Only 1% of U.S. adults have received TMS therapy, despite FDA approval since 2008. Dr. Martha Koo saw the potential early—so early she bought her first TMS machine in 2009, when most colleagues thought she was "a bit crazy."

‍

Today, her South Bay TMS & Wellness operates 12 centers across California. Her journey from skeptical peers to pioneering one of the country's largest TMS networks shows how a single psychiatrist's calculated risk became a blueprint for modern interventional psychiatry.

‍

What you'll learn:

‍

• Why Dr. Koo gambled on TMS when it was barely proven
  ‍
• The insurance workarounds that jump-started the field
  ‍
• How TMS differs fundamentally from medication and therapy
  ‍
• Where neuromodulation is headed next—from adolescents to implants

‍

Listen to the full Psychiatry Tomorrow episode here:

‍

‍
‍

The $100K Gamble When Most Psychiatrists Owned Only a Phone

In 2009, psychiatrists weren't buying medical equipment. "Our overhead was like a phone," Dr. Koo laughs. Radiologists had million-dollar MRI machines; psychiatrists had offices with two rooms if they were fancy.
‍

Spending six figures on a magnetic coil? Unheard of.
‍

"People did think I was a bit crazy," Koo recalls. "It was a lot of money just to commit to a device and there wasn't a lot of acceptance at the time that it was truly an efficacious and safe procedure."

‍

But she'd been working with neural modulation—performing outpatient ECT at UCLA - since the mid-1990s. When NeuroStar secured FDA clearance, she was ready. So confident, in fact, that she initially offered patients a money-back guarantee if insurance appeals failed.

‍

She never had to pay up.

‍

The Accidental Insurance Hack That Funded TMS Research

Early billing operated in a regulatory gray zone. With no established coverage, providers used temporary T-codes and charged about $350 per session. Some insurers mistakenly processed invoices like routine MRIs—and paid without question.

‍

Koo remembers. "Somebody thought individuals were getting 36 MRIs in nine weeks and they were paying for it."

‍

Patients would front the cost, complete treatment, and then appeal with objective outcome scores. Within three months, most appeals succeeded in third level appeals due to evidence-based rating scales documenting response or remission. Insurance companies, without meaning to, were underwriting the early research.

‍

This TMS Chair Is Not Santa's Sleigh

Dr. Will Sauvé, now Osmind's CMO, still tells the story of a reluctant patient who only agreed to TMS because his wife was pressuring him. "I don't believe in this," the man told him flatly. "I think it's silly." He used "some more less appropriate words" about what he thought TMS was.

‍

By the end of treatment, he was in complete remission. "I've never been so happy to be wrong," he told Sauvé.

‍

This crystallized something Sauvé had long suspected: "Our entire careers, we've been telling people you kind of have to have some faith in that pill if you think it's going to do you any good. You're somehow sabotaging your treatment."

‍

With TMS, that changes. "This TMS chair is not Santa's sleigh. It does not run on belief. It's going to stimulate your brain. All you got to do is let it."

‍

Koo agrees: "I've never seen someone's disbelief interfere with outcomes."
‍

"I'm Good, But I'm Not My True Full Self"

Koo's biggest revelation came not from new patients, but from her longtime therapy clients. After leaving a TMS brochure in her waiting room, they began asking about it.

‍

"Well, can I do TMS?" they asked. "Well, you're better, right?" she'd respond. "Yeah, I'm good, but I'm not my true full self."

‍

That response stopped her cold. "You lose perspective," she reflects. "I never met those people at their 100%."

‍

Psychiatrists often celebrate getting people 30–50% better and lose sight of complete recovery. "You can't put words on it," Koo says. "You see how people pop with TMS. They come to life with so much more color in it."

‍

Military Medicine: The Seven-Day Experiment - TMS for PTSD over polypharmacy?

After leaving the Navy, Sauvé brought his TMS experience to Poplar Springs Hospital in Petersburg, Virginia, where he ran an inpatient PTSD program. In 2011, he pitched TMS to his CEO there. The military was grappling with polypharmacy—multiple psychiatric medications, dangerous combinations, bad outcomes.

‍

His pitch was simple: "If you bring TMS and I can treat our patients without adding more drugs, it will be gold.”

‍

Because patients stayed for 28-day inpatient programs, Sauvé treated them seven days a week—breaking the standard five-day protocol. That five-day schedule, according to industry lore, only exists because the original researcher’s wife told him if he didn't come home on weekends, she'd leave him.

‍

Results exceeded expectations. Depression scores improved, but so did PTSD symptoms across the board—all without adding medications.

‍

The Future of Neuromodulation: Accelerated, Mobile, and Implantable

Koo and Sauvé see three major developments ahead:

‍

Accelerated protocols that compress six weeks of sessions into a single day. The research on durability is still emerging, but the potential to eliminate treatment burden is significant.

‍

Mobile devices that extend beyond psychiatric offices. "Why don't oncologists have TMS centers there to support their patients? So many people really struggle with depression around mortality and death. Why don't OB-GYNs have it for their postpartum depressed patients?" Koo asks.

‍

Implantable stimulators—tiny devices offering continuous brain modulation. Sauvé mentioned hearing about this from Dr. Nolan Williams' research at Stanford. While it sounds futuristic, so did magnetic brain stimulation 20 years ago.

‍

The conversation also touched on vagus nerve stimulation (VNS), which Koo sees as complementary to TMS. "I'm excited to hear about VNS making a comeback," she said, noting the strong outcomes from recent RECOVER trial data. Her practice is planning to offer VNS soon, with the idea that patients could get TMS during the six-month VNS activation period—a "top down and bottom up approach."

‍

Sauvé agrees about the combination potential: "TMS and VNS are sort of a match made in heaven" because TMS can provide immediate benefit while waiting for VNS to take effect.

‍

Why TMS for Adolescents Could Change Everything

With recent FDA approval for adolescent TMS, Koo sees major implications. Instead of telling 20-year-olds they have a chronic illness requiring lifelong medication, early intervention might prevent future episodes entirely.

‍

"How many 20, 30-year-olds maybe would have chosen a different career if they were feeling better? Maybe they would have chosen a different partner?" she wonders. "All these choices in life we make based on our mood and our energy and our self-esteem could be drastically different."

‍

If TMS can "retrain the brain to fire differently" during first episodes, it could fundamentally alter how we think about chronic mental illness.

‍

The Isolation Problem in Psychiatry and Its Professional Imperative

A 1960s New York Times article called psychiatry "The Impossible Profession," partly because of its inherent loneliness. COVID made this worse, with most medication management going virtual.

‍

"Even if you're in a group practice, you're in your little cubby hole all by yourself or you're at home," Koo notes.

‍

TMS changes that dynamic. "We have nine doctors at our practice. There is a real community feel." During COVID, patients were grateful just to have human contact—"particularly people who are single and live alone."

‍

This leads to Koo's blunt advice for colleagues still hesitating: "You've got to do it. I don't know how you can perceive a future in the field of psychiatry without integrating /neuromodulatory techniques."

‍

She compares resistance to staying stuck in the past: "It's no different than I could be deciding I'm putting every single one of my patients on Prozac... and deciding I'm going to be in the eighties... You don't want to just be practicing medicine in the olden days."

‍

"I don't see a world in future psychiatry that is going to just be medicine and therapy," she adds. "The cat's out of the bag on that one."

‍

Conclusion and Shownotes

Dr. Martha Koo's 15-year journey demonstrates what happens when psychiatrists bet on unproven tools and keep pushing boundaries. TMS doesn't require patient belief, can achieve more complete recovery than traditional approaches, and addresses both polypharmacy and professional isolation.

‍

The next wave—accelerated protocols, mobile devices, and implantable stimulators—will push the field further. For clinicians, the choice isn't whether to integrate neuromodulation, but how quickly they can learn it.

‍

‍

Timestamped Show Notes:
‍[08:09] The $100K gamble and early TMS adoption[
13:25] Insurance loopholes and money-back guarantees
[15:57] "Not my true full self": what patients really want
[19:44] Santa's sleigh and the belief problem
[22:50] Military medicine and the polypharmacy solution
[25:05] Why TMS is five days a week (blame Dr. George's wife)
[28:33] Accelerated, mobile, implantable: what's next
[34:05] VNS comeback and combination approaches[37:21] Interventional psychiatry as evolution, not revolution
[48:09] Advice for hesitant psychiatrists