The International New York Times
September 28, 2015
by Vanessa Barbara
Contributing Op-Ed Writer
SÃO PAULO, Brazil — It felt as if a woodpecker had mistaken my head for a tree, and was tapping frantically at the area above the temple. Or maybe as if a tiny soldier were firing a tiny machine gun at my skull.
It didn’t exactly hurt; it was more like a weird sensation of pressure at the scalp. In my first session of repetitive transcranial magnetic stimulation, two months ago, I tried to ignore the fact that a machine was delivering magnetic currents to my brain, pretending instead that I was doing a peculiar laser hair removal in each one of my neurons. (Definitely a crazy person, you see.)
T.M.S. is a procedure that applies magnetic pulses to stimulate the brain’s left dorsolateral prefrontal cortex, in the hope of alleviating the symptoms of depression. The doctor places an electromagnetic coil at a specific point on the patient’s skull. When activated, the device creates a pulsed magnetic field, of a similar magnitude to that produced by an M.R.I. machine, which passes readily into the brain, altering the brain’s electrical current in order to arouse or “reset” the mood regulatory system.
In my sessions, I counted 10 seconds of a quick and loud rat-a-tat-tat tapping sound, followed by 20 seconds of inactivity. That sequence was repeated for 30 minutes, amounting to a total of 6,000 pulses. (In the United States, different treatment parameters result in 3,000 pulses per session.)
The technique is often recommended for patients whose depression has not responded to antidepressants or who cannot tolerate the side effects of the drugs. It has emerged as an alternative to electroconvulsive therapy (ECT), formerly known as shock treatment, a highly stigmatized and more invasive technique that induces a controlled brain seizure, thus requiring general anesthesia in a hospital setting. In ECT, there may be cardiovascular complications and cognitive side effects such as memory loss. T.M.S., on the other hand, is a nonconvulsive procedure that can be performed in a clinic or a physician’s office; patients stay awake and alert during the session. Other than headaches and a small risk of seizure, there are no side effects.
According to the American Psychiatric Association practice guidelines, “a substantial number of studies of T.M.S. have been conducted, but most have had small sample sizes” or too-variable parameters, and have yielded uneven results. Studies have recently found “relatively small to moderate benefits” of T.M.S. over sham stimulation. The National Institute of Mental Health also says that clinical trials revealed “mixed results.” In 2008, the United States Food and Drug Administration approved the technique for use in treatment-resistant major depressive disorder, and it’s also in use in Australia, Israel and Canada. In Brazil, T.M.S. has been a subject of research for 16 years and was approved in 2012 as a treatment for both unipolar and bipolar depression.
Encouraging results from local practitioners drew the attention of my psychiatrist, who suggested I should give it a try. I have spent 10 years unsuccessfully pushing off depression, experimenting with four types of talk therapy, including cognitive behavioral therapy for a year and a half (it was fun) and Lacanian psychoanalysis for nine months (which I hated). I tried light therapy, mindfulness meditation, yoga and tap dance.
When I finally got to my T.M.S. doctor, an expert in electrical and magnetic brain stimulation, I had amassed a long list of psychotropic medications, all taken in the past with no discernible, or very little, positive effect. It is an inventory that includes 23 different drugs in several classes such as tricyclic antidepressants (Tofranil, Anafranil), all kinds of neurotransmitter reuptake inhibitors (Prozac, Zoloft, Effexor, Lexapro, Luvox, Paxil, Wellbutrin, Cymbalta), a melatonergic drug, benzodiazepines, anxiolytics, sedatives, hypnotics, stimulants, a mood stabilizer and even anticonvulsants and antipsychotics (although I’m not bipolar). At that point, I was officially tired and decided to stop taking medication for a while. Since then, I’ve stayed the same: sad, dispirited and anxious, with a score of 31 in the Beck Depression Inventory — a moderate to severe depression.
It takes a diligent person to endure half-hour T.M.S. sessions five days a week, for at least three weeks in a row. In the beginning, the constant hammering can cause pain or discomfort. Sometimes you feel your eyes twitching and your face or jaw muscles contracting, so you ask the doctor to adjust the coil angulation or, colloquially, “do something because my face feels funny.” Although one is allowed to read or listen to music during sessions, I chose to stay quiet, with my eyes open, allegedly meditating but actually dreaming that the magnetic field of one tesla would give me powers of telepathy or telekinesis, or maybe some kind of inner wireless router that would provide me with a free mobile 3G Internet connection.
The treatment is not only time-consuming but expensive: in Brazil, T.M.S. is in the range of 300 reais per session ($85), with a total cost of $1,700 for four weeks’ therapy. (And I earn a monthly salary of $1,500.) In the United States, according to an article in Scientific American, the cost of a typical session is $300. As the whole treatment often requires 20 to 30 sessions, the total bill could amount to something between $6,000 and $9,000.
I’ve done 19 sessions so far. I felt a little better after the second week, though it is difficult to say exactly whether it was a real change or even if any small progress could be attributed to the treatment. The only thing I’ve noticed for sure is that I became more tormented by thoughts of repetitive catchy songs: for three sessions in a row, I couldn’t stop playing “Bamboléo,” by the Gipsy Kings, in my head; this was later replaced by “Mahna Mahna,” by the Muppets, and the “Trololo” song, by Eduard Khil. If I did improve, it was briefly: by the third week, things went back to the usual sadness, where they seem to remain.
Last session, just before turning on the woodpecker, my physician said maybe I should consider getting ECT. For the next 30 minutes, while my eyes twitched, my thoughts resolutely looped around that matter: “Mahna Mahna/ Do doo be-do-do.”
Vanessa Barbara is a columnist for the Brazilian newspaper O Estado de São Paulo and the editor of the literary website A Hortaliça.
A version of this op-ed appears in print on September 28, 2015, in The International New York Times.
