Brain & Behavior Research Foundation (formerly NARSAD)

Susan Burns was a woman with few options. Her medicines—selective serotonin reuptake inhibitors (SSRIs), a commonly used class of antidepressants—had caused her sodium levels to drop precipitously. After spending an entire year, in her words, “walking a tight rope” trying to find an alternative treatment approach, she finally settled on a cocktail of three antidepressant medications. They helped, but they did not lift her depression.

Susan had once been an extrovert, with thriving friendships and close family ties. But, despite her three medications, she now had gotten to a point where she didn’t really care about going anywhere or doing much of anything. She was fearful of going out at night by herself or driving. She couldn’t even pick up the phone and talk to someone and regressed to only texting. Tasks she had once enjoyed, like shopping and hunting for little treasures, became a struggle. In the midst of her anhedonia—the medical name for the inability to experience pleasure—she couldn’t even play with her adorable little puppy.

On and off in her life Susan had had bouts of depression, going as far back as her teenage years. Her twenties and thirties had gone well, but in her midforties Susan had a major depressive episode following the end of her first marriage. Around the same time, her dad died, followed by the deaths of a best friend and her beloved brother-in-law. She went on antidepressant medication (Paxil) for the first time. A few years later, in 2006, Susan met her now-husband, and built herself a house. Feeling good, she stopped taking Paxil. However, her depression returned a few months later. She began to feel like a failure at her very stressful nursing job. Paxil no longer worked in alleviating her depression. Neither did any other new medication that she tried.

Her psychiatrist mentioned electroconvulsive therapy (ECT), a procedure conducted under anesthesia, in which a seizure is induced electrically in the brain. For Susan, as for many patients in her position, ECT seemed a last resort. She wasn’t ready to try it.

An R.N. for four decades, Susan was no stranger to the world of medicine. She began reading up on transcranial magnetic stimulation (TMS), another treatment option brought up by her psychiatrist. TMS, unlike ECT, is noninvasive. It involves the application of magnetic pulses to the scalp above the left eye, which corresponds with an area of the brain involved in depression. TMS does not induce a seizure, and has only minor side effects such as treatable headaches. For Susan, this seemed to be the best next-step treatment option.

Susan’s research led her to the Medical University of South Carolina (MUSC) in Charleston. It was at that institution two decades earlier that Mark S. George, M.D., now a distinguished professor and member of the BBRF’s Scientific Council, pioneered methods that led in 2008 to F.D.A. approval of TMS for treatment-resistant depression— depression that fails to respond to at least two prior courses of standard treatment. Dr. George performed his early work with the help of BBRF Young Investigator awards.

Susan’s TMS treatment was typical: intensive, with a daily session Monday through Friday for six weeks, followed by a tapering-off period involving an additional six treatments.

At her first appointment, the TMS physician put a skull cap on Susan to measure and mark exactly where to apply the magnetic pulses. At every subsequent session, Susan wore the marked cap as she reclined in what seemed to her like a dentist chair, ears protected by ear plugs. The machine whirred to life, with the magnet (placed over the brain’s left occipital lobe) turning on for 4 seconds, then off for 10 seconds. This on-off sequence was repeated for 37 minutes, the standard therapeutic dose established in large clinical trials prior to FDA approval of TMS. The repeated on-off pattern of pulses explains the formal name of the treatment: Repetitive Transcranial Magnetic Stimulation, sometimes abbreviated rTMS.

Susan describes her first few sessions as eliciting an odd feeling in her left eyebrow, almost like a little spark traveling down to the tip of her nose. The oddness of that feeling dissipated after a few sessions as Susan got used to it. Within a week of her first session, which was performed this past January, Susan began to feel better. The joy she had lost began trickling back.

Susan recently finished her course of TMS treatment, and she gratefully reports that it has completely transformed her life.

“I feel like the joy has returned in my life. I feel like I’m back where I was years ago,” she says.

She can once again enjoy going out and seeing friends and family, especially her grandchildren. Her husband, who has been her cheerleader throughout, feels that the woman he married has returned.

Susan’s depression has lifted for now. About one-third of treatment-resistant patients who try TMS similarly have a remission; about half of all who try it have what doctors define as a clinical response, which means they have a significant decrease in depression symptoms. Like other “responders,” it’s possible that Susan may not need further treatment, or that she may need a short course of TMS from time to time to maintain her remission.

Susan continues to take her standard antidepressant medications, even though she acknowledges that it was the addition of the TMS therapy that actually made the depression start to dissipate. Experts continue to investigate how antidepressant medications and TMS work together. It is possible, although unproven, that they may be working synergistically.

What makes TMS so exciting for patients like Susan is that unlike ECT, it has almost no side effects. Some patients get a temporary headache, and there is a rare risk of seizures. Susan experienced nothing but a temporary feeling of fullness in her head.

On her journey to wellness, Susan discovered something else: she no longer wanted to hide her depression. While once, she had never wanted anyone to know about her illness, she says she is now very open about what she is going through.

Susan recalls a conversation with a young doctor when she was at one of her darkest points. She told him that she felt like a dull penny that had been in circulation for many years. There are pennies that are shiny and look brand new. And then there was Susan. She told him that she always wanted to be the shiny penny. That was her goal.

“I’m almost that shiny penny again, with a few little rough spots on it. But that’s where I am,” says the 65-year-old. “That dull stuff is wearing off and this shiny person is coming out again.”