Performing perfectly while falling apart
James ran a 200-person software company in San Francisco. From the outside, his life was a success story — series B funding, strong growth metrics, a house in Pacific Heights, two healthy kids. From the inside, he was drowning.
“I was the CEO who had all the answers in meetings and then sat in his car in the parking garage for twenty minutes afterward because he couldn’t face going home. Not because anything was wrong at home. Just because everything required effort I didn’t have.”
High-functioning depression is a particular kind of cruel. It lets you keep performing — hitting targets, making decisions, showing up — while quietly hollowing you out. James maintained his responsibilities. He also hadn’t felt genuine enthusiasm about anything in over two years.
“My board was happy. My investors were happy. My wife knew something was wrong but I kept deflecting. I told her I was tired. I was — but tired doesn’t explain why you stop caring about things that used to matter.”
James’s primary care physician had prescribed escitalopram two years earlier. It prevented the worst lows but introduced a flatness that bothered him. He also experienced sexual side effects that strained his marriage, though he didn’t admit that to anyone for months.
“There’s a special kind of shame in being a man who can’t talk about side effects from antidepressants. You’re supposed to be grateful the medication works. And it did work — it kept me from falling into a hole. But it also made me feel like I was living in a room with no windows.”
The executive who couldn’t take time off
When James’s psychiatrist suggested TMS therapy, his first question was about the time commitment. Standard TMS protocols require daily sessions for six weeks. For a CEO with a calendar managed by two assistants and board meetings every other Tuesday, that sounded impossible.
“I said, ‘I can’t disappear for an hour every day for six weeks. People will notice. People will ask questions. I’m not ready for that conversation.’”
His psychiatrist suggested theta burst stimulation — an accelerated TMS protocol where each session’s active stimulation lasts about 3 minutes instead of the standard 19-37 minutes. Total in-clinic time: roughly 15 minutes per session.
“Fifteen minutes. I could do that. I could fit that between my 7 AM workout and my 8 AM standup. Nobody needed to know.”
James found a TMS clinic in San Francisco that offered 7 AM appointments and used NeuroStar equipment with the theta burst protocol. The clinic was ten minutes from his gym. He restructured his morning routine: gym at 5:30, TMS at 7:00, office by 7:30.
“The logistics mattered as much as the science. If this treatment didn’t fit my life, I wasn’t going to do it. Full stop.”
Insurance, privacy, and the CEO’s dilemma
James’s company insurance covered TMS after prior authorization. But James didn’t want to use company insurance. He didn’t want his treatment showing up on any benefits report that HR might see, even in aggregate.
He paid out of pocket. The total cost was roughly $12,000 for the full course.
“That’s a privilege I know most people don’t have. I’m not going to pretend otherwise. But the cost of TMS was the least significant decision in this process. The significant decision was admitting I needed it.”
James also chose not to tell his executive team, his board, or his employees. He told his wife and his psychiatrist. That’s it.
“There’s a conversation happening in tech about founder mental health. I support that conversation in theory. In practice, I wasn’t ready to be the case study. Maybe someday.”
What 36 sessions in 6 weeks felt like
James describes the theta burst sessions as “unremarkably routine.”
“You sit down. They position the coil. There’s a burst of clicking — loud, fast, like a machine gun stapler. It lasts three minutes. You get up. You leave. I was checking Slack on my phone in the waiting room thirty seconds later.”
Side effects were minimal. Light scalp soreness for the first three days. One headache after session four that he blames on poor hydration more than TMS. No cognitive effects, no fatigue, no impact on his work performance.
“I chaired a board meeting two hours after my third TMS session. Nobody noticed anything because there was nothing to notice.”
When the CEO started feeling again
James’s improvement didn’t announce itself. It crept in through small moments that accumulated over weeks.
Week two: He responded to his daughter’s piano recital with genuine emotion instead of performed enthusiasm. “She played ‘Fur Elise’ and made three mistakes and I didn’t care because I was actually proud of her. I hadn’t felt proud — really felt it, not just thought it — in months.”
Week three: He found himself interested in a new product feature during a design review. Not just evaluating it as a business decision, but genuinely excited about the technology. His CTO later told him, “You seemed like yourself today.”
Week four: The parking garage episodes stopped. James drove home from work wanting to be there.
Week five: He told his wife about the TMS. She cried. Not because he’d kept it secret, but because she’d been watching him fade for two years and hadn’t known how to reach him.
“She said, ‘I can see you in there again.’ I don’t have a better description of what TMS did for me.”
The results in clinical terms
James’s PHQ-9 dropped from 14 (moderate depression) to 4 (minimal). He worked with his psychiatrist to taper off escitalopram over the following three months. The sexual side effects resolved. The flatness lifted.
“I feel things now. Not just the good things — the hard things too. When we lost a key client last month, I was genuinely upset. Before TMS, I would have processed it as a data point. Now I process it as a loss, feel it, and then figure out what to do about it. That’s healthier, even though it’s harder.”
James is seven months post-treatment. He hasn’t needed maintenance sessions. His psychiatrist monitors him quarterly, and they’ve discussed maintenance TMS as an option if symptoms return.
The productivity angle James didn’t expect
“I went into TMS thinking about survival — just stop feeling terrible. What I didn’t expect was the performance improvement. When you’re not spending mental energy suppressing misery, you have more capacity for everything else.”
James estimates his decision-making speed improved by roughly 20% after treatment. He’s more present in meetings, more creative in strategy sessions, and — maybe most importantly — more effective at delegating because he’s no longer compensating for low energy by controlling everything himself.
“My CFO told me I’d become a better listener. He didn’t know about the TMS. He just noticed I was actually hearing people instead of waiting for my turn to talk.”
James’s advice for other executives
- High-functioning depression is still depression. Success doesn’t immunize you. If you feel nothing about things that should matter, that’s a clinical symptom, not a personality trait.
- Theta burst TMS fits an executive schedule. Three minutes of stimulation, fifteen minutes in the clinic. It’s shorter than your morning espresso routine.
- You don’t have to tell anyone. Privacy is valid. Treat TMS like any other medical appointment.
- The cost is manageable if you have means. If you don’t, insurance increasingly covers TMS. Push for prior authorization.
- The ROI is real. Better mental health makes you a better leader. James’s company had its best quarter in the months following his treatment. Correlation isn’t causation, but he doesn’t think it’s coincidence either.
- Find a specialist who understands your constraints. Search for TMS providers in your area.
Names and identifying details have been changed to protect patient privacy. This story is based on composite experiences reported by TMS patients and is presented for educational purposes only. It is not medical advice. Talk to a qualified specialist about whether TMS is right for your situation.