. And then people have to keep doing it sometimes for it to continue to work when it comes to more of the mainstream practices out there, bringing in ketamine, there's different forms of the ketamine, like inhaled nasal ketamine, which is Spravato, and that one's covered by insurance for treatment resistant depression as well. And then there's also IM or IV ketamine, which are not covered by insurance. And so people will sometimes spend money out of pocket to get that or go through their insurance and try something like Spravato. There's definitely some big differences. I mean, obviously mechanism of action is different with transcranial magnetic stimulation versus Spravato, but a lot of the clinics are now kind of doing everything, med management therapy, Spravato, TMS, offering it all, whereas I specialize specifically just in TMS and I've been blown away.

Eva Sheie (04:22):
So everyone's trying to do the same thing different ways. And a lot of the stuff that we ingest, we don't actually know, like you said earlier, what exactly is it doing once it goes into your body and it's going through your whole body and not just your head, am I picturing this correctly? And so TMS is doing something from the outside to the inside of just the part of your brain that is theoretically in trouble,

Dr. Bening (04:49):
Right. Like TMS is a very focal stimulation to the left dorsolateral prefrontal cortex. So it's safe. It does not cause systemic side effects like you're thinking with medication or something that you're really putting through to be passed through the gut to be absorbed in these kinds of things. So yeah, TMS is a really focal stimulation to the prefrontal cortex, and it's acting locally there where it's stimulating at the prefrontal cortex, but it's also targeting deeper brain structures that are connected to the cortex. There's connections between the outer cortex and say the limbic system. And so we're able to target these deeper brain structures by using the magnetic energy to activate underactive depression pathways in the deeper structures and or inhibit overactive anxiety pathways in the deeper structures. So that's the primary mechanism of action when it comes to depression. But there's so much improvement, again, the local simulation at the prefrontal cortex, it's like we're increasing blood flow to the prefrontal cortex, we are increasing something called BDNF, which is brain derived neurotrophic factor that stimulates new neuron formation, and it helps with neuroplasticity like strengthening the neuro connections in the brain. And it's activating cells locally as well where it's targeting. So there's studies that show things like long haul COVID when your cells have been affected by the virus, or let's say the vaccine, just whatever the toxic injury was to brain cells findings are now showing that noninvasive brain stimulation is reactivating cells that have been turned off. So it's pretty fascinating everything it can do.

Eva Sheie (06:49):
What other kinds of things can actually damage to cells in your brain? Like alcohol? Drugs?

Dr. Bening (06:56):
Substances, yep. Substances, alcohol and drug use, environmental, toxins, pesticides,

Eva Sheie (07:05):
IPads?

Dr. Bening (07:05):
There's so many. Yeah, iPads, AirPods, no, I don't know. We could go on a deep dive, I guess, into all that stuff, but just any insult or injury. And even things like chronic depression, chronic stress changes the cells of the brain. So even things that are, let's say situational do change our physiology. And so we know that there's brain changes in, people have chronic depression and chronic stress, so it's helping with all of that too. But yeah, any insult or injury, really, chemotherapy can be toxic to brain cells and to cells in the body, obviously that's why we use it. But yeah, there's so many different things that can affect our cellular health in the brain and in the body.

Eva Sheie (07:53):
How long has it been around? TMS.

Dr. Bening (07:57):
It's been FDA approved since 2008, which has been a while. I mean, I still think of that, I don't know. I still think 2000 was right around the corner, but shoot, it's been 25 years since 2000. So anyway, it's been FDA approved since 2008. They were studying it since the eighties, and they really moved it from peripheral stimulation for things like pain into studying it on the brain and how can it help with neurological symptoms and psychiatric symptoms.

Eva Sheie (08:28):
Does it have an origin story? Do we know who thought this up? Doctors do this all the time where they spot something, usually a pattern, and then they kind of pull the thread and they start going in that direction to figure out what's going on here.

Dr. Bening (08:44):
Yep. It was a Dr. Barker who's the one that's credited with being like the grandfather of TMS. So yep, he's the one that was working, moving it from peripheral stimulation to more central and focusing on the brain with magnetic therapy.

Eva Sheie (09:01):
Why do you think more people don't know about it now?

Dr. Bening (09:04):
I dunno. It's such a good question. I don't know. I mean, insurance, most of the major insurance carriers cover it when people have tried a couple of antidepressants, and so I don't have a good answer for that. I think ketamine and the psychedelics have kind of stolen the spotlight from it for some reason. And there's still so many commercials and big pharmaceutical companies, and the money has got to be probably their biggest.

Eva Sheie (09:39):
They're not making money on TMS.

Dr. Bening (09:41):
I know. Yeah. So I mean, that must be why. But I finished residency and went immediately into medication management, which is what psychiatrists do, and I did that practice for a long time. I started working in TMS about six years ago, and I was like, holy cow, this is unbelievable. This is the most transformative thing I've ever seen without side effects. I mean, when I did med management, there's definitely a time and place for medications, and still sometimes I'll see people and I'm like, Hey, I actually think a little bit of Zoloft is going to be the thing that's going to be really helpful for you. So I'm not anti meds whatsoever, although I'm not doing medication management appointments, I'm just doing the TMS.

Eva Sheie (10:23):
Did you fall into this backwards? How did you discover it?

Dr. Bening (10:27):
No, I always had my own practice doing the medication management, and then I got into drug and alcohol rehab. I've worked at three different drug and alcohol rehabs. Absolutely love that population. That's a big niche that I feel really strongly about and just have a heart for. And then I like doing multiple things. So I was doing that. I was working, I had my practice, I was working at the rehab, and then just another job opportunity came along to work at a TMS clinic, and I said, oh, this is cool. Something different. Let me explore. I'm always huge, just myself. I'm always looking at different, what's the latest research, what's the latest science? I love the biohacking conferences just for my own personal optimal wellbeing. And so when I came across this, the TMS opportunity, I said, oh, yeah, this is cool. I need to know about it. I need to get involved. And so that's how it was. And I started working for a company doing it, and I was like, this needs to be everywhere. And I live in a small town. There's TMS clinics in a lot of the big cities. I mean, most of them have TMS clinics, but I thought, oh my gosh, this needs to be, in the smaller towns, because people need to come for their sessions frequently. And so people don't want to have to drive into Austin from say, Fredericksburg or to San Antonio when they have to come three to five days a week.

Eva Sheie (11:51):
No, we already have to do that to go to Target. So

Dr. Bening (11:53):
True.

Eva Sheie (11:56):
Whenever I consider moving further that way, the first thing I say is, but it's too far away from Target.

Dr. Bening (12:03):
That's right.

Eva Sheie (12:04):
And so you've been expanding your services around the countryside. Where else are you seeing people for TMS?

Dr. Bening (12:14):
Yes. Our first location was in Burnett, and then about six months later, we opened in Killeen, and then the next one opened in Dripping Springs. Then we went to Fredericksburg, then Canyon Lake, and now Marble Falls, which Marble Falls is pretty close to Burnett, but we get so many people from Horseshoe Bay and Marble Falls that come over to Burnett, that we said, oh, you know what? We're busy enough. Let's put one in Marble Falls. Make it more convenient. If people have jobs, they want to pop over during their lunch break, get their session and go back. And so as convenient as it can be, that's key.

Eva Sheie (12:46):
How long does a session take?

Dr. Bening (12:48):
So it depends, cuz there's a few different protocols. The session can take under five minutes, or it can take around 10 minutes, or it can take around 20 minutes. So it kind of depends on their insurance. It depends on what's going on, whether we pick one protocol versus the other. But yeah, max of 20 minutes.

Eva Sheie (13:05):
That's easy. You don't want to drive an hour for a five minute appointment and then drive an hour back. That's no fun.

Dr. Bening (13:12):
Exactly. And thankfully, there's no activity restrictions. There's no observation period of time. They drive over, they get their session and they go. And so that's a big difference between the Spravato. So it's kind of like there's meds therapy and then there's Spravato or TMS, and then there's shock therapy. So that's a big difference between TMS and the Spravato. The inhaled ketamine. When people do the inhaled ketamine, they have to wait for two hours at the office to be observed, and they can't drive home. They have to have a ride. And so they have to do that a couple times a week during the course of the Spravato and just, I mean, I don't know how people do it, honestly. I,

Eva Sheie (13:51):
That's not very practical.

Dr. Bening (13:51):
A lot of people can't do it. It's not, yeah. Yeah.

Eva Sheie (13:55):
I think when we're desperate, we'll make stuff work, but then if it doesn't work for or if you have to do it forever, your willingness to do that kind of wanes. And I'm curious why Kileen was your first, well, was your second office, was there something about the military population that made you want to go there?

Dr. Bening (14:16):
Yep. I mean, there just wasn't, and there are a few other TMS places kind of nearby now, but yeah, it wasn't out there. And so yeah, we definitely wanted to be over close to Fort Cavazos, Fort Hood, Fort Cavazos.

Eva Sheie (14:33):
It's Hood. It's Hood.

Dr. Bening (14:37):
And so we wanted to be close enough so that those people could quickly get a treatment and get back on base and do what they got to do.

Eva Sheie (14:45):
Can kids do TMS?

Dr. Bening (14:48):
Kids can. The studies show that it's safe. It has FDA approval for ages 15 and older for adolescent depression. The insurances are kind of slower on covering it. A few of them are covering it. A few of them are lagging.

Eva Sheie (15:01):
And if your insurance didn't cover it, would it be cost prohibitive to just pay cash for the appointment? Is it crazy?

Dr. Bening (15:07):
No, no. I mean, so most of the TMS clinics out there do have a hefty rate per session. Usually it's around 300 to 600 per session. At our clinic we do it for a hundred per session, and then we can do packages for less if they're going to group sessions together and just want to pay in advance. So we try to make it affordable and work with people. We take Care Credit, we'll work out payment plans. I mean, we really don't want it to be prohibitive for anybody, but we definitely do try to take their insurance when they can. Even people can afford it. We have insurance and we're paying for our insurance. We want to use our insurance. You know what I mean? So that is a big priority for us to get people covered so they can use their benefits.

Eva Sheie (15:53):
I assume it's dependent on what you need, but what's a typical appointment schedule look like? Is it once a week or is it more often less often?

Dr. Bening (16:02):
So the treatment course itself is 36 sessions. That's what, insurance covers 36 sessions, and that is the FDA approved protocol. And so people will come three to five days a week to complete the 36 sessions. That's what it looks like.

Eva Sheie (16:18):
So a couple of months?

Dr. Bening (16:20):
Yes.

Eva Sheie (16:22):
Okay. And at what point do you see them start saying that they feel better or that they notice a difference?

Dr. Bening (16:30):
Usually pretty quickly. So 80% of responders are going to notice something in the first two weeks. Sometimes it is in one or two sessions, and people are, oh my gosh, is this placebo? I'm like, a lot of y'all are telling me you're noticing a decrease in brain fog and you slept better than you have in years in the first couple of days. So it's hard. I mean, yes, there's placebo potential with anything in life, but I don't know mean, it just seems to be just from my experience, even doing meds, I mean, there were times that people felt better immediately. And usually, in my experience, I felt like when somebody responded to a medication quickly and didn't have side effects, it was great. Usually that kept working for them. You know what I mean?

Eva Sheie (17:14):
Yeah.

Dr. Bening (17:14):
Even though in the books and what we're taught is like, well wait two months and see if it's going to do something. But if someone's having intolerable side effects and vomiting every day, I don't tell them to wait it out. I'm like, okay, get off. Let's try something different. Right? But no, with TMS, I mean, it is the fastest thing I have experienced working for the vast majority of patients quickly. And it really is the energy motivation, sleep and brain fog are the top things we're seeing quickly.

Eva Sheie (17:44):
I'm going to show my age here, but it sounds an awful lot like perimenopause.

Dr. Bening (17:50):
Yes.

Eva Sheie (17:51):
And I almost wonder if you could do TMS to see if it fixed perimenopause.

Dr. Bening (17:57):
Oh, we've had so many women

Eva Sheie (17:57):
It's the same thing.

Dr. Bening (17:58):
Yeah, no, I've had so many women who are like, Dr. Benning, is this, this is helping my menopause? Are there studies in it? I'm like, well, sure enough, there are some studies in it. So I mean, it can help with those symptoms. Yes. It does also have some regulation on the HPA axis, the hypothalamic pituitary adrenal axis, like our endocrine system. So whether that's what is or not, I don't know, but it's unbelievable. It's almost like the way I see it is what it's doing is getting the brain healthy. And when the brain is healthy, people feel better. We see not only improvements in just standard depression and anxiety symptoms, but even road rage. We see improvements in specific phobias. We had one person that wasn't driving over a bridge and then all of a sudden two weeks into TMS, they're like, oh my gosh, I can drive over bridges now.

(18:50):
Oh, interesting. Okay. That's not a specific TMS finding necessarily in studies, but we just hear anecdotally all the time. And then the other thing I hear so much is it's to do with metacognitive ability. So metacognition is where you can think about your thoughts, and it's a prefrontal cortex thing. And so with the stimulation to the prefrontal cortex, it's like we're seeing people better able to detach an emotion from a thought or memory so that they're able to think through something and not be so emotionally tied to it. And people will be able to have a longer gap between stimulus and response. They're not as reactive as they were before. They're able to think before they speak. They're able to let things roll off their back. Something that would've bothered them before is like, oh, okay, not such a big deal. And I think that's because of that metacognitive ability that we're really stimulating by doing the prefrontal cortex stimulation.

Eva Sheie (19:55):
I'm going to translate that into something I heard Dr. Phil say like 20 years ago, which was about breaking thought patterns. So when you say something to yourself over and over again, you would say you got to change the tapes. And it sounds like it helps you change the tape really fast.

Dr. Bening (20:13):
Yes, it is like an accelerated, and when we see people do say combination where they're doing EMDR or something for trauma or adverse childhood experiences and just different things that cause daily symptoms in their life that they're struggling with, it's like EMDR, something like EMDR plus TMS or even just talk therapy, cognitive behavioral therapy plus TMS. It is like a supercharged speedway just accelerated improvements in symptoms. It's really unbelievable. But the thing I like about it too, I mean when I did med management, I was always like, and you got to be exercising three times a week and you got to be eating more leafy greens and

Eva Sheie (20:55):
Nutrition has to be perfect, and you got to take your supplements and you got to avoid all these other things.

Dr. Bening (21:01):
Yes. And it's like, I don't do that anymore. I'm like, just come do TMS. That's it. Almost like make it as effortless as possible, and people start changing their behaviors. There's no magic pill. But shoot, I say this is the most magic machine I've ever seen. I mean, when it comes to almost like the effortlessness of people doing it, they don't have to do therapy plus TMS, they just do TMS alone. And people can be on medication, most people are on medication for something like say they have panic attacks and depression, but they're taking a Prozac for their panic attacks and it's helping. But they do TMS for depression. We see that a lot. So people can be on medication and do TMS or they can be off medication, doesn't work, they've tried it, they don't like it, and they're doing TMS as monotherapy treatment for depression. We get results either way. I mean, anecdotally, I've not seen anything that needs to be in conjunction with TMS for it to work wonders for a lot of people with obvious symptom improvement.

Eva Sheie (22:05):
Do some of those people end up quitting or not needing medication anymore?

Dr. Bening (22:10):
Some people will come off their medication. Usually my general recommendation is stay on the medication, do the TMS hold that variable constant, and then a couple months after you're still feeling great, start tapering off that medication with their provider. And a lot of people do it, and they're months, years down the road, they're like, I'm still off my medication. And so the results with TMS are something else that have been really astounding. I mean, long-term results. I mean, most people go a year and a half, two years plus not needing another recurrent course of it, basically. But the good thing is that if somebody responds to that 36 session course and they do have a backslide and they need to do it again, insurance will cover it again every six months. Most of the insurances are every six months if they need to do another course. And it's like automatic approval if they responded the first time and they're over 90% likely to respond again. So it's a pretty reliable form of treatment if they know they need in the future.

Eva Sheie (23:15):
You're blowing my mind today, and I just had no idea. And I'm so glad that we got to learn about this with you. And I feel like now I'm going to have to tell everyone, actually, I'm on my way. I'll be there in half an hour.

Dr. Bening (23:30):
We're ready for you. And we're small, we're a very small and simple company too. I don't complicate things. It's like they see the technician get the treatment. I'm right over the technician. People have access to me. If they ever need a phone call that day, boom, I'm on the phone with them. And we're just so communicative and make it easy. If someone needs to switch their appointment time from 10 o'clock to three o'clock, no worries. Shoot us a text. We'll get you in later. We try to be as flexible because it's a commitment for a patient to come in every day. But it's important to me to keep things simple and easy communication and not a million forms to fill out. Anything I don't want to do at a doctor's office. I'm not doing it at my personal doctor's office. You know what I mean?

Eva Sheie (24:13):
That's very wise. How did you get into psychiatry? What was your path like to get here?

Dr. Bening (24:20):
Well, I went to medical school to be an OB GYN actually. I thought I was going to deliver miracles into the world. And then when I was on that rotation, I was like, oh, oh crap. I don't really like this. And I had rotated through family medicine and internal medicine and pediatrics, and we go through all the different big specialties. Psych was the last thing I thought I would do. The last. But I ended up loving it. I was between psychiatry and surgery after having rotated through everything. And surgery is just one of the coolest things you can do. You're like in the body connecting the vessels and just, I mean, it's unbelievable. But psychiatry, I felt such a connection to the patients I was working with. I felt such a genuine just curiosity and compassion for people, and I felt like so much was out of their control.

(25:12):
I mean, when you see someone who has say a psychotic disorder, like schizophrenia, it, it's so out of their control. Whereas if you're on internal medicine and you're working with diabetes and they keep eating the beans and the tortilla and making their glucose out of whack, it's like, okay, come on. Change your behaviors. But again, that goes back to psychiatry. Why are they doing that? What's the reasoning for not making those habits or consistently doing something that's healthy for yourself? But I just felt like with a lot of the psychiatric disorders, it was so out of people's control, and I had so much compassion for that. There was one instance where I was on surgery. This was probably the biggest tipping point for me. There were three different things, but I'll just specifically talk about this one. And we were in the trauma pit. And a kid had come in after trying to hang himself.

(25:59):
And I am not a big crier, I wasn't a big emotional medical student or anything, but I had to leave. I mean, wasn't doing anything as the medical student, thank goodness, the chief trauma resident was directing all the residents and everything to save this kid's life. Thank God he did survive. But I was like, why, why, why, why did he do this? Turns out his sister had overdosed and killed herself a few weeks before. And I just was crushed about it. And I said, I want to be the person that helps prevent this kind of thing rather than fix it at the end. And that was the biggest thing for me. And I came after I started praying for my patient. I mean, I always pray, but I don't know why. I hadn't prayed for my patients when I was on internal medicine and family, and then all of a sudden I'm on psychiatry and I'm praying for my patients. And that was a big sign to me of just like, oh my gosh, I have such a heart for this. So yeah, those were some of the bigger things that really led me to psychiatry.

Eva Sheie (27:07):
That's an incredible story. What do you like to do away from work?

Dr. Bening (27:13):
I like to spend time with my three boys. That is the most fun thing I get to do. I like to travel. I like to travel with my kids. I've got three boys that are 13, 12, and nine. I like to travel with them. I like to travel with friends. Just got back from a trip to France, which was amazing, and last year Italy. So I kind of make that a priority to do a big trip each year. And I like being outside and I really like growing my business. It's fun. It's fun. I mean, we get to expand into different areas and people get so excited when we see new patients. It's when people come in to do TMS versus my experience doing med management, it's like our patients are excited and they're hopeful and they're like, oh my gosh, thank goodness there's something else available. And so it's really cool to see that. And I mean that alone, the hope they have, even going into the treatment is so refreshing.

Eva Sheie (28:15):
Nobody says, oh, I'm so excited to take my Zoloft today. That doesn't happen.

Dr. Bening (28:22):
Right? So it's by far the most rewarding thing and really the transformative aspect of it. That's why I love rehab too. I mean, you see somebody come in and get off of alcohol and drugs are a different person, right? In 30 days. Yeah. There's still a lot to work on and consistency to be had and everything. But it's like the amount of transformation I see with TMS is just as much, if not more than that, because it's just been such a life-changing treatment for so many people. So it's awesome.

Eva Sheie (28:55):
How can we find you and where can we learn more about your practice?

Dr. Bening (28:59):
Yeah, so the biggest plays is our website, which is Texas Hill Country TMS.com. And then we're on Facebook and we're on Instagram. So if people follow along there, we post little updates and just again, educational, what insurances we accept. Of course, that's on the website too. But Facebook, Instagram, we are @TexasHillCountryTMS. And again, the website, Texas Hill country tms.com.

Eva Sheie (29:25):
Thank you Dr. Bening. It was a pleasure to meet you today.

Dr. Bening (29:28):
Yes. Thank you so much for having me. I enjoyed it. I love talking about TMS because more people need to know about it.

Eva Sheie (29:34):
Well, I am thrilled to spread the word, so thank you for coming.

Dr. Bening (29:38):
Yes, thank you.

Eva Sheie (29:41):
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