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Provider EducationTMS is a well-established, FDA-cleared option for several mental health conditions. For most referring providers the open question is not whether it works, but when to reach for it — and the answer turns out to be more specific, and earlier, than the “last resort” framing suggests.
What follows is the clinical picture in the order a referring provider tends to need it: what the therapy actually does, what it is cleared to treat, how it performs against sham in the published trials, what a course looks like from the patient’s side, and where the referral threshold sits.
TMS therapy uses magnetic energy to stimulate nerve cells in the brain, primarily to treat depression and other psychiatric disorders. An electrical current runs through a coil positioned against the scalp to generate rapidly changing magnetic pulses. Those pulses pass through the skull and induce an electric field in the underlying brain tissue, altering neuron activity and the connected neural circuits.
To treat depression, stimulation typically targets the dorsolateral prefrontal cortex, a region involved in cognitive control and emotion regulation. Repeated stimulation over a series of sessions promotes communication across the brain networks associated with depression.
The scientific basis dates back to Faraday’s Law of Induction in the early 1830s, though modern TMS treatment began in the mid-1980s.
BrainsWay’s Deep TMS (dTMS) uses H-Coil technology to deliver broader, deeper pulses — as deep as 3.2 centimetres — across a wider area of the scalp.
Repetitive TMS (rTMS), also called standard TMS, uses a figure-8 coil to deliver focused magnetic pulses to one precise, mapped site. Those pulses do not penetrate as deeply.
Both follow an outpatient format and a similar treatment cadence. Unlike ECT and other brain stimulation therapies, TMS does not intentionally induce a seizure or require anaesthesia, so patients can drive themselves to and from appointments. Unlike vagus nerve stimulation (VNS) or deep brain stimulation (DBS), it requires no surgical implantation.
TMS therapy is cleared to treat:
BrainsWay’s Deep TMS systems are specifically cleared for MDD, anxious depression, OCD and smoking cessation. Researchers are currently studying TMS for post-traumatic stress disorder (PTSD), bipolar disorder, Alzheimer’s disease and other conditions.
A 2015 World Psychiatry study of more than 200 patients examined the effects of Deep TMS on MDD. Patients received active or sham Deep TMS over the prefrontal cortex for 20 sessions across four weeks. At week five, 38% of active dTMS patients responded to treatment compared with 21% on sham, and 32.6% achieved remission compared with 14.6%.
In a real-world study of more than 1,300 Deep TMS patients, roughly four in five who completed at least 30 sessions responded to treatment, and nearly two in three achieved remission.
Deep TMS proved effective for OCD as well. A 2019 American Journal of Psychiatry study of 99 participants found 38.1% of the active Deep TMS group demonstrated significant clinical improvement, against 11.1% in sham treatment.
The changes are often gradual and cumulative as the brain’s networks begin functioning more efficiently over several weeks of consistent treatment.
Dr. Stefani LaFrenierre, MDDr. LaFrenierre encourages patients to look for small wins first — getting out of bed more easily, enjoying music again, concentrating better at work, or being less emotionally reactive.
During the first session, the provider maps the patient’s skull to evaluate optimal coil placement and conducts a motor threshold test — determining the minimum energy required to make the patient’s finger twitch, which sets the correct stimulation parameters.
In a typical session, the patient sits in a comfortable chair while a trained practitioner fits the helmet or positions the coil and selects the prescribed protocol and individualised stimulation settings. TMS is performed without sedation or anaesthesia, so patients remain awake and alert and typically drive themselves to and from appointments.
Most people report no significant side effects. About half report mild headaches that diminish over the course of treatment. Some experience scalp discomfort or facial twitches.
TMS therapy is prescribed by medical doctors, psychiatric mental health nurse practitioners and physician assistants. Treatment is typically conducted by TMS-trained psychiatrists, technicians or nurses under supervision.
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For treatment-resistant depression — failing to respond to two different antidepressant medications — Deep TMS is a reasonable next step. The STAR*D study showed that after an inadequate response to at least two different antidepressants, the likelihood of remission from another antidepressant alone decreases substantially.
The earlier patients are evaluated, the sooner we can determine whether TMS fits into their treatment plan. Many patients spend years cycling through medication after medication before even learning they had another evidence-based option available.
Dr. Stefani LaFrenierre, MDShe encourages primary care physicians to normalise TMS as one of several evidence-based treatment options rather than presenting it as a last resort — framing that, in her words, “unintentionally reinforces outdated misconceptions, destroys hope, and delays patients from receiving an effective treatment.”
Dr. Irfan Handoo, MD notes that patients with a biologically based family history of depression tend to respond well to TMS.
Not everyone is a candidate. The screen splits into three tiers, and only the first is an outright stop.
After a provider submits a referral, the TMS team conducts an initial assessment — psychiatric history, mental status exam, risk assessment and TMS safety screen — then schedules a mapping appointment to determine the individualised treatment plan.
Treating patients with TMS requires collaborative effort between the referring doctor and the TMS team. Three things are worth flagging early.
If a patient has medication changes while undergoing TMS therapy, the TMS practitioner must recheck the motor threshold before the next session to recalibrate. Severe sleep deprivation lowers the brain’s seizure threshold, increasing the rare risk of seizure during treatment.
The TMS team needs to know whether a patient has a substance use history and whether they are still actively using. Many patients with treatment-resistant depression have current or prior substance use disorders.
A history of substance use doesn’t automatically make someone a poor candidate for TMS. The important question isn’t whether they’ve struggled with addiction; it’s whether we understand where they are in recovery and how substance use may be interacting with their psychiatric symptoms.
Dr. Stefani LaFrenierre, MDAdvise patients to stay the course. Dr. Handoo indicates it often takes until session 16 or 17 for patients to notice improvement in depression symptoms. In some cases, full benefits do not appear until after the final session.
Antidepressants are usually first-line treatment for depression alongside psychotherapy, typically taken orally at home. Side effects vary but can produce system-wide effects. When patients fail medication trials of at least two different antidepressants, they typically become candidates for TMS.
The best outcomes happen when TMS is paired with healthy routines, psychotherapy when appropriate, and thoughtful medication management. TMS creates an opportunity for the brain to recover, but patients still have to build on that momentum once treatment is over.
Dr. Stefani LaFrenierre, MDElectroconvulsive therapy (ECT) is more invasive, involving seizure induction under anaesthesia. Anaesthetic drugs have wide-reaching systemic effects including nausea, confusion and occasionally short-term memory impairment.
Many of my patients have described ECT as putting on a mask that covers up their depression, and they describe TMS as actually helping to unveil the mask.
Dr. Irfan Handoo, MDEsketamine, a nasal spray derivative of ketamine, was FDA-approved in 2019 for treatment-resistant depression but must be taken with an oral antidepressant. It typically relieves symptoms within one to three days. Common side effects include dissociation, nausea, drowsiness and temporary increases in blood pressure.
| Aspect | TMS | Medication | ECT | Esketamine |
|---|---|---|---|---|
| Mechanism | Coil against the scalp induces electrical currents in targeted brain regions | Alters production or use of neurotransmitters involved in mood and stress | Controlled current through scalp electrodes induces a brief seizure | Blocks NMDA receptors to help form and strengthen new connections |
| Invasiveness | Noninvasive outpatient; no anaesthesia or sedation | Usually taken at home; no anaesthesia | Requires anaesthesia and muscle relaxants | No anaesthesia required |
| Course length | 20-minute sessions daily, five times weekly, four to six weeks | Usually taken daily | Two to three times weekly for three to four weeks | Commonly twice weekly for four weeks, then weekly |
| Seizure risk | Rare potential adverse event | Varies by medication, dosage and individual factors | A controlled seizure is the intended mechanism | Does not typically cause seizures |
| Systemic effects | No medication circulates; systemic effects limited | Produces systemic exposure; side effects vary | Anaesthetic effects include confusion, headache, nausea, memory impairment | Sedation, dissociation, temporary blood pressure spikes |
| Positioning | Often after inadequate response to two or more antidepressants | Generally the initial treatment for depression | Often reserved for severe, treatment-resistant depression | For treatment-resistant depression, with an oral antidepressant |
This table summarises general treatment characteristics. It is not a substitute for prescribing information or individual clinical judgement.
One of the biggest mistakes I see is describing TMS as either a miracle treatment or a last resort. Neither is accurate. When I counsel patients, I explain that TMS is a process rather than a single intervention.
Dr. Stefani LaFrenierre, MDPatients wear earplugs during treatment and experience a sensation resembling tapping on the head, with loud clicking sounds. The sensation stops when the machine shuts off. Most report no side effects, though some report headache, scalp discomfort or facial muscle twitching. Providers can adjust stimulation parameters to reduce them.
I tell patients that progress isn’t always linear. Some people improve steadily, while others experience temporary plateaus or fluctuations before continuing to improve. That variability is completely normal and shouldn’t be mistaken for treatment failure.
Dr. Stefani LaFrenierre, MDTMS is a well-established, FDA-cleared option for several mental health conditions. The real question is when to use it, and the referral criteria are straightforward: the patient has failed adequate trials of at least two different antidepressants, and there are no absolute contraindications.
Transcranial magnetic stimulation is an FDA-cleared, noninvasive treatment shown to improve symptoms of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), migraine with aura and smoking cessation. As an outpatient procedure requiring no anaesthesia, patients can drive themselves to and from appointments and resume their normal day. Most report little to no side effects; when present, they are usually mild.
TMS is a brain stimulation therapy. A primary care provider or psychiatrist may recommend TMS and refer a patient to a TMS clinic. During a typical session, the patient sits in a comfortable chair while a trained practitioner positions the coil against the scalp and selects the prescribed treatment protocol and individualised stimulation settings. TMS is an outpatient procedure performed without sedation or anaesthesia, so patients remain awake and alert and typically drive themselves to and from appointments.
A common course is one 20-minute session per day, five days per week, for about four to six weeks. Many physicians then taper treatments and offer maintenance sessions over the following weeks. The length, frequency and total session numbers vary by protocol.
Most report no side effects, though some report headache, scalp discomfort or facial muscle twitching. Providers can adjust stimulation parameters to reduce side effects.
If a patient has had an inadequate response to two or more antidepressants and carries no absolute contraindications, a TMS evaluation is a reasonable next step — not a last one.
The provider finder lists BrainsWay Deep TMS sites by location, so you can identify a referral destination before raising the option with a patient.
This article is intended for healthcare professionals and is provided for educational and informational purposes only. It is not medical advice and does not replace individual clinical judgement, prescribing information, or a full safety screen. Treatment results vary between patients. Learn more about our editorial standards.
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Deep TMS uses H-Coil technology to stimulate structures associated with mood regulation, without anaesthesia, sedation or downtime. Patients drive themselves home and return to their day.
