TMS stands for transcranial magnetic stimulation. It uses a magnetic field to create a pulse strong enough to get reach 2 to 3 centimeters into the human skull and stimulate the area of the brain responsible for the production of mood chemicals in patients suffering from depression.  It can also help people suffering from OCD, trauma such as concussions and TBI, PTSD, anxiety, and a host of other behavioral health issues. 

TMS generates highly concentrated magnetic fields, which turn on and off very rapidly. These magnetic fields are similar to those produced by a magnetic resonance imaging (MRI) machine. These magnetic fields do not directly affect the whole brain; they only reach about 2-3 centimeters into the brain directly beneath the treatment coil (6 cm. for the OCD coil and deep TMS).

 As these magnetic fields move into the brain, they produce very small electrical currents. These electrical currents activate cells within the brain, which are thought to release neurotransmitters like serotonin, norepinephrine, and dopamine. Since depression is thought to be the result of an imbalance of these chemicals in the brain, TMS can restore that balance and, thus, relieve depression.

TMS repairs damaged or sluggish neural networks through repetitive activation.  The more often a neural network is activated by the repetitive stimulation of TMS, the stronger it becomes.  TMS improves depression by retraining your brain cells to work together. 

The length of a TMS session depends on the protocol that is being used. Protocols are based on the condition being treated. For depression, the protocol is either 19 minutes, which has been the standard for some time, or the new protocol (Theta Burst) which is only three minutes. 

The FDA-approved protocol for OCD is 18 minutes.  For off-label conditions like post-concussion syndrome, the protocol is 7 minutes. 

The individual TMS session length is dependent upon the condition being treated and the protocol being used. Protocols are established through clinical trials.  The trials evaluate what TMS parameters work best for that particular condition. 

For example, in depression, the standard protocol was 19 minutes.  Now that the Theta Burst Protocol (3 minutes) has been proven to be equal in efficacy to the standard 19-minute protocol, that is another session option. 

1. Location of the coil

a) For depression patients the coil is placed on the left dorsal lateral prefrontal cortex or LDLPFC; for OCD patients, the coil is placed on the top of the head and stimulates the supplementary motor area or SMA.

2. The frequency of the coil (Hz)

a) TMS can be low frequency or high frequency. The frequency is the Hz.  Low-frequency TMS is considered inhibitory or lowering activity level.  Higher frequency TMS is considered excitatory, or increasing activity level. 

b) To further clarify the concept of frequency, it is important to understand the hertz. The hertz (Hz) is a unit of measure used to describe frequency. 1 Hz is equal to 1 cycle per second. Supposing we were to use 1 Hz in the settings for a TMS treatment session, one pulse would be delivered per second, provided of course that the pulses are delivered continuously (i.e. an interval time of 0). A session that lasts 10 minutes would therefore deliver 600 pulses at 1 Hz.

3. The intensity of the TMS coil

a) The TMS machine has the ability to regulate the level of power or intensity that it delivers. Usually, TMS machines have power level settings of 1 to 100. 

b) When the doctor determines the motor threshold (MT) they are determining the minimum amount of power to get the desired result. In the case of mapping for a depression patient, the MT is the minimum amount of power to get movement in the right thumb. 

c) With the depression protocol, the best results have been established to be the treatment that occurs at the intensity level of 120% of the MT. So, if a patient is successfully mapped at an intensity level of 40, their ideal intensity for treatment would be 48 (120% of 40).

4. The number of pulses in a train

a) These are the individual pulses that are activated by the TMS machine in one train.

b) Each train has a certain amount of pulses before the pause starts.

5.The amount of time in between the trains (pause time)

a) The amount of time between trains (11 seconds for the standard depression protocol) is another variable in a TMS protocol.

b) The machine beeps and alerts the patient when it is about to activate another train.

6. The total amount of trains

a) The total amount of trains is a function of the number of pulses in a train and the total amount of trains, which would be the total amount of pulses in a session.

7. Session length

a) Session length is an important variable as well. Some sessions are longer than others, depending on the condition being treated. 

8. Total amount of sessions

a) The total amount of sessions is dependent on the protocol being used.

b) The standard depression protocol is 36 sessions.

c)The SAINT protocol for depression is 50 sessions.

d)The post-concussion protocol is 20 sessions.

Research into optimal TMS treatment parameters for a given condition is ongoing.  New protocols are beings tested through clinical trials and researchers are looking for better, more efficient, and more effective treatment variables.  The SAINT protocol (10 sessions per day for 5 days) was just recently FDA-Approved after rigorous testing.  TMS technology is still in its infancy and is a very exciting development in the treatment of many brain-related conditions, even outside of behavioral health, like treatment for strokes and other trauma. 

Most health insurance plans pay for TMS.   However, insurance plans have several requirements that the patient must meet to pay for TMS treatment. Normally, these include a (1) diagnosis of depression or OCD, normally by a mental health professional like a psychiatrist, (2) some evidence of trying medication like antidepressants with no results or bad side effects, (3) some insurance companies require talk therapy, and (4) almost all insurance plans require the patient to be at least 18 years old.

When TMS was initially invented and studied, it was designed to treat people who were treatment-resistant or did not respond well to medication.  The individuals involved with the studies that eventually led to the FDA approving the efficacy of TMS treatment for depression all had patients who failed four or more antidepressant trials.  The studies did not include anyone under the age of 18 as well.  Most of the participants in these studies also had tried some talk therapy before TMS.

 Insurance company requirements to qualify for TMS coverage tracked the research parameters in these trials and included these requirements in their policies regarding TMS treatment.  In addition, medication is a lot less expensive for the insurance company than TMS treatment. The insurance companies want to see that a patient has at least tried some antidepressants before trying TMS in the hopes that it will remedy the problem before attempting TMS.

However, the amount of failed antidepressants/medications has dropped from four down to one for Medicare, and most commercial insurance policies only require two failed trials of medication before they will agree to pay for TMS. 

TMS was initially FDA-approved for depression in 2008. Since then, hundreds of thousands of patients have seen relief from their depression symptoms with TMS, and the insurance companies and medical science in general, now recognize TMS as not only a valid treatment option, but the preferred treatment option in many circumstances.

As a result, insurance companies have lessened the requirements to pay for TMS treatment. Also, the efficacy of medication goes down substantially as patients try different types and doses of antidepressants. It became apparent that additional antidepressants would most likely not help patients who had already failed an initial round. (See the Star D Study)

Most health insurance plans require a pre-authorization to pay for TMS. This means that they will review a potential patient’s medical records and prescription records to determine whether they are eligible for coverage for TMS.   A pre-authorization will be denied if the patient does not meet their insurance plan’s requirements for TMS, namely a diagnosis of depression (or OCD), some failed medication, the appropriate age, and some talk therapy.  Some plans have additional requirements that could result in a denial of coverage as well.

The cost of TMS with insurance depends on the individual insurance policy. Every policy has different payment components, including copays and deductibles. With TMS, a person’s out-of-pocket expense is a function of their deductibles and copays. A standard depression treatment protocol is 36 sessions, and under most circumstances that would result in 36 copayments if the individual is treating one session per day. 

Yes. The standard depression protocol with one session per day is five days a week for six weeks with weekends off. We have had patients who have to miss an appointment or two during the week and that will not affect the efficacy or results. However, if you plan on being on vacation for more than a week it is recommended that you do not start TMS until you are generally available and in town for your entire course of treatment.

Your health insurance plan will dictate whether they will pay for more than one session per day. If you are private pay or if your insurance will pay for more than one session per day, you can treat with multiple sessions in a day. We recommend no more than two treatments per day. There needs to be around 45 to 50 minutes in between treatment sessions. There have been numerous studies on the efficacy of multiple treatments in a day and the science shows that the efficacy is the same as one session per day. There is no evidence that safety or results are better through just one session per day.

We anticipate most insurance companies will loosen this requirement in the future. Medicare is silent on whether they will pay for multiple sessions in a day and we have successfully treated Medicare patients with two sessions per day.

It depends on what medication you are currently taking.  Our psychiatrists are trained in what medication can be safely taken while someone is undergoing TMS and what medication needs to be lessened or stopped altogether.  Some medication stunts the efficacy of TMS. 

Transcranial Magnetic Stimulation (TMS) therapy has been studied extensively as a treatment option for depression, with numerous clinical trials showing its efficacy. A meta-analysis of 13 randomized controlled trials published in JAMA Psychiatry in 2022 found that TMS therapy resulted in significant improvement in depression symptoms compared to placebo, with an effect size of 0.60 (95% CI, 0.46-0.74). The same meta-analysis also found that TMS was well-tolerated, with a low rate of adverse events.

Additionally, a study published in the American Journal of Psychiatry in 2022 found that TMS therapy was effective for treating depression in patients who had not responded to antidepressant medication. The study found that TMS therapy was associated with a response rate of 40.4% and a remission rate of 25.7%.

A randomized controlled trial published in the Journal of Clinical Psychiatry in 2022 found that TMS therapy was effective for treating depression in veterans. The study found that TMS therapy was associated with a significant improvement in depression symptoms compared to a sham treatment, with an effect size of 0.51 (95% CI, 0.27-0.75).

Overall, the body of evidence suggests that TMS therapy is an effective and well-tolerated treatment option for depression, with multiple studies showing significant improvement in depression symptoms compared to placebo.