In a small room at Butler Hospital, Cheryl Palmer reclined in a chair as Dr. Linda Carpenter, a psychiatrist, positioned a curved device against Palmer's head. A ding-dong warning sounded. Then the coil emitted loud rapid-fire taps, 10 per second, for 4 seconds.
Though she could feel the taps against her skull, Palmer didn't even wince. "It's like a little birdie going at my head," she said. "You get used to it." A few seconds passed, the ding-dong sounded again and the rat-tattats resumed.
Palmer, 54, of South Kingstown, has suffered from episodes of depression since she was 20. Over the years, she has tried 27 medications and even had electrodes implanted next to a nerve in her neck.
Nothing was good enough. That's why Palmer came to Butler Hospital, a psychiatric hospital in Providence, to try a new machine. This one beams magnetic pulses through the skull. It is hoped that, after four to six weeks of daily 40-minute treatments, the electrical current will perk up brain cells that are known to be underactive in depressed people. "I haven't forgotten what it's like to be happy," Palmer said. "This particular machine is bringing me back."
In October, the Food and Drug Administration approved the NeuroStar Transcranial Magnetic Stimulation(TMS) machine to treat major depression in people for whom an antidepressant medication didn't work, and Butler was one of the first hospitals to get one. Butler is leasing the $60,000 machine.
"I think we're really at the beginning of an era with this," says Carpenter, who is chief of Butler's mood disorders program and neuromodulation clinic. But she adds, "This is not a cure that makes depression go away forever."
Each treatment costs $300. Patients typically undergo 20 or 30 of these sessions, so the total cost comes close to $6,000. So far, health insurance does not cover the treatment, but the machine's manufacturer is working to change that.
Palmer, whose illness forced her to leave her middle-management job with a retail company, pays for the TMS with help from her husband and a small inheritance. Palmer described what a bad depression feels like: "You have no desire to do anything. You can't focus on anything. … You feel like you're on the outside of the world looking in. You can see the stuff there but you can't feel."
There are many treatments for depression, but none works for everyone and some people get no lasting relief. Palmer has tried almost everything in the book. She sees a psychotherapist and exercises diligently both of which can ease depression. She also tried medications. "There were a couple I couldn't tolerate," she said. "Some give you low blood pressure. Some give you high blood pressure. Others take away the ability to think."
In the room at Butler, the tapping started up again. Unlike the medications, TMS doesn't get into her bloodstream or affect other organs. Instead, magnetic fields travel through her skull about an inch into her brain, reaching an area of the left prefrontal cortex that regulates emotion. The magnetic forces induce an electric current, which triggers the firing of nerve cells and the release of chemicals that transmit nerve impulses.
The only side effect most people experience is a headache or some scalp pain. The long-term effects of repeated exposure to magnetic pulses are not known, but the pulses are the same strength as those in an MRI, and people who have undergone repeated MRIs have not reported problems.
In 2006, Palmer had tried another non-drug treatment called vagus nerve stimulation. A slender generator was implanted beneath the skin of her chest, and wire threaded under her skin to a nerve in her neck that carried electrical impulses into her brain. It didn't help then. But vagus nerve stimulation might work hand-in-hand with TMS.
Even before the TMS machine was approved as a depression treatment, Palmer tried it at experimental sites in Toronto and Boston. She felt much better each time, but the effect didn't last.
TMS doesn't affect memory or function. Palmer was able to get up from her chair after her 40-minute session at Butler and drive home.
But does it work? The answer appears to be: sometimes. Success rates have varied in different studies. The manufacturer, Neuronetics, conducted an experiment in which half the patients received TMS and half received a sham treatment. Only 24 percent of the patients who received TMS had their symptoms cut in half. But that was twice the number of sham-treated patient who got results. That difference is evidence that TMS has a genuine effect, says Dr. Mark Demitrack, Neuronetics' chief medical officer.
But Demitrack says that the 24-percent response rate "isn't a good predictor of what you are likely to see as treatment outcome in the real world," because neither the patients nor the researchers knew who was getting the treatment. In a follow-up study, patients who received the sham treatment but didn't respond were offered a course of TMS treatment. About half of them felt significantly better.
That's about what Carpenter says she expects: half the patients using TMS at Butler should see improvement.
"I realize that 50 percent seems dismal for this or any treatment we have to offer," Carpenter said in an e-mail. "It is sad that our current bag of tricks is so limited."
Of the six TMS patients treated at Butler so far, Carpenter says, four saw significant improvement that is, the severity of their depression was reduced at least by half. One patient saw only a slight improvement. The other one is still undergoing the treatment. Palmer was among the four who felt much better. In fact, she needed only 10 treatments, an unusually fast response, probably because she'd undergone TMS in the past, and because she also marshals many interventions: psychotherapy, meditation, exercise. A month afterward, her mood started to decline again, and last week she returned to Butler for a maintenance treatment.
"It's a battle," Palmer says. "I'm fighting it valiantly. I will never give up."