In this episode, Brain & Life Podcast host Dr. Katy Peters speaks with Dr. Sandeep Vaishnavi, a neuropsychiatrist and cognitive neuroscientist.  He serves as the President of the Center for Neuropsychiatry and Brain Stimulation and Chief Medical Officer Designate for ARC Health. Dr. Vaishnavi is also the author of Healing the Traumatized Brain: Coping After Concussion and Other Brain Injuries. Together they discuss the intersection between psychiatry and neurology, accessible and upcoming treatment options for neuropsychiatric symptoms, and the stigma behind mood and behavioral symptoms.

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Episode Transcript

Dr. Daniel Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Katie Peters:
And I am Dr. Katie Peters, and this is the Brain & Life Podcast.
In this episode, I discussed brain trauma with the neuropsychiatrist, Dr. Sandeep Vaishnavi, particularly about his professional lens of neuropsychiatry. He points out the important aspects on mood disorders, depression and cognitive changes after brain trauma. The healing aspects focuses on how key psychiatric care and recognition that psychiatric illness is truly a brain disease. He gives us great hope for patients, for their care partners that are contending with brain injury.
Daniel, in your practice, do you often see the intersection between neurology and psychiatry?

Dr. Daniel Correa:
I think it's under-recognized. The reality, I think, is any condition that affects how you function and interact with the world, interpret all the different stimuli and sensations that we have on ends up impacting how we feel about ourselves and about the world around us. Whether it's a migraine taking you out of being able to go to work or just spend time with your family, that can cause depression and anxiety.
As some of our listeners know, in the past, I also worked in the military as a military neurologist during the time that there was a significant increase in traumatic brain injury in our service members, and almost everyone living with traumatic brain injury dealt with some levels of psychiatric symptoms that either got worse because of the injury or were new afterwards.
And this is part of how the brain works together. Our brain isn't just a collection of little on and off switches, it's a network of systems much closer to a extremely complex computer, much stronger than that iPhone in our pockets or the computers on our desktop.
And there are lots of overlays with psychiatric conditions among people who live with neurologic conditions; things like traumatic brain injury, migraines, the patients I see with epilepsy; not just because of the medicines, not just because of the condition going on, affecting their mood, these conditions can affect your sleep, which then further contributes to mood disorders. But then there's also just the stigma of living with that condition and how it impacts your relationships, how you interact with the world and how you move through the world and day. And those are all things that can affect not just us individually, but our own mood and health.

Dr. Katie Peters:
I know just after that discussion with you, you're going to really enjoy this episode, because he highlights so many of those topics that you just mentioned; the brain networks, the stigma of the psychiatric illness.
And what I really enjoyed about this podcast is he really talked about, "What can we do?" And one of the things is actually just reading his book, getting that information and having those care partners have the resources to take care of their loved ones.

Dr. Daniel Correa:
That's great.
First is just acknowledging that it's there and the challenges and that they come together, but then to have the steps of, "Okay, where do you move forward?", is such an essential thing that I think we all need after dealing with any trauma and injury, but particularly thinking about traumatic brain injuries and concussions.

Dr. Katie Peters:
Welcome Brain & Life listeners. Today we will speak with Dr. Sandeep Vaishnavi, a neuropsychiatrist and author of Healing the Traumatized Brain: Coping After Concussion and Other Brain Injuries.
Dr. Sandeep Vaishnavi is a neuropsychiatrist and cognitive neuroscientist. He serves as the president of the Center for Neuropsychiatry and Brain Stimulation, and he's the Chief Medical Officer designee for ARC Health.
He is certified in behavioral neurology and neuropsychiatry. His PhD is in cognitive science with a specialization in cognitive neuroscience. He's done residencies at Duke University in psychiatry, as well as in clinical psychopharmacology, and a fellowship at Johns Hopkins Hospital.
He's also the author of other books, the Traumatized Brain and Healing the Traumatized Brain, which was just released in July, 2023. He has written five book chapters and several peer reviewed scientific papers and abstracts. He's received funding for research studies from the National Institutes of Health and the US Department of Defense.
He has been quoted in the popular media, and these outlets include USA Today, Rolling Stone, Huffington Post, and the Raleigh News & Observer.
Today we will be discussing his recent book, Healing the Traumatized Brain: Coping After Concussion and Other Brain Injuries.
Welcome to the podcast, Dr. Vaishnavi.

Dr. Sandeep Vaishnavi:
Thank you, Dr. Peters.

Dr. Katie Peters:
Dr. Vaishnavi, before we discuss your book, can you just tell us a little bit more about yourself, like where you're coming from today? And also tell us, what is neuropsychiatry?

Dr. Sandeep Vaishnavi:
Neuropsychiatry is really thought of as the intersection you can think of between neurology and psychiatry. I've always felt it really odd that neurology and psychiatry are two very separate fields, but we deal with the same organ. We deal with the brain. And I don't know if there's any other medical organ or any other organ where you have two specialties like this. So I think in my own mind, I certainly feel like neurology and psychiatry are kind of looking at the same thing, but from different perspectives. And it's kind of an artificial separation between the two specialties.
Historically at one time it was one specialty. And I think as we learn more and more about the brain, about neuroscience, I'm hoping and I think that ultimately there'll be a reunion again between neurology and psychiatry, because ultimately, again, we're looking at the same organ. We're looking at outcomes of damage or injury to that same organ manifested behaviorally or cognitively or with mood or with movements or with other sensory issues. And we divide neurology and psychiatry, I think, kind of artificially between sensory and motor is neurology and then behavior and mood is psychiatry. But ultimately it's from the same brain.

Dr. Katie Peters:
I completely agree. And I once toyed with going into neuropsychiatry myself, and I did a fellowship in cognitive neuroscience really from the neurology side. So I do think we can come and marry that.
Now you see patients that have had brain trauma. Can you just describe, what is brain trauma and what are some of the causes of brain trauma?

Dr. Sandeep Vaishnavi:
Yes, I see patients with various types of trauma to the brain, meaning physical trauma to the brain. So people who've had accidents and developed a traumatic brain injury, for example; patients who may have injury to their brain because of brain tumors or strokes; or people who may have a neurodegenerative illness like Alzheimer's disease. I mean, ultimately these are all different types of brain injury, just different causes of injury.
And ultimately what I focus on is really the mood, behavioral and cognitive aspects of brain injury. I don't focus on the motor and sensory aspects. Again, coming more from psychiatry and into neuropsychiatry, I've been focusing more on mood, behavior and cognition.
So in terms of mood, just to give an example, there are lots of studies that show that there are changes in mood that occur with brain injury, with physical brain injury. Those changes in mood are because certain circuits or neural networks are affected. And because those circuits are affected, just like if you affect a sensory circuit, you're going to have certain sensory symptoms. If you affect a mood circuit in the brain by an injury, you're going to have mood symptoms.
So it's not ... You know, we oftentimes think of mood and behavioral issues as something that the patient can control themselves. It's not the injury, it's them. But what we think of the way we think about in neuropsychiatry is that there might be a component of that certainly, but ultimately, if you have a injury to a certain circuit that is important for mood regulation, for example, you can very well have a mood regulation disorder that develops. If you have damaged a circuit that affects attention or memory, you're going to have attentional and memory problems.
So it's not really a question of the patient being able to pull themselves up by the bootstraps and being able to get over it. And I think that some people still have that notion that you can do that. But just like with a stroke that's affecting your arm and you can't move your arm, we don't say to people, "Well, just get over it. Move your arm." We know that there is a problem in the brain that's preventing them from doing that. And it's the same sort of thing with the mood and behavioral aspects too.

Dr. Katie Peters:
I think that's so important, that you really need to have the tools and the professionals to help people through these challenges when they have brain trauma, and that mood and also their cognition can definitely be affected.
Now I have the pleasure of sharing patients with you because I see patients with brain tumors, I'm a neuro oncologist, and you see some of my patients. And they can really benefit from seeing you and working with you.
Can you elaborate sort of how patients with brain tumors are sort of similar to patients with brain trauma?

Dr. Sandeep Vaishnavi:
I would say that ultimately one of the tenets of neuropsychiatry is that what matters more than anything in terms of the actual cause of the brain injury is where in the brain the injury is affecting. So what are the circuits? What are the neural networks that are being affected? And so with brain tumors, certainly if you have a brain tumor in a certain part of the brain that's important for mood, for example, or let's say memory, well, it's a similar thing to a person who has a traumatic brain injury that's affecting the same circuits. So ultimately you end up having very similar symptoms because it's really about the circuitry that's affected.
And another way to look at it is that I also do a lot of brain simulation, so TMS, transcranial magnetic stimulation, in my clinic, and transcranial magnetic simulation is really based on this notion of what I just mentioned, this tenet that ultimately you can improve symptoms, you can improve circuits in the brain for certain symptoms no matter what the cause is. So if the cause is brain tumor, if the cause is a traumatic brain injury, if the cause is more genetic and it's more developmental, whatever the cause may be, those are all different types of brain injury. We work on the circuitry that's affected with medication, with therapy, and now also with brain simulation technology.

Dr. Katie Peters:
Do you mind elaborating a little bit more about exactly what is involved with TMS and what it means and what's required of patients or caregivers if they undergo TMS?

Dr. Sandeep Vaishnavi:
Yeah. So TMS stands for transcranial magnetic stimulation. It's basically a technology where we have magnetic pulses that are transmitted through the scalp, through the skull into the brain. One of the things about the magnetic field is that it goes straight into the brain. There's no resistance from the skull or the scalp. So again, it's a direct way of modulating brain circuits.
And there's an old saying in neuroscience, which I'm sure, Katie, you know well, which is that, "Neurons that fire together wire together." The idea here is that as the neurons are assimilated over and over again, ultimately they form more connections between each other. And these are fiscal connections by dendrites, dendritic growth, those sorts of things at the neuronal level. But they're connections. So we say that there's greater connectivity between different circuits or different nodes in the circuit.
And so with TMS, our goal is to basically form these connections where there's dysfunction. So you can imagine if a person has a brain injury and there's dysfunction in a certain circuit, if we stimulate that circuit repetitively with magnetic pulses, over time we're able to get that circuit potentially to connect better again.
So it's really a direct way of dealing with brain injuries of various sorts. For example, right now, TMS is approved by the FDA for a number of things, including treatment-resistant depression, obsessive compulsive disorder, just recently chronic pain, as well as migraines. But the TMS is really more like a technology that acts on networks and modulates networks. And ultimately, I think there are going to be many, many things that we're going to be able to help modulate different networks, we're going to be able to modulate and improve symptoms for.
It's not just neurology, it's not just psychiatry. This is true neuropsychiatry, at least the way I envision it. Because the brain doesn't know the difference between what's neurology and what's psychiatry. In the future, we could very well be using the same technology for stroke rehabilitation, for example, recovering from stroke. There's some data that suggests that. But we're also using it for obsessive compulsive disorder, which is very much we consider a psychiatric disorder.
So again, I think this is a great example of where neurology and psychiatry are kind of meeting in the middle, and this is true neuropsychiatry.

Dr. Katie Peters:
That sounds wonderful.
And could you, for our listeners, because a lot of them may not know how it's delivered, could you just tell me what's sort of involved with, if someone has to get TMS?

Dr. Sandeep Vaishnavi:
So it is, as I said, a repetitive simulation, right? So it does take time. So the way we typically do it, let's say for ... There's different protocols for different disease states, but let's say for depression, which is kind of the most commonly used of TMS right now.
So what we do is we target the left dorsolateral prefrontal cortex, so the left front part of the brain. We know that that part of the brain is important in regulating our emotional networks, mood networks, and one of the ways we conceptualize depression; no matter what the cause may be, by the way. It could be genetic related, environmentally related, or it could be due to brain injury. But whatever the cause is, we know that people with chronic depression have hypometabolism in the left frontal cortex, less activity. And so we want to stimulate that part of the brain to basically get it back up to where it should be. Right? So stimulate that part of the brain.
Once we stimulate that part of the brain, it actually allows the brain to regulate the emotional networks much better. So you can think of depression as when you're stuck in a certain mood state, you can't get out of that mood state. And so the left prefrontal cortex is usually important in contextualizing what's going on and allowing the brain to leave that state. And so using TMS, we're able to actually get that brain network to work better, to be less dysfunctional, and therefore improve depression.
And in terms of what to do day to day, you come into the clinic, it's an outpatient procedure. You'd come into my clinic, for example. It takes about 20 minutes of stimulation a day. It's five days a week for six weeks is the acute course, and then typically we have six additional sessions to sort of wean people off the treatment.

Dr. Katie Peters:
That's great. Thank you for sharing that. I'm sure a lot of our listeners will find that very useful given the myriad of different diagnoses that can be used, but also the fact that it's accessible.

Dr. Sandeep Vaishnavi:
Yeah, one of the good things about it is it is covered by insurance generally.

Dr. Katie Peters:
Great.

Dr. Sandeep Vaishnavi:
So it is accessible and affordable for most people.

Dr. Katie Peters:
Now, I know that I do a lot of brain imaging in my world, and I was just wondering, in neuropsychiatry, do you use any specific imaging or blood tests to help with either guiding treatment or to diagnose patients?

Dr. Sandeep Vaishnavi:
It's interesting that you bring that up, because with TMS, we're actually using neuro navigated TMS now. So what that means is that we can get an MRI off that particular patient, we feed it into our system, and based on the software, based on algorithms, it actually tells us where exactly we should target on that patient's brain.
And one of the really nice things about this technology is that we have real time feedback. So as we move the magnet, we're seeing exactly where we are on the patient's brain in relation to the patient's brain.
So that's a new technology. I use that personally in my clinic currently.
And then the other way we could do it is that in people who don't have a personal MRI, we can actually use a templated brain MRI from the MNI brain, it's called the Montreal Neurological Institute, and the system conforms to the patient's facial landmarks. So the brain is morphed basically into a form that fits into the patient's skull. Then we also get [inaudible 00:16:44] targets that way. It's not as personalized, but it's another way that we have to use neuro navigation.
And then finally, this is something which is new, not yet clinically available, but it will be soon, is FMRI guided neuro navigation. So there's actually something called the SAINT protocol, S-A-I-N-T, from Stanford University, and it's basically a treatment, right now it's FDA cleared, for depression, treatment-resistant depression, and it's a protocol where you basically do 10 hours of treatment per day for five days. It's very intense. You get nine minutes of stimulation per hour, so it's not like you're stimulated the whole day, but nine minutes of stimulation approximately per hour times 10 hours for five days.
The other part of it though is that you get basically an FMRI, the patient does, and based on a particular propriety algorithm that they have, essentially what it does is that it helps target in a very individual way where the magnet should be placed in the dorsolateral prefrontal cortex.
It's basically we want to figure out, "Okay, what's the location where I put the magnet where I'm most likely to get less activity in the emotional brain, more activity in the cognitive brain?" And that's at an individual level.
And the data, the outcomes that have been published have been really quite remarkable depending on the study you look at; remission rates of perhaps 80%. And these are treatment resistant depression patients who've tried many, many medications and many therapies and have failed them, and these patients are doing incredibly well with this kind of technology.

Dr. Katie Peters:
Well, that is really exciting. And I would say for our listeners, it'll be very interesting.
And I love the idea and concept, and I completely agree with you, of brain diversity. Like it's individualized for each patient.
Now, let's go back to your book again, Healing the Traumatized Brain: Coping After Concussion and Other Brain Injuries. What really inspired you to write this book?

Dr. Sandeep Vaishnavi:
Maybe two things.
One is, as we've talked about, is this sort of notion of neuropsychiatry and letting people understand that we're really not that different. I mean, the brain is the brain. And people haven't really focused so much I think in the past about the mood, behavioral and cognitive aspects of brain injury, and so that was one of the motivations of writing the book was to really expose people to that, number one.
Number two is to help with stigma, because as I said at the very beginning, people still oftentimes think, "Oh, well, my family member's mood is really weird and different now after this," but they don't necessarily correlate that with the brain injury. They may say, "Oh, well, he's not doing well. He's not adapting well to what happened to him," for example. And there's still that stigma that, "Well, just pull yourself up from your bootstraps and get going. What's stopping you?" And so that was another big motivation is for people to really understand, for family members and patients themselves to really understand that it's not their fault that this happened. It's not their fault that they have these particular symptoms.
Sometimes behavioral symptoms are hard to figure out. So if a person has a personality change after a brain injury, we don't necessarily automatically say, "Oh, it's the brain injury that did it." It may be that, "Well, there's something going on in his life", or whatever. We find out some sort of excuse for why their behavior might be that way. But oftentimes it really is the brain injury. And so I just wanted to really help people understand that, just like you have, as I said, when you have a stroke and you lose movement in one part of your body, it's not your fault. And similarly, it's not your fault if you have a brain injury that causes mood and behavioral issues.

Dr. Katie Peters:
And you just mentioned that this book can really help caregivers and care partners. Can you describe the journey that those caregivers and care partners go through when they have to deal with a loved one who has brain trauma?

Dr. Sandeep Vaishnavi:
The initial aspect of brain injury, the brain trauma treatment is sort of one thing, and then as the loved one gets out of the hospital, for example, and gets through rehab and so forth, ultimately what's residual or leftover oftentimes are these mood and behavioral problems and cognitive problems. They may not be as important initially because the doctors are trying to save the patient, so there are different priorities initially, but as it turns out, as time goes on, these mood, behavioral and cognitive problems are a huge component to quality of life.
And so I think for the caregiver, there is that journey. First of course, they're worried about their loved one and making sure that they survive or get through this, and then they get to the point where the patient is, say, back at home, and now they're noticing, "Okay, there are these chronic issues now. There are these problems with their behavior or their mood", and they don't know quite how to deal with it oftentimes.
And that's really one of the motivations of this book is to help caregivers understand where these changes are coming from and then provide some practical tools as to how to deal with it.

Dr. Katie Peters:
Your book, of course, is a resource for caregivers and for care partners. Can you describe some other resources that are available for caregivers and care partners out there that they can take advantage of?

Dr. Sandeep Vaishnavi:
The Brain Injury Association of America has a very good website. There are resources located on that website that can be very helpful for people.
Of course, if you're talking about other types of brain injuries, such as dementia, it's a kind of brain injury, of course it's neurodegenerative, the Alzheimers Association has a lot of good resources, the Brain Tumor Association as well.
So there are lots of organizations out there that have really good information on their websites to really help caregivers get the resources that they need. Because ultimately and oftentimes people don't know what to do.
For example, for Alzheimer's disease, The 36-Hour Day is a very well-known book that has helped lots of caregivers; also from Johns Hopkins, I might add. And so those are the kinds of books I think that can be incredibly helpful for patients and caregivers.

Dr. Katie Peters:
Well, thank you again, Dr. Vaishnavi, for sharing your specialty of neuropsychiatry. This discussion I think will really help our listeners and their loved ones really move towards seeing a psychiatrist or seeing a neuropsychiatrist and knowing what's out there. And so thank you for joining us on the Brain & Life Podcast.
Do you want to share anything else with our listeners?

Dr. Sandeep Vaishnavi:
Well, I just want to encourage them to keep in mind, again, the main point that I was making, that there's a stigma still that people have about psychiatric disorders, and I think we're getting over that. I think as people have understood more and more about their brain, people are getting over that, which is great. But I think people still don't understand that psychiatric disorders are brain disorders. And because they are brain disorders, it is important to understand, "Okay, how can we change those networks that are dysfunctional in the brain?"
And certainly our new technologies, like TMS, are directly doing that. So I think there's a lot of hope. Just really my message ultimately is that there a lot of medications, of course, but there are also these newer technologies and therapies, which I think are much more direct at applying the neuroscience that we have learned over the years.
The 1990s was the decade of the brain, and now here we are in the 2020s, we're finally, at least in psychiatry, we're now finally utilizing neuroscience in a clinical way, which to me is super exciting because I think it gives a lot of hope for patients that it's just like any other disorder really. You do tests, you have evaluations. I personally do a lot of cognitive testing, and like I said, I'll do imaging and things like that. So these are things that we didn't do before. It's a great time to be in this field, in neuropsychiatry and psychiatry.
But more importantly, it's a great opportunity for patients to really learn about where we are now compared to where we were years ago. And I think the field has really evolved to the benefit of patients.

Dr. Katie Peters:
Well, again, thank you very much. I'll say the quote of the day was, "Psychiatric disorders are brain disorders." And I agree that these new technologies like TMS are bringing us hope.
So a reminder to our listeners to check out Healing the Traumatized Brain: Coping After Concussion and Other Brain Injuries, and I want to thank Dr. Vaishnavi and thank our listeners, and wishing all brain wellness.

Dr. Daniel Correa:
Thank you again for joining us today on the Brain & Life Podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life magazine for free at brainandlife.org. Don't forget about Brain & Life in español.

Dr. Katie Peters:
Also, for each episode, you can find out how to connect with our team and our guests along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in an email to blpodcast@brainandlife.org and leave us a message at (612) 928-6206.

Dr. Daniel Correa:
You can also find that information in our show notes, and you can follow Katie and me and the Brain & Life Magazine on many of your preferred social media channels.
We are your hosts, Dr. Daniel Correa, connecting with you from New York City and online @neurodrcorrea.

Dr. Katie Peters:
And Dr. Katie Peters joining you from Durham, North Carolina and online @katiepetersmdphd.

Dr. Daniel Correa:
Most importantly, thank you and all of our community members that trust us with their health and everyone living with neurologic conditions.

Dr. Katie Peters:
We hope together we can take steps to better brain health and each thrive with our own abilities every day.

Dr. Daniel Correa:
Before you start the next episode, we would appreciate if you could give us five stars and leave a review. This helps others find The Brain & Life Podcast.
See you next week.

 

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