TMS for Depression: Benefits, Protocols, Safety, and What the Evidence Really Shows

TMS is a noninvasive treatment for major depression, but its results and schedule depend on the exact device, coil, target, and pulse pattern.

Direct answer: TMS can reduce symptoms of major depression, especially after antidepressants have not helped enough. It uses focused magnetic pulses to create small electrical currents in brain areas linked to mood. It is usually outpatient and does not need anesthesia. Results vary, and the exact device, coil, target, and schedule matter.

Key points

• Strongest evidence is in adults whose depression did not improve enough with prior treatment.
• Standard 10 Hz TMS and brief iTBS both have good adult evidence.
• Accelerated treatments are different packages. SAINT, SWIFT, and MagVenture schedules should not be treated as the same protocol.
• Some devices have adjunctive clearance for ages 15 through 21. That is not a class-wide pediatric label.
• TMS is generally well tolerated. It still has risks and is not emergency care for suicidal thoughts.

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What is TMS for depression?

Transcranial magnetic stimulation, or TMS, uses a coil placed on the scalp. A fast current inside the coil makes a magnetic field. That field passes through the skull and creates a small electric field in the outer brain tissue. This can activate nerve cells without surgery or an implant.[1] For a plain-language tour of the machine, the coil, and the seven settings that define any TMS protocol, start with how TMS works and why the details matter.

For depression, treatment often aims at the dorsolateral prefrontal cortex, or DLPFC. This front area is linked to deeper mood networks. Some DLPFC sites have an opposite activity pattern to the subgenual cingulate. A stronger pattern has been linked with better results.[2,3]

The coil acts most directly in nearby cortex. Changes in deeper areas are indirect. Repeated pulses may affect plasticity and communication across mood networks. This is a supported theory, not a complete or proven chemical explanation.[4]

Who was studied?

Most major trials enrolled adults who had not improved after one or more adequate antidepressant trials. Definitions differed by study and considered dose, duration, and adherence. If you are still in the early weeks of a new antidepressant, why antidepressants take time explains what an adequate trial looks like.

The later 2008 NeuroStar K083538 summary covers people after one antidepressant did not help. This must be in the current episode. The drug must have been given at an effective dose and for enough time.[5] The 2022 VA/DoD guideline suggests rTMS. It applies after at least two adequate medication trials did not help enough. This was a weak recommendation. The guideline rated the evidence very low and came before the newest accelerated clearances.[6]

A device label says what the FDA cleared for that product. A guideline weighs benefits, harms, and evidence. Neither replaces a full clinical and safety evaluation.

Which TMS treatment is being offered?

TMS is not one machine or recipe. The platform makes the pulse. The coil shapes the field. The target sets placement. The schedule sets the daily and total dose.

Motor threshold is the lowest strength that makes a small hand-muscle response. Clinics use it to set dose and may recheck it during care.

Standard left, right, bilateral, and iTBS options

Left-sided 10 Hz rTMS has the longest U.S. trial history. Right-sided 1 Hz may help. Still, one Hz is not a universal brain “off switch.” Bilateral treatment stimulates both sides in sequence. It is not proven better than unilateral care.

Intermittent theta-burst stimulation, or iTBS, groups pulses into short bursts. The 414-person THREE-D trial compared iTBS with 10 Hz TMS. iTBS took about 3 minutes, while 10 Hz took 37.5 minutes. iTBS met the preset noninferiority margin. Response was 49% with iTBS and 47% with 10 Hz. Remission was 32% and 27%. This was an active comparison, not a sham trial. It supports similar average short-term results but did not test either treatment against sham.[10]

SAINT is not a general name for accelerated TMS

Magnus SAINT is a full treatment package. A resting-state fMRI scan selects a left DLPFC point. That point has strong negative connectivity to the subgenual cingulate. Each session uses 1,800 iTBS pulses. There are 10 sessions a day with 50-minute gaps, for 5 days. That is 90,000 pulses. Stimulation and gaps take at least about 9 hours 10 minutes each day, before setup.[12]

BrainsWay SWIFT uses an H1 coil and standard placement. It gives 5 sessions a day on 6 days over 2 weeks. Then it gives 2 sessions once weekly for 4 weeks. MagVenture K260189 instead lists four schedules with different doses and course lengths.[13,14]

Ask for the exact FDA number and protocol. A clinic should not borrow the SAINT name for any fast course.

What the research shows

Conventional TMS works better than sham on average

The first large NeuroStar trial randomized 301 adults. Its planned week-4 MADRS outcome narrowly missed statistical significance, at p=.057. Secondary scales and later outcomes favored active treatment. At week 6, remission was 14.2% to 17.4% with active TMS. It was 5.2% to 8.2% with sham. The range reflects different scales.[15]

An independent NIMH-funded trial randomized 190 medication-free adults. Remission was 14.1% with active TMS and 5.1% with sham. The odds ratio was 4.18, and the number needed to treat was 12.[16] Trial rates may differ from clinic reports because entry rules and endpoints differ.

The H1-coil trial allocated 233 adults. Its 212-person ITT primary contrast was not significant: -2.23 points, 95% CI -4.54 to .07, p=.0578. The favorable per-protocol set included 181 people. Response was 38.4% with active treatment and 21.4% with sham. Remission was 32.6% and 14.6%. The study was supported by BrainsWay. One seizure occurred after a protocol violation.[11]

Response usually means a symptom score fell by at least half. Remission means it fell below a study cutoff. Scales and time points differ. So do the people studied and the rules for missing data. Separate studies are not a fair brand contest.

Accelerated evidence is encouraging but smaller

The first randomized SAINT trial treated 29 people, 14 with active treatment and 15 with sham. Four weeks later, 13 active and 14 sham participants had data. Average MADRS reduction was 52.5% with active treatment and 11.1% with sham. Response was 9 of 13, or 69.2%, versus 1 of 14, or 7.1%. Remission was 6 of 13, or 46.2%, versus 0 of 14. The study was small and came from one site. It stopped at a planned interim review after meeting its superiority rule. Stanford licensed related intellectual property to Magnus. Several authors reported related financial interests.[17]

A 2026 randomized replication included 48 people. At one month, remission was 50.0% with active SNT and 20.8% with sham. Response was 54.2% and 25.0%. This strengthens the signal. It still comes from the Stanford program, and the evidence base remains small.[18]

The 2026 SWIFT trial randomized 104 adults to accelerated or standard H1 treatment. In the per-protocol group, the depression-score drop was similar and met the prespecified noninferiority margin. Response was 87.8% with SWIFT and 87.5% with standard H1. Remission was 78.0% and 87.5%. There was no sham group, and the sponsor and several authors had BrainsWay ties.[19] These high rates should not be compared directly with rates from the older sham trials.

Adolescents need a separate evidence discussion

NeuroStar K231926 cleared adjunct treatment for ages 15 through 21. The FDA record relied mainly on past real-world data. It included 1,169 per-protocol patients ages 12 through 21. Only 10 were ages 12 through 14. The final label starts at age 15.[20]

Several later devices received their own 15-through-21 adjunct labels. Some relied on predicate and bench evidence rather than a new device-specific adolescent trial. That does not make every TMS system cleared for teenagers.

The largest adolescent sham trial randomized 112 people ages 12 through 21. The article called its 103-person analyzed group the ITT population; entry required at least one treatment and a later HAM-D24 rating. After 6 weeks, improvement was -11.1 points with active treatment and -10.6 with sham. Response was 41.7% versus 36.4%. Remission was 29.2% versus 29.0%. No new safety signal appeared, but active TMS did not beat sham.[21]

A 2026 review found large gains in studies without a control group. Yet the RCT-only estimate crossed zero. Results differed widely, and most studies had a high risk of bias.[22] Some devices are cleared, and real-world results encourage further study. Controlled adolescent efficacy remains uncertain.

Anxious symptoms in MDD are not generalized anxiety disorder

BrainsWay K210201 and NeuroStar K220127 include wording about anxiety symptoms. It applies to adults who have MDD and may have comorbid anxiety symptoms.[23,24] The analyses used anxiety items within depression data. These are not FDA clearances for generalized anxiety disorder, panic disorder, or every anxiety condition.

Time course, durability, medication, and therapy

Some people improve in the first weeks. Others improve later or not at all. Regular use of the same symptom scale can guide review of the plan.

Benefits can last, but relapse happens. In one open 6-month follow-up of 99 people who had benefited, 10 relapsed and 38 worsened. Of those 38, 32 regained benefit after TMS was added again.[25] In a 12-month observational study, 75 of 120 acute responders or remitters still had a sustained response. Medication continued, and 93 of all 257 followed patients received TMS again.[26]

These were not randomized maintenance trials, and no single schedule is proven. Plan medication, psychotherapy, symptom checks, and what to do if symptoms return. Adolescent labels call TMS adjunctive care.

Safety and suitability

Common effects include scalp pain, headache, tapping, tingling, and brief facial movement. Hearing protection is required. Severe or lasting symptoms need review.[27]

Seizure is rare. A survey reported 18 seizures across 586,656 sessions, about .31 per 10,000 sessions. It was retrospective, only 6 events were verified, and data ended in 2018.[28] Screen seizures, brain injury, sleep loss, withdrawal, and factors that lower seizure threshold.

Metal or an implant near the head needs exact review. Risk depends on material, location, distance, electronics, and both labels. Aneurysm clips, cochlear implants, stimulators, pumps, and metal fragments need special attention. Not every remote implant is an automatic ban.[27]

Clinicians should screen for bipolar disorder. An older review found mania or hypomania in .84% with active TMS. It found .73% with sham, and the dataset was small. Watch for much less need for sleep, unusual energy, racing thoughts, or risky behavior.[29]

TMS is not known for the marked memory loss linked with ECT. Still, “no cognitive effects” is too broad. A 2025 review of 15 sham trials found no reliable cognitive benefit over sham.[30] Report new memory or focus concerns.

TMS is not emergency treatment for suicidal thoughts. A meta-analysis found no significant reduction in randomized trials, although uncontrolled studies improved.[31] Worsening thoughts need prompt assessment.

Related TMS guides

• How TMS works: the coil, the target, the dose, and the seven settings to ask about
• TMS for OCD: a different target, a symptom-provocation step, and a mixed evidence picture
• TMS for PTSD: what the 2026 MeRT clearance does and does not prove
• Why antidepressants take time, and how to make the first six weeks count

What we still do not know

• Which target and pulse pattern is best for one person.
• Whether fMRI personalization itself improves results, apart from the high dose and close timing used in SAINT.
• Whether accelerated schedules match conventional care over years.
• The best taper, maintenance, and retreatment plan.
• Which adolescents are most likely to benefit beyond usual medication and psychotherapy.
• Whether a biomarker can reliably predict response before treatment starts.

Questions to ask a TMS clinic

1. What is the exact platform, coil, FDA number, target, and protocol you plan to use?
2. Is this use cleared for my diagnosis and age, or is it off-label?
3. How will you find the target and measure motor threshold?
4. How many pulses, sessions per day, total sessions, and hours in the clinic are planned?
5. What evidence supports this exact package, and was it sham-controlled or only compared with another active treatment?
6. How will you measure response, remission, side effects, mania, and suicidal thoughts?
7. What is the plan if I improve slowly, do not improve, or relapse later?
8. How will medication, psychotherapy, sleep, and substance use be handled during treatment?
9. What emergency equipment, hearing protection, and seizure-response training do you have?
10. What parts of care and cost are covered? Coverage and out-of-pocket costs vary.

Frequently asked questions

1. Does TMS work for everyone with depression?

No. Trials show an average benefit, but some people do not respond. Past treatment, diagnosis, protocol, dose, and individual brain networks may matter. No test can promise success.

2. Is iTBS weaker because it lasts only a few minutes?

Not on average in the THREE-D trial. Once-daily iTBS was noninferior to 10 Hz treatment even though each session was much shorter.[10] That does not mean every iTBS schedule works the same.

3. Is accelerated TMS the same as SAINT?

No. SAINT is the Magnus imaging-guided, 10-session-a-day package. SWIFT uses an H1 coil and a different six-week plan. MagVenture lists four other accelerated schedules. Names should follow the exact device record.

4. Can a teenager receive TMS?

Certain devices are cleared as adjunct treatment for MDD at ages 15 through 21. The exact device matters. Controlled efficacy evidence is still uncertain. Care should include a youth mental health clinician, family discussion, and close safety checks.

5. Can TMS treat my anxiety too?

It may reduce anxiety symptoms that occur with MDD on devices with that wording. This is not the same as clearance for generalized anxiety disorder. Ask which diagnosis and label apply.

6. Will I lose my memory or need someone to drive me?

TMS usually does not require anesthesia and is not known for ECT-like memory loss. Most people return to normal activity. Pain, dizziness, medicines, or other health issues may change driving advice. Follow the clinic’s safety instructions.

7. How long will the benefit last?

There is no guaranteed length. Some people stay well for months, while others need medication changes, maintenance, or a new TMS course. Ask for a written relapse plan before treatment ends.

A reasonable next step

Bring your medicine and therapy history to a psychiatrist or another qualified TMS clinician. Ask for the exact device and protocol. Review the evidence for your age and diagnosis, time in clinic, safety checks, and symptom plan. A careful visit can help you compare options without a promised result.

Medical education disclaimer: This article is for general education. It does not diagnose a condition or replace care from a qualified clinician. FDA clearance is device and indication specific. Individual risks, benefits, medication decisions, and emergency needs require personal assessment.

Crisis safety note: If you may act on thoughts of suicide or cannot stay safe, get help now. Call 911 or go to the nearest emergency department. In the United States, call or text 988 for the Suicide & Crisis Lifeline. Do not wait for a TMS appointment or session. More crisis resources are listed at the end of this page.

References

1. National Institute of Mental Health. Brain Stimulation Therapies. Current government overview. Direct link.
2. Fox MD, et al. Efficacy of transcranial magnetic stimulation targets for depression is related to intrinsic functional connectivity with the subgenual cingulate. Biological Psychiatry. 2012. PMID 22658708. DOI.
3. Weigand A, et al. Prospective validation that subgenual connectivity predicts antidepressant efficacy of transcranial magnetic stimulation sites. Biological Psychiatry. 2018. PMID 29274805. PubMed.
4. Downar J, et al. Mechanisms of Action of TMS in the Treatment of Depression. Current Topics in Behavioral Neurosciences. 2024. PMID 38844713. DOI.
5. U.S. Food and Drug Administration. NeuroStar TMS Therapy System, K083538. 2008. Decision summary.
6. Department of Veterans Affairs and Department of Defense. Clinical Practice Guideline for the Management of Major Depressive Disorder. 2022. Guideline PDF.
7. Cao X, et al. Response and Remission Rates Following High-Frequency vs. Low-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Over Right DLPFC for Treating Major Depressive Disorder (MDD): A Meta-Analysis of Randomized, Double-Blind Trials. Frontiers in Psychiatry. 2018. PMID 30245641. PubMed.
8. Fitzgerald PB, et al. A randomized, controlled trial of sequential bilateral repetitive transcranial magnetic stimulation for treatment-resistant depression. American Journal of Psychiatry. 2006. PMID 16390894. PubMed.
9. Fitzgerald PB, Hoy KE, Herring SE, et al. A double blind randomized trial of unilateral left and bilateral prefrontal cortex transcranial magnetic stimulation in treatment resistant major depression. Journal of Affective Disorders. 2012;139(2):193-198. doi:10.1016/j.jad.2012.02.017. PMID 22397890. PubMed.
10. Blumberger DM, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. Lancet. 2018. PMID 29726344. DOI.
11. Levkovitz Y, et al. Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry. 2015. PMID 25655160. DOI.
12. U.S. Food and Drug Administration. Magnus Neuromodulation System, K220177. 2022. Decision summary.
13. U.S. Food and Drug Administration. BrainsWay Deep TMS System SWIFT schedule, K251449. 2025. Decision summary.
14. U.S. Food and Drug Administration. MagVenture TMS Therapy, accelerated schedules, K260189. 2026. Decision summary.
15. O’Reardon JP, et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biological Psychiatry. 2007. PMID 17573044. DOI.
16. George MS, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Archives of General Psychiatry. 2010. PMID 20439832. DOI.
17. Cole EJ, et al. Stanford Neuromodulation Therapy (SNT): a double-blind randomized controlled trial. American Journal of Psychiatry. 2022. PMID 34711062. DOI.
18. Kratter IH, et al. Stanford neuromodulation therapy for treatment-resistant depression: a randomized controlled trial confirming efficacy, and an EEG study providing insight into mechanism of action and a potentially predictive biomarker of efficacy. World Psychiatry. 2026. PMID 41536095. DOI.
19. Hanlon CA, et al. Accelerated TMS with the H1-coil for depression: a multisite, randomized non-inferiority trial. Brain Stimulation. 2026. PMID 41781301. DOI.
20. U.S. Food and Drug Administration. NeuroStar Advanced Therapy System adolescent MDD indication, K231926. 2024. Decision summary.
21. Croarkin PE, et al. Left prefrontal transcranial magnetic stimulation for treatment-resistant depression in adolescents: a double-blind, randomized, sham-controlled trial. Neuropsychopharmacology. 2021. PMID 32919400. DOI.
22. Rakic L, et al. Repetitive Transcranial Magnetic Stimulation (rTMS) for Adolescent Depression: A Systematic Review and Meta-Analysis of Treatment Response and Suicidal Ideation Reduction. Acta Psychiatrica Scandinavica. 2026. PMID 42223086. DOI.
23. U.S. Food and Drug Administration. BrainsWay Deep TMS System, MDD with anxiety-symptom wording, K210201. 2021. Decision summary.
24. U.S. Food and Drug Administration. NeuroStar Advanced Therapy System, MDD with anxiety-symptom wording, K220127. 2022. Decision summary.
25. Janicak PG, et al. Durability of clinical benefit with transcranial magnetic stimulation in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study. Brain Stimulation. 2010. PMID 20965447. DOI.
26. Dunner DL, et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1-year follow-up period. Journal of Clinical Psychiatry. 2014. PMID 25271871. DOI.
27. Rossi 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(1):269-306. PMID 33243615. DOI.
28. Taylor JJ, et al. Seizure risk with repetitive TMS: survey results from over a half-million treatment sessions. Brain Stimulation. 2021. PMID 34133991. DOI.
29. Xia G, et al. Treatment-emergent mania in unipolar and bipolar depression: focus on repetitive transcranial magnetic stimulation. International Journal of Neuropsychopharmacology. 2008. PMID 17335643. PubMed.
30. Fu L, et al. Effects of repetitive transcranial magnetic stimulation (rTMS) on cognitive impairment in depression: a systematic review and meta-analysis. Journal of Affective Disorders. 2025. PMID 39793617. DOI.
31. Mehta S, et al. The Effect of Repetitive Transcranial Magnetic Stimulation on Suicidal Ideation in Treatment-Resistant Depression: A Meta-Analysis. Journal of Clinical Psychiatry. 2022. PMID 35044731. DOI.

If you or someone you know is in crisis

• Call 911 or go to your nearest emergency room for any life-threatening emergency.
• 988 Suicide & Crisis Lifeline — call or text 988, available 24/7. En español: marque 988 y oprima 2. Veterans: 988 and press 1, or text 838255.
• Crisis Text Line — text HOME to 741741.
• The Trevor Project (crisis support for LGBTQ+ young people) — call 1-866-488-7386, or text START to 678-678.
• National Sexual Assault Hotline (RAINN) — call 1-800-656-HOPE (4673) or text HOPE to 64673; free, confidential, 24/7. Online chat at RAINN.org/hotline.
• National Domestic Violence Hotline — call 1-800-799-SAFE (7233) or text START to 88788; 24/7, help in 200+ languages. Online chat at TheHotline.org. If your phone or computer may be monitored, calling from a safer device is an option.
• Riverside County — Inland SoCal Crisis Helpline 951-686-HELP (4357), 24/7 (Inland SoCal United Way / 211+, in partnership with RUHS-BH); Community Access, Referral, Evaluation and Support (CARES) Line 800-499-3008, 24/7.
• San Bernardino County — Access Unit (Behavioral Health Helpline) 888-743-1478, 24/7; Mobile Crisis/CCRT 800-398-0018 (24/7, all ages) or text 909-420-0560. Arrowhead Regional Medical Center (ARMC) has a dedicated walk-in adolescent psychiatric ER (ages 13–17).
• Children under 13 — call 911 for immediate danger, contact your county's mobile crisis team (they respond to all ages), or go to the nearest pediatric emergency room.
• California Peer-Run Warm Line (non-crisis — someone to talk to) — call or text 1-855-600-WARM (9276); daytime and evening hours, not a 24/7 line.
• NP Fady (non-emergency) — for routine scheduling or questions, call (909) 707-6261. This line is not monitored for emergencies.