rTMS, the first experience

This post is ridiculously late. I’m already past my halfway point in the treatments, but to be honest the depression has ripped my motivation out and replaced it with things like a “paint by number” app on my phone, or making endless tunnels in Terraria. Or just staring at walls. I’m zoning out a lot lately and finding my eyes stuck on a distant point, unfocused. Usually until they’re so dry they blink automatically, but sometimes that doesn’t even snap me out of it.

So the initial consult was a telemedicine call with what I call my “physical psychiatrist” – the one who hooked me up (literally) with ECT and now rTMS.

rTMS, or TMS is:

(repetitive) Transcranial Magnetic Stimulation is a noninvasive form of brain stimulation in which a changing magnetic field is used to cause electric current at a specific area of the brain through electromagnetic induction.


It was (I think) shortly after my current episode kicked into high gear back in March or April. Wife and I chatted with the doctor, who I really like despite the number of times he’s electrocuted me. Since ECT took so long to really show benefit, and we’re not even sure it was the ECT – it might have been meds or simply passing time that got me out last time – we decided to go with TMS. I know last time they gave me the choice between ECT and TMS and I said “go big or go home” and went with ECT. It was going to take a bit of time to get on the schedule, so in the interim I was admitted to the partial hospitalization program to hopefully stabilize me, and after that the Day Treatment (Arts and Movement) to give me some structure to my days, as well as refresh my mindfulness learnings. Apparently last time my memory was so bad I couldn’t remember any of the previous days lessons, but they let me keep going just for the fun of it.

I didn’t have a lot of expectations except for the fact that one of the women in the Day Program in 2019 was doing TMS at the same time, and sometimes she would kind of drag herself into attendance, and someone else mentioned that TMS can really “take it out of you” on the day of treatment.

I did a ton of research, of course. Web pages and blog posts, YouTube videos and books. Pretty much everything agreed – no serious side effects, maybe some head pain during treatment, and in some cases, headaches afterward which could be treated with ibuprofen but they usually went away as you got used to the treatments. In rare cases where something wasn’t done right, there was a risk of seizure. My depression brain was hoping for the drama of that last one, but so far no luck. I did have a particularly bad day outside of TMS and during the treatment various limbs were flopping about here and there, but nothing so interesting that anyone noticed.

So the first appointment involved going to the TMS area and seeing my Doc. It was to calibrate the machine to my particular brain and give me my first treatment. The TMS department is near one of the main entrances to the hospital. I’d drive or ride my scooter, park in the ramp, and pop across the greenspace to the entrance. For more than half of my treatment weeks the ramp was being updated, so it was free. Which was nice. I never really like paying full price to park a tiny little scooter, so this kept me a little less grumpy.

Because of COVID, only a few entrances are open. When you come in you have to tell them why you’re there, and they give you a sticker with the date and where you’re going. They hand it to you and then tell you to use the hand sanitizer. At this point I just walk up and say “TMS” and they’re good to go. Sometimes I have to say it once or twice, but to be honest I’ve seen them write TMS, TMC, and a variety of other wrongness. If I’m there on time they get that sticker out quickly, and if I’m running a little late they need to do it in calligraphy with illustrations and an edition number and artist signature. I’m still waiting for them to recognize me and kick a sticker out without asking. Hasn’t happened yet. Guessing on my last day they will.

There is a waiting room that you breeze through, a subwaiting room (with lockers) that I haven’t had to wait in, and finally the TMS antechamber. The TMS room is like a recording studio, with desks and monitors on one side, and a room with two big dentist looking chairs, the TMS apparatus and two big screen TVs. On the TVs they have drone footage of beautiful locations and landscapes, or underwater scenes. Think a visual version of elevator music. For a normal treatment you just go in, get set up and they start the treatment.

Every week they give you a depression inventory and an anxiety inventory (if you’re there for both.) and I can’t remember what my scores were that first week, but they were pretty bad-ish. For every single treatment you get a standard hospital wristband, which they then cut off after the procedure and throw away. I get that it’s in case you have a seizure or heart attack or something and they have to wheel you off to parts unknown, but it feels silly when you’re just in and out in 45 minutes.

For the first treatment, they have to figure out where your brain is. They know where (in general) the motor activating part of your brain is, so they find that and then use brain orienteering to hike over to the part of the brain they want to stimulate:

Schematic representation of TMS coil location for the stimulation of... |  Download Scientific Diagram
I stole this image from somewhere. If you want it back, just ask.

They have you hold your hand up and then they start zapping your brain with very specific, high intensity magnetic waves. Depending on what twitches, they know where they are. They really wanted just my thumb to twitch. So when the pinky went, they moved a bit and then a different finger twitches, they move again and so forth until just the thumb twitches. They tells them exactly where they are along that line of motor control brain stuffs, and from there they can estimate the location of the target area. For future treatments they have it all recorded on the machine and you just have to be in the right spot for it to work. That was calibration, and it was relatively painless and pretty interesting.

I got my first treatment right after calibration. For a standard treatment they have you sit in one of the two chairs (I’m usually in the first, and the main difference is the height of the seat, so one you’re kind of slouching down a bit and another you’re sort of stretching up a bit. But nothing worth mentioning twice, they’re just different. To align you to the machine properly, they shine a weak laser at the right hand corner of your eye, from beside you. If it’s not quite lined up, they’ll tell you to scootch up or down a bit until it’s juuuust right. I’m fairly good at getting in the right spot on the first try, and I can see the light just out of the corner of my eye so I know if they’re going to say high or low.

Once I’m positioned they start with the left side, for depression. It’s a series of a dozen or so taps in rapid succession, followed by 10-15 seconds of rest, then do it again and again. This goes on for 18 minutes. The person administering the treatment will let the first set run and ask where on the pain scale it is. If it’s 6 or more they offer to reposition the tapper and that sometimes makes it feel better. If you’re tired, it tends to hurt more. The pain is in two parts, but pretty minimal. First, it feels like they’re tapping on your forehead with a blunt screwdriver. Second, there is a deep throbbing pain like someone is stabbing your brain with a magnetic hammer. Both are only felt when the tapping is happening and the moment it stops tapping, the pain is completely gone.

On the right side, for anxiety, it’s similar except instead of bursts, it’s one tap per second, and that hurts much much less. Another 18 minutes of that and you’re done. The problem is that it sounds like a metronome and the rhythm helps you get to sleep. Except you’re not supposed to sleep during treatment, so I struggle to stay awake. This might be why I’m tired afterward.

During the treatments I usually plug into my phone and listen to audiobooks. I’ve finished one already but forgot what book it was. I think it was a good one, so maybe I’ll listen to it again anew one of these days. I tried “Zen and the art of motorcycle maintenance” but found the main character a bit annoying. So I fell back on a favorite: Life on the Mississippi by Mark Twain. It’s like 40+ hours long, and just a lot of great stories about the river. And being Twain it’s funny, but not so funny that you laugh out loud and get out of alignment.

When you get out of alignment, something on the machine gets a clue that you moved, and it stops with a quiet beep. The attendant comes in, adjusts you and the machine, and they turns it back on. I know if you move a lot, it’ll pause, but I don’t move much at all, and the few times I’ve paused I was quite literally as still as a marble statue, so I’m not sure why it happens sometimes. I’ve seen other people who get pauses all the time and I’m totally going to judge them and say it’s all their fault.

That’s about it. The attendants are super nice, and make light chitchat as a distraction but given the questions they ask repeatedly, I have a feeling it’s an assessment, as well. If my score on the depression inventory is in the red, they ask the same questions the psychiatrist asks for safety, and then just little “what do you have planned for later” or “how was your morning” questions.

That’s about it. If you have questions, please ask!

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