Welcome And Why Neurocare Matters

Dr Andrew Greenland 0:00

Welcome to the Voices in Health and Wellness podcast, where we explore real conversations with the practitioners, founders, and innovators who are shaping the future of care. I'm Dr. Andrew Greenland, I'm your host today, and today's episode is especially meaningful as we dive into the evolving world of mental health and neurocare, an area that's seeing rapid innovation but also increasing demand and complexity. I'm joined by Dr. Scott West, Chief Medical Officer at Nashville Neurocare Therapy. Dr. West is a nationally recognized, board-certified psychiatrist with over 30 years of experience, particularly in the treatment of clinical and treatment-resistant depression. His work sits at the intersection of traditional psychiatry and of emerging neurotherapies, helping patients access more advanced and personalized care options. So with that, Scott, I'd love to welcome you to the show and thank you so much for joining me today.

Dr West’s Path Into TMS

Dr Scott West 0:50

Thank you for the invitation. I'm glad to be here.

Dr Andrew Greenland 0:52

So maybe we could start at the top. Could you talk a little bit about your role and your journey into the work that you do? Because I always find that's inspiring and gives a lot of context for people that might be listening.

Dr Scott West 1:03

Sure. I finished my residency in psychiatry in the 80s and started a private practice, worked in hospitals, and as well as having an outpatient practice. And at some point early in that journey, uh the local University of Vanderbilt referred a student to me who had a mix of anxiety, depression, obsessive-compulsive disorder. She eventually was referred to the facility in the Northeast and decompensated there, was hospitalized at Harvard. When she came back ultimately to Nashville, she told me about the research that was being done there on something called transcranial magnetic stimulation, which was quite interesting to me as a way of non-invasively doing something in the brain to facilitate some positive clinical change. And so I paid attention to that as the research came out over years. And eventually in the early 2000s, when it was being researched with an intent to have uh FDA clearance, I was paying more attention. I made an assumption then that it would probably be at either academic institutions or large facilities. But when it was FDA cleared in 2008, and then I looked into it further, I found out it was an outpatient procedure. And at the time, having more than 20 years of experience seeing people with uh depression, and that's what uh transcranial magnetic stimulation was FDA cleared for initially, uh I thought there's a people get better. People do well with therapy, with medications, the first-line treatments, but not everybody really gets well, and some people don't seem to respond at all. Uh, we had at that time an option of electroconvulsive therapy, but in terms of looking at less invasive opportunities to help patients improve their clinical situation and the quality of life, this seemed like something that was worth pursuing as I reviewed the literature. And uh so I contacted the organization and in 2009 made arrangements to begin the process of this new type of non-invasive treatment on an outpatient basis. And it started in 2010. And what we found was that a lot of people did really, really well. Uh, most of our initial patients were patients that I knew that had been in my practice, and I knew their course of treatment and knew how aggressive the treatment had been. And so when we found those people having an improved quality of life reduction of symptoms, uh, thought we needed to pursue this. So over time we uh expanded the clinic a bit in doing it in our one of our offices in uh Nashville. And as time went on, uh we needed to grow more. I had the opportunity uh with uh neurocare to collaborate on that, to increase the footprint, to get more uh have the treatment available to more people. Uh and uh some of my colleagues around the country of the U.S. have done that as well, uh, and now uh across the globe. Uh so it became a treatment that was working. The idea was how to make that more available to people, and one person alone has some limits with that, so collaborating seemed like the thing to do. Uh, TMS has grown to where there were a few hundred of us at the beginning, and now there are thousands of systems around the world. But neuromodulation didn't really stop there. We TMS has grown, and there are different uh variations of it, different parameters that can be used. So it's maturing in its own right, uh, but now the whole world of neuromodulation is uh becoming something that incorporates different types of therapies of not just activating the dorsal lateral prefrontal cortex, but uh using different uh treatment modalities to activate the trigeminal, occipital nerves, uh, uh transcutaneous electrical stimulation. Now we have uh pharmacological uh uses that are in the world of neuromodulation, including ketamine and es ketamine. And there's I think opportunity for growth with many other things down the road.

Dr Andrew Greenland 5:26

Thank you. So tell us a little bit about the setup at Nashville Neurocare and what's your role specifically there?

Dr Scott West 5:32

Uh I uh am the uh medical director, chief medical officer. We now have uh several clinics around the state. Uh, some uh of our my colleagues in Knoxville uh do the medical management, direct medic management in that clinic. Uh I supervise the uh practitioners, the physicians, the nurse practitioners that are doing either medication management or TMS. Um and that's my specific role. Uh also as um part of the uh the the group that manages it, we am involved in all sorts of discussions that have to do with the back office management decisions about human resources, about marketing, uh, about um insurance negotiations and so forth.

Dr Andrew Greenland 6:22

And I guess your role has evolved as the practice has grown. I mean, how has it changed with time?

Dr Scott West 6:28

When I first started, it was uh I was the person who did everything uh from uh going to talk to local colleagues to um uh intakes, uh doing the motor threshold determination, the mapping that's essential to TMS in the beginning, um, sometimes doing the treatments, uh having all of the business decisions, because it was my business alone, didn't have anybody to bounce the ideas off of other than the occasional colleague that we can talk about things. Uh so it's grown uh to be more focused on the clinical, uh, but still having some input into the back office type of things.

Dr Andrew Greenland 7:09

Thank you. And in terms of the patients that you're seeing, the patients that you're helping at your clinic, can you give us sort of a range of the different presentations and how your approaches are doing things differently to perhaps how others are doing them?

Dr Scott West 7:24

Uh yes, the the initial FDA indication with transcranial magnetic stimulation was for major depressive disorder that hadn't responded to medication. It has expanded over time uh to include anxious depression, uh, uh OCD uh with a different type of uh treatment location. Um and so it's been very diagnostic driven. I in many ways don't like that because TMS is a tool that is increasing uh circuit activity in the brain, and it's increasing plasticity, uh, it's increasing the activity of monoamines throughout the brain. And depending on what part of the brain is particularly activated, uh it can do other things. There are a lot of, if you will, off-label uses for TMS, but they are off-label without an FDA indication. But there's a lot of research out there looking at it for a myriad of clinical issues. Uh so while most of our patients do have major depressive episode, oftentimes with anxiety, and a smaller number have obsessive-compulsive disorder, there's oftentimes a mix of symptomatology that we have to deal with. We're also now dealing with the possible additions of other types of therapies to use synergistically with TMS that include medication management, include psychotherapy. So it's everybody is an individual and they come with their own issues, their own psychodynamic situation, and we're looking at what we can do with each patient to help facilitate the improvement in their clinical symptoms.

Awareness Is Rising Yet Insufficient

Dr Andrew Greenland 9:09

Thank you. And you what are the sort of major shifts that you're seeing right now in the wider mental health world and neurocare from your perspective?

Dr Scott West 9:19

I think the first thing that comes to mind is the expect the greater awareness of the need for mental health services. Um for so many years, decades, centuries, it's been not talked about much. Uh now it is talked about a fair amount. Uh more people are comfortable with it. Uh, particularly a younger generation seem to be much more comfortable talking about it without having to be pride to get information from them. Um so awareness is the first thing. The other thing that um comes to mind is the lack of awareness. Because as much as we have made progress with people knowing about mental health issues, treatment options, there's still so many people who um don't pay attention to it. And it it doesn't serve our population well. We know, for example, in the uh with employment uh that about 20% of people are struggling with some type of depression. Uh about a third of those are really struggling, and they're they're not doing well, they're uh have this issue of presenteism where they're there, but that they're not fully able to function because the issues specifically with depression that have to do with motivation, um, persistence of activity, cognitive functioning and efficacy aren't there, so they're not fully able to be as quality an employee as they need to be. Thus it's causing problems to the employers. But also, when those people go home, it's not about employment, it's about their home life, their children, their family. Um, when they're not going to the children's plays or productions at school and they're not socializing with friends, it limits their quality of life. So, as well as much as we're talking about mental health more, we're not talking about it enough so that people implement changes in their lives that can accomplish improvement in their what they're trying to do in their lives.

Dr Andrew Greenland 11:19

Thank you. I guess you're saying that there is a rise in treatment-resistant depression. Um, that being the case, how has it impacted your approach at um where you're working?

Dr Scott West 11:29

Uh it's uh just gives us the incentive to try to make us available to other people. Um, we continue to try to look at clinical changes we can make in what we do. Uh, so we're providing people with optimal treatment.

Dr Andrew Greenland 11:46

And you were talking about the awareness of your approach. I mean, what is the level of awareness? I mean, do people um appreciate that there are the options when you know the drugs aren't working?

Dr Scott West 11:56

Uh some people are aware of that, others aren't, and they just stagnate and they are um they're kind of sort of maybe better, but not really better, but don't know what to do about it. And that includes some of our uh my colleagues don't know what to offer them. Uh neuromodulation, specifically TMS, has not penetrated into the greatest awareness with uh therapists, clinicians, psychiatrists, uh, and primary care doctors.

Dr Andrew Greenland 12:28

What about patient expectations? Have you noticed a change in patient expectations since you've been in practice? And what are you kind of picking up on in 2026?

Dr Scott West 12:38

Yes, patients tend oftentimes will want uh the to be all better. Um they're they're looking for something that's going to make all the symptoms better. And I think we're much more complex than that. Even if we can improve symptoms, sometimes people's psychosocial situation is not optimal. They have difficulties with relationships or with work or with um uh neighbors, and sometimes within families. And if they don't address those and learn ways of positively uh moving forward with life and dealing with conflict, unfortunately the symptoms recur so often.

Dr Andrew Greenland 13:22

And um, you mentioned obviously the general increase in mental health disorders. Do you think the system is keeping up with this level of demand at the moment, the wider system?

Dr Scott West 13:32

I don't think so. I think there are efforts to do that, but it's uh there are not enough therapists, there are not enough uh psychiatrists uh around here, and from what I hear and uh around our country. Um it so I I think there are efforts to try to do that, but it's it's a challenge.

Dr Andrew Greenland 13:53

And what do you think the solution is? I mean, how how are we going to get to a situation where supply and demand are kind of matched?

Dr Scott West 14:01

Well, I I don't know that there is a fix to that, but I do think that as we can encourage uh people to move into the areas of um being therapists and being clinicians in that space, um, that we we move toward that direction of improving that imbalance.

Dr Andrew Greenland 14:22

So thinking about your clinic as a business, because it is at the end of the day, what what are you most proud of and what's working really well for your practice right now?

Dr Scott West 14:31

Uh the our per are people. Uh we have put a priority on finding people who are very invested in helping others uh in uh doing their particular job, and we cross-train people so people are very familiar with all the aspects of what we do, uh, but it's the personnel that we're involved with that um is I think at the height of my uh awareness when I think of what I'm proud about.

Dr Andrew Greenland 15:02

So the $60 million question is how do you get good people and what's so how how do you train them in such a way as you have such good people working for you? What's the what's the secret sauce?

Dr Scott West 15:14

Um I think it to the degree it's a secret sauce, it's involvement. Uh it's clear expectations, uh real guidelines that make sense, um, and an upfront discussion about uh with people about what those expectations are and what their uh uh strengths are, what their weaknesses are. I have an interview this afternoon with someone, uh one of our treaters has moved on to other things in their life, and so we're uh looking for somebody right now. So it's kind of top of my mind. How do you find the right people to do uh the best job they can?

Dr Andrew Greenland 15:53

And we talked about what's going well, what you're proud of. What's most frustrating or challenging, or things that you've had to overcome in doing the work that you do?

Dr Scott West 16:03

There are two things. One of them I've mentioned the lack of awareness. Um it's uh frustrating to do something that we know based on our own experience as well as the research that is very helpful to people, but so many people don't know about it, and trying to help my colleagues and the community be aware is one of the frustrations. The other one has been dealing with uh our insurance system where they have finally have coverage for uh neuromodulation techniques, TMS and eschetamine, uh, but the criteria are onerous at times. Um they our patients have to jump through hoops to be able to get the treatment that we think would be of help.

Dr Andrew Greenland 16:48

So the insurance seems to be a universal conversation I have with all everybody working in America and all the discussions I've had. What is it about um this particular technique that causes so many issues in terms of getting the reimbursement? Why is it such a treacherous journey?

Dr Scott West 17:06

Part of it in in terms of reimbursement but also patient access was um there was such a paradigm shift. Transcranial magnetic stimulation is unlike anything that's uh been done in our world before. Um and um so it the insurance companies didn't know what to expect. Uh and I think that has caused a lot of it. Uh there's uh a concern that there would be some type of overuse, uh misuse, and I think we all want to guard against that because that's a possibility. Uh, but it's the in most people with the insurance companies, at least early on specifically, just did not know what to think about uh using a electromagnetic current to activate the brain. That was an unusual thing for them.

Dr Andrew Greenland 17:55

Um as a medical director, I guess that you're there are some particular metrics or outcomes that you're always interested in. What are those for your clinic? And is there anything that you're most focused on trying to improve?

Dr Scott West 18:06

Uh response and remission rates are the number one thing. Uh, and uh with the original studies that were done when people were um off of medicines for a long period of time, not in any type of therapy, uh, we had uh remission or response rates that were over 50 percent. Uh and we we try to improve that as we use that mix of treatment opportunities with patients and uh newer type of techniques where that there might be, for example, multiple treatments a day and so forth, and uh and we're moving up toward the 75 to 80 percent response rates. Uh, and that's that's extremely uh positive from our standpoint when we see our patients respond. Uh so the focus is on the remission and response rates.

Dr Andrew Greenland 18:58

Thank you. So, with the medical director hat on, I guess you do have lots of hats. Um, and I'm just curious to know if there are any particular bottlenecks that you are having to face or deal with in the kind of the back end of the operation, not necessarily the patient facing, but all the stuff that goes on behind the scenes.

Dr Scott West 19:14

Uh that would include uh again getting helping people understand that we exist. Um the uh it deals with dealing with insurance companies just in uh nothing unique to us, but that process is never easy for any of the uh clinicians to deal with. Um and personnel issues. Um we value our personnel, and uh even as we have very good people that work with us, there are also always issues that come up uh just as we're handling all of that type of thing. And then the the expectation, uh and this is really much more of a positive opportunity, I think, but looking forward, how can we advance what we're doing? How can we refine it? Uh how can we um add to what we're doing to um with new technologies and so forth? So the opportunities of of progress.

Dr Andrew Greenland 20:11

And um from a medical director's point of view, the chief medical officer's point of view, what's the biggest time drain for you?

Dr Scott West 20:16

What takes you away from the things that you enjoy doing in your practice that um well, just curious to know what what are the what are the personal time drains for you um the administrative issues that take up most of that are going to be doing peer-to-peer uh conversations with insurance companies. Um it's going to be uh the supervision of going through the charts and kind of making sure uh all the all the things are done that need to be done. Uh they're not bad, it's just those are uh just the things that uh it'd be nice not to have to do, but that's part of the requirement.

Dr Andrew Greenland 21:01

I guess everybody wants to grow, but if you had a sudden inflex of, I don't know, 50 new patients next week, what would happen from a business point of view at your end?

Dr Scott West 21:13

Uh we would be much busier. Uh that would that type of uh increase in patients uh would necessitate the question of what do we want to do? Because we don't want to withhold treatment from people. Uh we would probably be referring people to colleagues in the surrounding areas if uh people came in because there's only so much we can handle. But if that did occur, we would be looking at the opportunity for is that a sign that things are picking up so much? We need to hire more people, we need to do more, have expand what we're doing. Uh again, that would be uh uh quite an opportunity uh to uh address.

Dr Andrew Greenland 21:56

And are there parts of the practice you've deliberately chosen not to grow? Scale and is there a reason behind that at all?

Dr Scott West 22:05

We haven't decided not to, but we have decided to not do as aggressively as in a fantasy world we might want to because it just takes uh there's there's only so many of us, there's only so many time, so much time. Um so I I spend some part of my time encouraging my colleagues to uh think about this to grow uh so that we don't have to. So the uh we I supervise uh residents from a local rep uh psychiatric residency program, encouraging them to consider moving in the direction of neuromodulation, and fortunately, uh so many of them are interested right now.

Dr Andrew Greenland 22:50

And if you have any thoughts on group programs or digital tools or education to support patients beyond the one-to-one care in the in this sort of sector, just because it's something a lot of people talk about. I just wonder if you have any thoughts on this.

Dr Scott West 23:05

The thing that I have contemplated with that, and some of us have been talking about it now for a little while, of trying to monitor the response rates digitally over time through some technologies. So there is some consideration of how we can incorporate uh such technologies in a way of maintaining uh more consistent improvement over time. That's one thing that we're not things aren't built the way to do that since we don't follow everybody. We lose people to the community, and so we don't have a good handle on what's happening with that. And we've contemplated using some uh digital programs to pursue greater clarification of that.

Dr Andrew Greenland 23:54

Um, if you had a magic wand and you could fix anything in the business tomorrow, what would it be? And I will assume that we've solved the problem of awareness through other means, but is there anything else that you would love to be able to fix very quickly with the magic wand?

Dr Scott West 24:06

The magic wand I would put myself out of business. I'd uh you you erase depression and no CD and anxiety from uh from people. I'm not sure I mean that because I think those uh types of things do serve a purpose as uh red flags for us in life. Uh but I would certainly there would would want uh to minimize that in terms of the degree of difficulty it causes people.

Dr Andrew Greenland 24:34

And finally, where would you like to see the practice in six, twelve months' time? So just thinking ahead, you know, 2026, 2027, where would you like to be in a year's time?

Magic Wand Hopes And Hindsight

Dr Scott West 24:44

Uh would like for us to grow. Uh we're looking at some different options in terms of how we can expand. Um if we maintain volume as we are now, then we're going to have more opportunities to do that. Uh, and so we might uh expand the size of our uh current locations, we might consider adding some locations, um, we might consider adding some different uh protocols. Um expansion is just doing what we do, but doing it at a larger scale, and that's what I'd like to see over the next six to twelve months.

Dr Andrew Greenland 25:26

Well, we wish you all the best with that. And finally, if you were starting Nashville Neurocare again tomorrow, would you do anything differently with the benefit of hindsight and all that you know?

Dr Scott West 25:36

The one thing that I would do is as you mentioned earlier, it is a business. Uh, I would seek out um somebody who has more of a business mind uh as a consultant uh to help me think things through. Um I I used people that I've uh had had known, but nobody that had the real more um strategic vision. And I think that would have been helpful to begin with, uh, and I think have erased some of the struggles we had along the way.

Dr Andrew Greenland 26:12

Wonderful. With that, I'd love to thank you very much, Scott, for joining us today. It's been a really interesting discussion learning about the technique, your clinic, your approach, and some of the kind of business angles to running the clinic that you do. So thank you so much for joining us. It's been a real pleasure. Thank you.

Dr Scott West 26:26

Thank you, Dr. Grinland. It's been nice.