VERIGRATE HEALTH · A PHYSICIAN’S GUIDE
Transcranial Magnetic Stimulation (TMS)
Transcranial Magnetic Stimulation (TMS)
Transcranial Magnetic Stimulation (TMS)
An evidence-based guide to transcranial magnetic stimulation—how it works, where the evidence is established, how accelerated protocols differ, and what is known and not yet known about one-day treatment.
An evidence-based guide to transcranial magnetic stimulation—how it works, where the evidence is established, how accelerated protocols differ, and what is known and not yet known about one-day treatment.
An evidence-based guide to transcranial magnetic stimulation—how it works, where the evidence is established, how accelerated protocols differ, and what is known and not yet known about one-day treatment.
Transcranial magnetic stimulation (TMS) is a noninvasive form of neuromodulation that uses rapidly changing magnetic fields to induce electrical activity in targeted regions of the cerebral cortex. Its strongest established psychiatric evidence is in major depressive disorder. Newer approaches—including intermittent theta-burst stimulation and accelerated treatment schedules—have substantially shortened the time required to deliver stimulation, although the evidence differs meaningfully across protocols. [1]
Transcranial magnetic stimulation (TMS) is a noninvasive form of neuromodulation that uses rapidly changing magnetic fields to induce electrical activity in targeted regions of the cerebral cortex. Its strongest established psychiatric evidence is in major depressive disorder. Newer approaches—including intermittent theta-burst stimulation and accelerated treatment schedules—have substantially shortened the time required to deliver stimulation, although the evidence differs meaningfully across protocols. [1]
Conventional rTMS
Established evidence
Once-Daily iTBS
Established evidence
Accelerated TMS
Evolving evidence
Single-Day TMS
Emerging evidence
Evidence strength varies not only by treatment category but also by specific device, target, pulse dose, stimulation pattern, schedule, and patient population. These categories refer primarily to depression treatment. [1–4]
IN THIS GUIDE
01 · FOUNDATIONS
What is transcranial magnetic stimulation?
What is transcranial magnetic stimulation?
What is transcranial magnetic stimulation?
Transcranial magnetic stimulation is a noninvasive technique that uses a magnetic coil placed against the scalp to generate rapidly changing magnetic fields. These fields induce electrical currents in underlying cortical tissue and can alter activity within neural networks involved in mood and other functions. [1, 7]
Transcranial magnetic stimulation is a noninvasive technique that uses a magnetic coil placed against the scalp to generate rapidly changing magnetic fields. These fields induce electrical currents in underlying cortical tissue and can alter activity within neural networks involved in mood and other functions. [1, 7]
This process is called electromagnetic induction. Repetitive TMS (rTMS) delivers repeated pulses rather than a single pulse. Patients remain awake; general anesthesia is ordinarily unnecessary. Therapeutic TMS for depression does not intentionally produce a generalized seizure and is fundamentally different from electroconvulsive therapy. [1, 7]
This process is called electromagnetic induction. Repetitive TMS (rTMS) delivers repeated pulses rather than a single pulse. Patients remain awake; general anesthesia is ordinarily unnecessary. Therapeutic TMS for depression does not intentionally produce a generalized seizure and is fundamentally different from electroconvulsive therapy. [1, 7]
TMS is not a single protocol.
TMS is not a single protocol.
TMS is not a single protocol.
Target, frequency, stimulation pattern, pulse dose, intensity, session duration, intersession interval, number of sessions, total treatment schedule, and patient selection all matter. A familiar treatment name does not establish that two protocols are clinically interchangeable.
Target, frequency, stimulation pattern, pulse dose, intensity, session duration, intersession interval, number of sessions, total treatment schedule, and patient selection all matter. A familiar treatment name does not establish that two protocols are clinically interchangeable.
How does TMS affect the brain?
How does TMS affect the brain?
How does TMS affect the brain?
TMS induces electrical currents that can depolarize neurons and change cortical excitability. Repeated stimulation may influence neuroplasticity and communication across connected brain networks; the full antidepressant mechanism is not established. [1, 5, 7]
TMS induces electrical currents that can depolarize neurons and change cortical excitability. Repeated stimulation may influence neuroplasticity and communication across connected brain networks; the full antidepressant mechanism is not established. [1, 5, 7]
Stimulation patterns can have relatively excitatory or inhibitory effects, but these labels are simplifications: physiological responses vary with dose, timing, and the individual. Depression protocols often target the dorsolateral prefrontal cortex (DLPFC), which participates in distributed networks involved in cognitive control and mood regulation. [1]
Stimulation patterns can have relatively excitatory or inhibitory effects, but these labels are simplifications: physiological responses vary with dose, timing, and the individual. Depression protocols often target the dorsolateral prefrontal cortex (DLPFC), which participates in distributed networks involved in cognitive control and mood regulation. [1]
The effects are therefore not adequately described as simply “stimulating one spot.” A cortical target provides access to a network, not a definitive map of the cause of a person’s depression. “Brain reset” and “rewiring” metaphors imply more mechanistic certainty than the science supports.
The effects are therefore not adequately described as simply “stimulating one spot.” A cortical target provides access to a network, not a definitive map of the cause of a person’s depression. “Brain reset” and “rewiring” metaphors imply more mechanistic certainty than the science supports.
TMS coil
Changing magnetic field
Cortical electrical current
Distributed network modulation
A cortical stimulus can influence connected networks. This schematic explains the sequence, not the complete antidepressant mechanism. [1, 7]
What conditions is TMS used to treat?
What conditions is TMS used to treat?
What conditions is TMS used to treat?
Major depressive disorder is the most established psychiatric use of TMS. Other applications depend on the particular device, protocol, indication, and patient population—not on TMS as a category. [1]
Major depressive disorder is the most established psychiatric use of TMS. Other applications depend on the particular device, protocol, indication, and patient population—not on TMS as a category. [1]
For example, the FDA authorized the Brainsway Deep TMS system for obsessive-compulsive disorder; FDA materials also describe authorization of TMS for pain associated with certain migraine headaches. These are distinct applications, not evidence that a depression protocol treats every condition. [8]
For example, the FDA authorized the Brainsway Deep TMS system for obsessive-compulsive disorder; FDA materials also describe authorization of TMS for pain associated with certain migraine headaches. These are distinct applications, not evidence that a depression protocol treats every condition. [8]
FDA clearance applies to specific devices, protocols, indications, and patient populations. A cleared machine does not make every schedule used with it FDA-cleared. Clinicians should check the current labeling for the exact treatment proposed, including any off-label use.
FDA clearance applies to specific devices, protocols, indications, and patient populations. A cleared machine does not make every schedule used with it FDA-cleared. Clinicians should check the current labeling for the exact treatment proposed, including any off-label use.
TMS for major depressive disorder
TMS for major depressive disorder
TMS for major depressive disorder
TMS has its strongest psychiatric evidence in major depressive disorder, particularly when previous treatment has provided insufficient benefit or has not been well tolerated. Conventional rTMS and once-daily left-DLPFC iTBS are established options. [1, 2]
TMS has its strongest psychiatric evidence in major depressive disorder, particularly when previous treatment has provided insufficient benefit or has not been well tolerated. Conventional rTMS and once-daily left-DLPFC iTBS are established options. [1, 2]
Treatment-resistant depression describes persistent depression despite adequate treatment attempts; it is not a reason to bypass diagnostic reassessment. Severity, functional impairment, prior treatment response, medication intolerance, and patient preference inform the decision. Not everyone who has failed medication should receive TMS.
Treatment-resistant depression describes persistent depression despite adequate treatment attempts; it is not a reason to bypass diagnostic reassessment. Severity, functional impairment, prior treatment response, medication intolerance, and patient preference inform the decision. Not everyone who has failed medication should receive TMS.
TMS is a treatment modality—not a substitute for careful diagnosis.
TMS is a treatment modality—not a substitute for careful diagnosis.
TMS is a treatment modality—not a substitute for careful diagnosis.
Before recommending a procedure, consider bipolar-spectrum illness, medication-induced symptoms, substance use, sleep disorders, medical contributors, neurological history, and psychosocial context. Review what was actually tried, at what dose and duration, with what benefit or harm, and what alternatives remain. At Verigrate, psychiatric assessment precedes treatment selection.
Before recommending a procedure, consider bipolar-spectrum illness, medication-induced symptoms, substance use, sleep disorders, medical contributors, neurological history, and psychosocial context. Review what was actually tried, at what dose and duration, with what benefit or harm, and what alternatives remain. At Verigrate, psychiatric assessment precedes treatment selection.
02 · PROTOCOLS & SCHEDULES
What does conventional TMS treatment involve?
What does conventional TMS treatment involve?
What does conventional TMS treatment involve?
Conventional rTMS commonly involves once-daily outpatient treatment over several weeks. Traditional high-frequency stimulation of the left prefrontal cortex is a well-studied approach; the schedule is not identical for every device or protocol. [1]
Conventional rTMS commonly involves once-daily outpatient treatment over several weeks. Traditional high-frequency stimulation of the left prefrontal cortex is a well-studied approach; the schedule is not identical for every device or protocol. [1]
Clinicians determine the motor threshold—a measure of the intensity needed to produce a motor response—to inform dosing, localize the treatment target, and monitor symptoms and adverse effects. The contemporary consensus commonly recommends a full acute course of approximately 30–36 sessions, with reassessment and adjustments when clinically indicated. [1]
Clinicians determine the motor threshold—a measure of the intensity needed to produce a motor response—to inform dosing, localize the treatment target, and monitor symptoms and adverse effects. The contemporary consensus commonly recommends a full acute course of approximately 30–36 sessions, with reassessment and adjustments when clinically indicated. [1]
This is an educational description of conventional treatment, not Verigrate’s routine service model. Verigrate specializes in physician-directed one-day TMS rather than operating a conventional multiweek daily TMS clinic.
This is an educational description of conventional treatment, not Verigrate’s routine service model. Verigrate specializes in physician-directed one-day TMS rather than operating a conventional multiweek daily TMS clinic.
What is intermittent theta-burst stimulation (iTBS)?
What is intermittent theta-burst stimulation (iTBS)?
What is intermittent theta-burst stimulation (iTBS)?
Intermittent theta-burst stimulation is a patterned form of repetitive TMS that can deliver a treatment session in several minutes rather than the longer duration required by traditional high-frequency rTMS. [1, 2]
Intermittent theta-burst stimulation is a patterned form of repetitive TMS that can deliver a treatment session in several minutes rather than the longer duration required by traditional high-frequency rTMS. [1, 2]
Theta-burst stimulation groups pulses into rapidly repeated bursts. Standard once-daily left-DLPFC iTBS uses 600 pulses. The THREE-D randomized noninferiority trial demonstrated that once-daily iTBS was noninferior to standard high-frequency rTMS in adults with treatment-resistant depression; both groups received treatment across multiple weeks. Once-daily iTBS is an established option. [1, 2]
Theta-burst stimulation groups pulses into rapidly repeated bursts. Standard once-daily left-DLPFC iTBS uses 600 pulses. The THREE-D randomized noninferiority trial demonstrated that once-daily iTBS was noninferior to standard high-frequency rTMS in adults with treatment-resistant depression; both groups received treatment across multiple weeks. Once-daily iTBS is an established option. [1, 2]
A shorter session does not automatically mean a shorter treatment course.
A shorter session does not automatically mean a shorter treatment course.
A shorter session does not automatically mean a shorter treatment course.
What is accelerated TMS?
What is accelerated TMS?
What is accelerated TMS?
Accelerated TMS generally refers to treatment schedules in which multiple stimulation sessions are delivered within the same day, with the aim of compressing treatment that would otherwise be distributed across many days or weeks. [1]
Accelerated TMS generally refers to treatment schedules in which multiple stimulation sessions are delivered within the same day, with the aim of compressing treatment that would otherwise be distributed across many days or weeks. [1]
Accelerated TMS is a category—not a single protocol.
Accelerated TMS is a category—not a single protocol.
Accelerated TMS is a category—not a single protocol.
Protocols differ in stimulation pattern, pulses per session, sessions per day, total sessions, intensity, target, targeting method, intersession interval, cumulative dose, and number of treatment days. Research supports benefit for particular accelerated approaches, but faster response or greater efficacy than established once-daily treatment has not been conclusively demonstrated across the category. [1]
Protocols differ in stimulation pattern, pulses per session, sessions per day, total sessions, intensity, target, targeting method, intersession interval, cumulative dose, and number of treatment days. Research supports benefit for particular accelerated approaches, but faster response or greater efficacy than established once-daily treatment has not been conclusively demonstrated across the category. [1]
Stanford Neuromodulation Therapy as a specific accelerated protocol
Stanford Neuromodulation Therapy as a specific accelerated protocol
Stanford Neuromodulation Therapy as a specific accelerated protocol
Stanford Neuromodulation Therapy (SNT) is a specific high-dose accelerated iTBS protocol with individualized resting-state functional-connectivity targeting. Its randomized, sham-controlled evidence concerns a defined multiday treatment—not an interchangeable family of accelerated schedules. [3]
Stanford Neuromodulation Therapy (SNT) is a specific high-dose accelerated iTBS protocol with individualized resting-state functional-connectivity targeting. Its randomized, sham-controlled evidence concerns a defined multiday treatment—not an interchangeable family of accelerated schedules. [3]
SNT uses functional MRI to select a left-DLPFC site based on its relationship to the subgenual anterior cingulate cortex, and delivers multiple sessions per day with a high cumulative pulse dose. A commercial implementation, the Magnus Neuromodulation System with SAINT Technology, has an FDA clearance record. This does not establish clearance for unrelated one-day regimens. [1, 3, 9]
SNT uses functional MRI to select a left-DLPFC site based on its relationship to the subgenual anterior cingulate cortex, and delivers multiple sessions per day with a high cumulative pulse dose. A commercial implementation, the Magnus Neuromodulation System with SAINT Technology, has an FDA clearance record. This does not establish clearance for unrelated one-day regimens. [1, 3, 9]
Evidence from SNT should not automatically be extrapolated to protocols with different targets, doses, session spacing, schedules, or treatment durations.
Evidence from SNT should not automatically be extrapolated to protocols with different targets, doses, session spacing, schedules, or treatment durations.
Evidence from SNT should not automatically be extrapolated to protocols with different targets, doses, session spacing, schedules, or treatment durations.
Can TMS be delivered in one day?
Can TMS be delivered in one day?
Can TMS be delivered in one day?
Yes. Multiple TMS sessions can be delivered during a single day, creating an especially compressed form of accelerated treatment. However, single-day TMS has a substantially smaller evidence base than conventional multiweek TMS or established once-daily iTBS. [1, 4]
Yes. Multiple TMS sessions can be delivered during a single day, creating an especially compressed form of accelerated treatment. However, single-day TMS has a substantially smaller evidence base than conventional multiweek TMS or established once-daily iTBS. [1, 4]
One-day TMS is an emerging treatment model. Target, stimulation pattern, dose, intersession spacing, and patient selection remain central. Multiday accelerated outcomes should not be borrowed to estimate the results of a single-day protocol.
One-day TMS is an emerging treatment model. Target, stimulation pattern, dose, intersession spacing, and patient selection remain central. Multiday accelerated outcomes should not be borrowed to estimate the results of a single-day protocol.
The ONE-D publication cited on Verigrate’s one-day TMS page describes an open-label case series, not a randomized comparison. Uncontrolled observations cannot separate treatment effects from other influences or establish equivalence to conventional TMS. Larger controlled studies and longer-term follow-up are needed; no remission percentage from another protocol is presented as an expected one-day outcome. [4]
The ONE-D publication cited on Verigrate’s one-day TMS page describes an open-label case series, not a randomized comparison. Uncontrolled observations cannot separate treatment effects from other influences or establish equivalence to conventional TMS. Larger controlled studies and longer-term follow-up are needed; no remission percentage from another protocol is presented as an expected one-day outcome. [4]
Different schedules. Different evidence.
Different schedules. Different evidence.
Different schedules. Different evidence.
Conventional TMS
One session per treatment day; usually several weeks
Once-daily iTBS
Shorter individual sessions; usually multiple weeks
Accelerated TMS
Multiple sessions per day; often several days
One-Day TMS
Multiple sessions within a single treatment day
Specific protocols differ substantially. This illustration describes scheduling concepts, not protocol equivalence. Markers are schematic—not a session count or a treatment prescription. [1–4]
03 · THE VERIGRATE MODEL
Why Verigrate focuses on one-day TMS
Why Verigrate focuses on one-day TMS
Why Verigrate focuses on one-day TMS
Verigrate does not operate as a high-volume conventional TMS center. Its neuromodulation program addresses a narrower clinical question: whether a carefully selected patient may reasonably benefit from a concentrated treatment schedule that reduces the logistical burden of attending treatment over many weeks.
Verigrate does not operate as a high-volume conventional TMS center. Its neuromodulation program addresses a narrower clinical question: whether a carefully selected patient may reasonably benefit from a concentrated treatment schedule that reduces the logistical burden of attending treatment over many weeks.
Many clinics lead with a machine or protocol. Verigrate begins with psychiatric assessment: diagnosis, previous treatment, medication burden and effects, medical and neurological screening, and consideration of alternatives. A compressed schedule is a clinical choice—not a claim that emerging evidence is as mature as conventional treatment evidence.
Many clinics lead with a machine or protocol. Verigrate begins with psychiatric assessment: diagnosis, previous treatment, medication burden and effects, medical and neurological screening, and consideration of alternatives. A compressed schedule is a clinical choice—not a claim that emerging evidence is as mature as conventional treatment evidence.
Physician-directed evaluation, individualized judgment, a private environment, concentrated scheduling, and longitudinal psychiatric context where appropriate define the model. Patient convenience matters, but it does not override suitability, informed consent, or scientific uncertainty.
Physician-directed evaluation, individualized judgment, a private environment, concentrated scheduling, and longitudinal psychiatric context where appropriate define the model. Patient convenience matters, but it does not override suitability, informed consent, or scientific uncertainty.
04 · READING THE EVIDENCE
How should claims about accelerated TMS be evaluated?
How should claims about accelerated TMS be evaluated?
How should claims about accelerated TMS be evaluated?
Outcomes from an accelerated TMS study are most informative when the treatment offered clinically resembles the treatment actually studied. A protocol name alone is insufficient. [1, 3]
Outcomes from an accelerated TMS study are most informative when the treatment offered clinically resembles the treatment actually studied. A protocol name alone is insufficient. [1, 3]
Was the same stimulation pattern and pulse dose used?
Were the number of sessions and intersession intervals similar?
Were treatment intensity and target comparable?
Was targeting scalp-based, structural MRI-guided, or functional-connectivity guided?
Was treatment delivered over one day or several days?
Was the patient population similar?
Was the study randomized, sham-controlled, open-label, or observational?
Were outcomes measured immediately or weeks after treatment?
Was the same stimulation pattern and pulse dose used?
Were the number of sessions and intersession intervals similar?
Were treatment intensity and target comparable?
Was targeting scalp-based, structural MRI-guided, or functional-connectivity guided?
Was treatment delivered over one day or several days?
Was the patient population similar?
Was the study randomized, sham-controlled, open-label, or observational?
Were outcomes measured immediately or weeks after treatment?
A protocol should not inherit the evidence of another protocol merely because both are called “accelerated TMS.”
A protocol should not inherit the evidence of another protocol merely because both are called “accelerated TMS.”
A protocol should not inherit the evidence of another protocol merely because both are called “accelerated TMS.”
How is the TMS treatment target selected?
How is the TMS treatment target selected?
How is the TMS treatment target selected?
Many depression protocols target the left DLPFC. Localization may use validated scalp measurements, structural MRI neuronavigation, or functional-connectivity methods; these approaches answer different questions. [1]
Many depression protocols target the left DLPFC. Localization may use validated scalp measurements, structural MRI neuronavigation, or functional-connectivity methods; these approaches answer different questions. [1]
The 5.5-cm method estimates position relative to a motor-cortex location. Beam F3 uses scalp measurements to estimate the F3 location. Structural MRI neuronavigation relates coil position to individual anatomy; functional MRI examines activity or connectivity, including resting-state relationships among brain regions. [1]
The 5.5-cm method estimates position relative to a motor-cortex location. Beam F3 uses scalp measurements to estimate the F3 location. Structural MRI neuronavigation relates coil position to individual anatomy; functional MRI examines activity or connectivity, including resting-state relationships among brain regions. [1]
Structural and functional imaging can support individualized targeting, but whether these approaches produce clinically meaningful improvements over validated scalp-based targeting remains an active area of investigation. MRI-guided TMS should not be presented as universally superior. [1]
Structural and functional imaging can support individualized targeting, but whether these approaches produce clinically meaningful improvements over validated scalp-based targeting remains an active area of investigation. MRI-guided TMS should not be presented as universally superior. [1]
Left DLPFC
Left DLPFC
Left DLPFC
A common cortical treatment target
Distributed mood network
Distributed mood network
Distributed mood network
Connected regions—not a single “depression spot”
Many depression protocols target the left dorsolateral prefrontal cortex, although localization methods differ. Conceptual illustration—not an anatomical localization guide. [1]
05 · THE PATIENT EXPERIENCE
What does TMS treatment feel like?
What does TMS treatment feel like?
What does TMS treatment feel like?
Patients commonly feel tapping or knocking at the scalp and hear clicking from the coil. Local scalp discomfort or contraction of nearby facial muscles can occur; tolerability varies among patients. [1, 7]
Patients commonly feel tapping or knocking at the scalp and hear clicking from the coil. Local scalp discomfort or contraction of nearby facial muscles can occur; tolerability varies among patients. [1, 7]
The patient remains awake, generally without anesthesia. Ordinary activity can often resume afterward, subject to the clinician’s instructions and individual circumstances. Hearing protection is important. Treatment is not universally painless, and discomfort should be reported rather than minimized. [1, 5, 7]
The patient remains awake, generally without anesthesia. Ordinary activity can often resume afterward, subject to the clinician’s instructions and individual circumstances. Hearing protection is important. Treatment is not universally painless, and discomfort should be reported rather than minimized. [1, 5, 7]
What are the risks and side effects of TMS?
What are the risks and side effects of TMS?
What are the risks and side effects of TMS?
Common adverse effects include scalp discomfort, headache, local pain, and facial muscle contraction. Serious adverse events are uncommon with appropriate screening and accepted safety standards, but TMS is not risk-free. [1, 5]
Common adverse effects include scalp discomfort, headache, local pain, and facial muscle contraction. Serious adverse events are uncommon with appropriate screening and accepted safety standards, but TMS is not risk-free. [1, 5]
Clinically important risks include syncope, hearing injury without appropriate protection, treatment-emergent mania or hypomania in susceptible patients, and seizure—a rare but serious event. The risk assessment must concern the actual protocol being proposed. [1, 5]
Clinically important risks include syncope, hearing injury without appropriate protection, treatment-emergent mania or hypomania in susceptible patients, and seizure—a rare but serious event. The risk assessment must concern the actual protocol being proposed. [1, 5]
Screening reviews seizure history, neurological disease, medications and other factors affecting seizure threshold, intracranial metal, implanted electronic devices, and bipolar-spectrum symptoms. Device compatibility and contraindications require individualized assessment against the relevant labeling; not every implant or neurological history is equivalent. [1, 5]
Screening reviews seizure history, neurological disease, medications and other factors affecting seizure threshold, intracranial metal, implanted electronic devices, and bipolar-spectrum symptoms. Device compatibility and contraindications require individualized assessment against the relevant labeling; not every implant or neurological history is equivalent. [1, 5]
What TMS cannot tell us
What TMS cannot tell us
What TMS cannot tell us
A response to TMS does not prove a psychiatric diagnosis, and nonresponse does not disprove it. Treatment response is an outcome—not a diagnostic test.
A response to TMS does not prove a psychiatric diagnosis, and nonresponse does not disprove it. Treatment response is an outcome—not a diagnostic test.
TMS does not identify a single biological cause of depression. A treatment target is not a definitive map of an individual patient’s pathology, and neuroimaging does not currently supply a routine stand-alone diagnostic biomarker for major depressive disorder. These limitations matter when interpreting claims of personalized treatment. [1]
TMS does not identify a single biological cause of depression. A treatment target is not a definitive map of an individual patient’s pathology, and neuroimaging does not currently supply a routine stand-alone diagnostic biomarker for major depressive disorder. These limitations matter when interpreting claims of personalized treatment. [1]
Technological precision does not eliminate diagnostic uncertainty.
Technological precision does not eliminate diagnostic uncertainty.
Technological precision does not eliminate diagnostic uncertainty.
A technically sophisticated treatment is not automatically the clinically appropriate treatment. Diagnosis, risk, alternatives, and the patient’s priorities remain central.
A technically sophisticated treatment is not automatically the clinically appropriate treatment. Diagnosis, risk, alternatives, and the patient’s priorities remain central.
06 · TREATMENT ALTERNATIVES
TMS vs electroconvulsive therapy
TMS vs electroconvulsive therapy
TMS vs electroconvulsive therapy
TMS and ECT are different treatments with different clinical roles. TMS uses magnetic induction without intentionally causing a seizure; ECT uses electrical stimulation to produce a monitored seizure under anesthesia. [6, 7]
TMS and ECT are different treatments with different clinical roles. TMS uses magnetic induction without intentionally causing a seizure; ECT uses electrical stimulation to produce a monitored seizure under anesthesia. [6, 7]
Clinical consideration | TMS | ECT |
|---|---|---|
Mechanism | Magnetic induction in cortical tissue | Electrical stimulation producing a monitored seizure |
Anesthesia | Generally unnecessary | General anesthesia and muscle relaxant |
Seizure induction | Not intentional; rare adverse risk | Intentional therapeutic seizure |
Typical setting | Outpatient clinical or appropriately staffed setting | Hospital or specialized treatment setting |
Cognitive effects | Not typically associated with ECT-like memory effects | Confusion and memory effects can occur |
Evidence | Established for particular depression protocols | Highly established for severe depression and catatonia |
Treatment burden | Repeated visits or concentrated scheduling; protocol-dependent | Anesthesia, recovery, and transportation planning |
Severe depression | Suitability depends on presentation and urgency | Often important when rapid, established treatment is needed |
Psychotic depression | Not a routine substitute for ECT | May be preferred |
Catatonia | Not an established substitute | An established treatment option |
Urgency | Do not assume a compressed schedule ensures rapid relief | May be appropriate when illness is life-threatening |
Clinical comparisons are qualitative, not a ranking. On small screens, the table scrolls horizontally. [1, 6, 7]
ECT remains one of the most effective acute treatments in psychiatry and may be preferred when depression is severe, psychotic, catatonic, life-threatening, or requires a rapidly acting and highly established intervention. Less procedural burden does not make TMS the better treatment in every situation. [1, 6]
ECT remains one of the most effective acute treatments in psychiatry and may be preferred when depression is severe, psychotic, catatonic, life-threatening, or requires a rapidly acting and highly established intervention. Less procedural burden does not make TMS the better treatment in every situation. [1, 6]
TMS vs ketamine
TMS vs ketamine
TMS vs ketamine
TMS is a device-based neuromodulation treatment; ketamine is a pharmacologic treatment. Neither is superior for every patient, and evidence must be considered for the particular protocol or drug formulation. [1, 10]
TMS is a device-based neuromodulation treatment; ketamine is a pharmacologic treatment. Neither is superior for every patient, and evidence must be considered for the particular protocol or drug formulation. [1, 10]
Intravenous ketamine can produce rapid antidepressant effects, but dissociation and increases in blood pressure or heart rate require appropriate monitoring. Infusions belong in an appropriately equipped clinical setting. TMS generally does not require anesthesia or produce ketamine-like dissociation. [1, 7, 10]
Intravenous ketamine can produce rapid antidepressant effects, but dissociation and increases in blood pressure or heart rate require appropriate monitoring. Infusions belong in an appropriately equipped clinical setting. TMS generally does not require anesthesia or produce ketamine-like dissociation. [1, 7, 10]
Both approaches may require further treatment or maintenance. Frequency, durability, medical risks, prior response, and patient preference matter more than a simple ranking. Evidence for IV racemic ketamine should not be assumed to apply identically to every ketamine formulation. [10]
Both approaches may require further treatment or maintenance. Frequency, durability, medical risks, prior response, and patient preference matter more than a simple ranking. Evidence for IV racemic ketamine should not be assumed to apply identically to every ketamine formulation. [10]
TMS vs antidepressant medication
TMS vs antidepressant medication
TMS vs antidepressant medication
TMS and antidepressant medication are not mutually exclusive treatment philosophies. TMS may be considered after medication trials, alongside medication, or when benefit or tolerability is insufficient. [1, 2]
TMS and antidepressant medication are not mutually exclusive treatment philosophies. TMS may be considered after medication trials, alongside medication, or when benefit or tolerability is insufficient. [1, 2]
Patient preference and clinical circumstances also matter. Medication effects, withdrawal symptoms, and current medication burden deserve review; patients should not stop or change medication on their own to prepare for TMS. [1]
Patient preference and clinical circumstances also matter. Medication effects, withdrawal symptoms, and current medication burden deserve review; patients should not stop or change medication on their own to prepare for TMS. [1]
Treatment should be proportionate to the individual patient rather than driven by allegiance to a particular modality.
Treatment should be proportionate to the individual patient rather than driven by allegiance to a particular modality.
Treatment should be proportionate to the individual patient rather than driven by allegiance to a particular modality.
07 · CLINICAL JUDGMENT
Who may be a candidate for TMS?
Who may be a candidate for TMS?
Who may be a candidate for TMS?
A person with major depressive disorder may be considered when prior treatment has been insufficiently effective or poorly tolerated. Candidacy also depends on functional impairment, severity, treatment history, preference, safety, and the specific protocol. [1, 2]
A person with major depressive disorder may be considered when prior treatment has been insufficiently effective or poorly tolerated. Candidacy also depends on functional impairment, severity, treatment history, preference, safety, and the specific protocol. [1, 2]
Candidacy is more than checking boxes. The evaluation should establish a coherent diagnosis, examine previous trials, discuss expected benefit and uncertainty, and compare the burden of TMS with reasonable alternatives. Eligibility for conventional treatment does not automatically establish suitability for one-day treatment.
Candidacy is more than checking boxes. The evaluation should establish a coherent diagnosis, examine previous trials, discuss expected benefit and uncertainty, and compare the burden of TMS with reasonable alternatives. Eligibility for conventional treatment does not automatically establish suitability for one-day treatment.
When might TMS not be the appropriate next treatment?
When might TMS not be the appropriate next treatment?
When might TMS not be the appropriate next treatment?
TMS may not be the next step when diagnostic uncertainty, an untreated contributor, or the urgency of the illness changes treatment priorities. This is a clinical judgment, not a universal contraindication list.
TMS may not be the next step when diagnostic uncertainty, an untreated contributor, or the urgency of the illness changes treatment priorities. This is a clinical judgment, not a universal contraindication list.
Examples include possible medication-induced symptoms, substance use, an untreated sleep disorder or medical condition, and unresolved bipolar-spectrum illness. Psychosis, catatonia, or a need for hospitalization may require a different pathway; ECT may be more appropriate for severe or urgent presentations. [1, 6]
Examples include possible medication-induced symptoms, substance use, an untreated sleep disorder or medical condition, and unresolved bipolar-spectrum illness. Psychosis, catatonia, or a need for hospitalization may require a different pathway; ECT may be more appropriate for severe or urgent presentations. [1, 6]
A lower-burden intervention may deserve consideration first. Treatment should be deferred or redirected when expected benefit does not justify burden or uncertainty. Careful medication review can be as consequential as adding a procedure.
A lower-burden intervention may deserve consideration first. Treatment should be deferred or redirected when expected benefit does not justify burden or uncertainty. Careful medication review can be as consequential as adding a procedure.
08 · OUTCOMES & FOLLOW-UP
How effective is TMS for depression?
How effective is TMS for depression?
How effective is TMS for depression?
Established rTMS and once-daily iTBS can reduce depressive symptoms, but efficacy cannot be responsibly summarized by one marketing percentage. A result applies to the protocol, population, and outcome measure studied. [1, 2]
Established rTMS and once-daily iTBS can reduce depressive symptoms, but efficacy cannot be responsibly summarized by one marketing percentage. A result applies to the protocol, population, and outcome measure studied. [1, 2]
Outcomes vary with treatment resistance, concomitant care, target, dose, duration, study design, and the scale used. Response means a substantial, study-defined reduction in symptom severity; remission means symptoms fall below a specified threshold. The two are not interchangeable.
Outcomes vary with treatment resistance, concomitant care, target, dose, duration, study design, and the scale used. Response means a substantial, study-defined reduction in symptom severity; remission means symptoms fall below a specified threshold. The two are not interchangeable.
Randomized sham-controlled evidence, open-label results, and clinical registries answer different questions. No remission rate from SNT, conventional TMS, or another accelerated protocol should be used as an expected one-day TMS outcome. [1, 3, 4]
Randomized sham-controlled evidence, open-label results, and clinical registries answer different questions. No remission rate from SNT, conventional TMS, or another accelerated protocol should be used as an expected one-day TMS outcome. [1, 3, 4]
How long do the effects of TMS last?
How long do the effects of TMS last?
How long do the effects of TMS last?
Some patients maintain improvement after an acute course; others relapse. Durability varies, and a successful treatment day or course does not eliminate the need for follow-up. [1]
Some patients maintain improvement after an acute course; others relapse. Durability varies, and a successful treatment day or course does not eliminate the need for follow-up. [1]
Repeat treatment, continuation, or maintenance TMS may be considered. Maintenance schedules are less standardized than acute treatment schedules. Ongoing psychiatric care should address symptoms, medication, psychotherapy, and other contributors; long-term benefit should not be promised, particularly for emerging single-day regimens. [1, 4]
Repeat treatment, continuation, or maintenance TMS may be considered. Maintenance schedules are less standardized than acute treatment schedules. Ongoing psychiatric care should address symptoms, medication, psychotherapy, and other contributors; long-term benefit should not be promised, particularly for emerging single-day regimens. [1, 4]
Frequently asked questions about TMS
Frequently asked questions about TMS
Frequently asked questions about TMS
Selected References
Selected References
Selected References
[1] Trapp NT, Purgianto A, Taylor JJ, et al. Consensus Review and Considerations on TMS to Treat Depression: A Comprehensive Update Endorsed by the NNDC, Clinical TMS Society, and IFCN. Clinical Neurophysiology. 2025;170:206–233. DOI: 10.1016/j.clinph.2024.12.015.
[2] Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. The Lancet. 2018;391:1683–1692. DOI: 10.1016/S0140-6736(18)30295-2.
[3] Cole EJ, Phillips AL, Bentzley BS, et al. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial. American Journal of Psychiatry. 2022;179:132–141. DOI: 10.1176/appi.ajp.2021.20101429.
[4] Vaughn DA, Marino B, Engelbertson A, et al. Real-world effectiveness of a single-day regimen for transcranial magnetic stimulation using Optimized, Neuroplasticity-Enhanced techniques in Depression (ONE-D): An open-label case series. Transcranial Magnetic Stimulation. 2025;5:100200. DOI: 10.1016/j.transm.2025.100200.
[5] Rossi S, Antal A, Bestmann S, et al. Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology. 2021;132:269–306. DOI: 10.1016/j.clinph.2020.10.003.
[6] American Psychiatric Association. What is Electroconvulsive Therapy (ECT)? Patient and family educational resource.
[7] National Institute of Mental Health. Brain Stimulation Therapies. Patient educational resource.
[8] U.S. Food and Drug Administration. FDA permits marketing of transcranial magnetic stimulation for treatment of obsessive compulsive disorder. August 17, 2018. Device-specific regulatory announcement.
[9] U.S. Food and Drug Administration. 510(k) clearance record K220177: Magnus Neuromodulation System with SAINT Technology, Model 1001K. Decision September 1, 2022.
[10] Swainson J, McGirr A, Blier P, et al. The CANMAT Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder. Canadian Journal of Psychiatry. 2021;66:113–125. DOI: 10.1177/0706743720970860.
[11] American Psychiatric Association. What is Transcranial Magnetic Stimulation? (TMS). Patient and family educational resource.
Clinical content reviewed by Christian S. Monsalve, M.D.
Clinical content reviewed by Christian S. Monsalve, M.D.
Clinical content reviewed by Christian S. Monsalve, M.D.
Board-Certified Psychiatrist
Founder & Medical Director, Verigrate Health
This page is intended for general educational purposes and does not constitute individualized medical advice. Treatment decisions require clinical evaluation and should take into account diagnosis, medical history, prior treatment, risks, alternatives, and patient preferences.
Considering One-Day TMS?
Considering One-Day TMS?
Considering One-Day TMS?
Verigrate offers physician-led evaluation for selected patients considering a concentrated one-day TMS treatment model. Evaluation begins with diagnosis, previous treatment, medical history, medications, treatment goals, risks, alternatives, and whether TMS is clinically appropriate—not simply whether a patient wishes to undergo the procedure.
Verigrate offers physician-led evaluation for selected patients considering a concentrated one-day TMS treatment model. Evaluation begins with diagnosis, previous treatment, medical history, medications, treatment goals, risks, alternatives, and whether TMS is clinically appropriate—not simply whether a patient wishes to undergo the procedure.