A major challenge for patients with depression is that traditional antidepressant medications often take weeks or months to show results — if they work at all. This delay can be especially distressing for those with severe depression symptoms, including suicidal thoughts.
To solve this issue, researchers and clinicians are continuously working on developing faster-acting depression treatments, one of the most promising being accelerated transcranial magnetic stimulation (TMS).
In this article, we cover the main factors patients should consider when choosing a clinic to receive accelerated TMS therapy:
Does the clinic offer MRI and/or neuronavigation for precise targeting and coil placement?
Does the clinic combine accelerated TMS therapy with psychotherapy or other treatments?
Cognitive FX offers the most advanced, safe, and precise method of accelerated TMS for people with treatment-resistant depression. Click here to learn more and see if you’re a good fit for treatment.
When exploring clinics for accelerated TMS treatment, it's crucial to recognize that "accelerated TMS" encompasses various protocols with differing speeds and effectiveness. Understanding these differences will help you clarify what each clinic offers, ensuring you receive the treatment you want.
In general, “accelerated TMS” refers to protocols that use intermittent theta-burst stimulation (iTBS). In contrast to the original and most common form of TMS (rTMS), which requires 37-minute daily treatment sessions over 4 to 6 weeks, iTBS can be delivered in just 3-minute sessions making it much more convenient for patients. Typically, patients respond faster to iTBS than standard TMS therapy while achieving similar (or superior) results.
With that said, there are at least three accelerated TMS protocols that you might encounter:
One iTBS session per day over 4 to 6 weeks: TMS clinics may offer iTBS which provides the convenience of short 3-minute treatment sessions, but do so over the standard 4 to 6 week treatment period which can be difficult for many patients to adhere to due to work and life commitments. This protocol produces similar results to rTMS where about 50% of patients see improvement in symptoms and around 30% reach complete remission.
Multiple iTBS sessions per day over a condensed period: TMS centers may offer multiple iTBS sessions per day which condenses the time it takes to complete treatment by half or more.
Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT): A few clinics, including Cognitive FX, offer SAINT TMS. Developed at Stanford University, this newly FDA-approved protocol uses iTBS in coordination with fMRI and neuronavigation for precision targeting (more on this below). SAINT treatment involves 10 sessions per day over 5 days for 50 sessions total. In a double-blind randomized clinical trial, about 85.7% of patients responded to the treatment (meaning they met prespecified criteria for reduced depressive symptoms) and around 78.6% met the remission criterion. All the individuals in the study had treatment-resistant depression and had failed at least two other depression treatments. At the one-month mark, 60% were still in remission. In addition, this protocol quickly reduces depressive symptoms and suicidal ideation within 5 days, without serious negative side effects.
A comparison of remission rates for rTMS/iTBS, electroconvulsive therapy (ECT), and SAINT-iTBS.
When discussing options with TMS providers, ask them to clarify which accelerated treatment protocols they offer. This ensures you can choose a provider that meets your specific needs, whether you're looking for a condensed treatment schedule or cutting-edge options like SAINT TMS, which offers a higher likelihood of rapid relief.
Aside from the condensed treatment time frame, the key thing that separates SAINT TMS from the other forms of accelerated TMS we discussed above is the use of fMRI for locating the target area of the brain (the dorsolateral prefrontal cortex or DLPFC), and neuronavigation for placing the magnetic coil over that exact spot on the patients head for every treatment session.
The reason this matters, and likely the key reason that SAINT is producing significantly higher response and remission rates compared to standard rTMS or iTBS treatments, is that without fMRI and neuronavigation, the magnetic coil is often placed slightly off target. Even a few millimeters off can reduce the treatment’s effectiveness.
If the clinic you’re considering offers SAINT treatment, this is synonymous with using fMRI and neuronavigation. This is the ideal treatment option from an outcomes perspective.
If the clinic you’re considering offers accelerated TMS that is not SAINT, this is when you want to ask about what method they use for targeting the DLPFC and placing the coil for each session.
Some clinics will offer a structural MRI (as opposed to fMRI) with neuronavigation. This would be second in line for ideal options. However, many clinics do not offer MRI or neuronavigation, and simply use one of the following methods for coil placement:
The 5 cm method (most common; least accurate): This method involves identifying an area on top of the head called the motor cortex. Operators locate this area using magnetic pulses, which force the patient’s thumb to move. Once the motor cortex is located, operators measure 5 cm along the parasagittal plane anterior to the activation hotspot in the motor cortex. Many studies now show that this method can be unreliable and doesn’t account for individual variations in brain size and shape between patients.
Beam F3 method (EEG Cap): This method relies on the International 10–20 EEG system to locate the DLPFC. Operators place a cap with a grid on the patient’s head and find position F3 to place the magnetic coil. Although studies show that the F3 method is slightly more accurate and reliable compared to the 5 cm method, differences are minor and unlikely to be substantially better. In addition, even a simple haircut can change how the cap fits the patient, which means it can vary from session to session.
If you can find a clinic that offers some form of MRI and neuronavigation, this is likely to give you the best treatment outcomes. If this isn’t an option for you, it can still be worth proceeding with treatment. Even standard forms of rTMS or accelerated TMS are likely to offer fewer side effects and equal or better results than antidepressant medications.
Note: For patients who have not responded to rTMS or accelerated TMS protocols that lacked MRI and neuronavigation, it is possible that they didn’t respond because the coil was in the wrong location. With the increased accuracy of fMRI, patients have a better chance of recovery.
Many clinics enhance the effectiveness of TMS by integrating it with other therapies, such as psychotherapy, neurofeedback, EMDR, or yoga. At our clinic, we believe that combining TMS with cognitive behavioral therapy (CBT) offers the greatest potential for improving long-term outcomes.
While TMS provides fast symptom relief, CBT has been shown to deliver more lasting benefits. Among the various forms of psychotherapy, CBT stands out with the strongest scientific backing for treating depression, supported by a substantial number of randomized controlled trials.
Meta-analyses consistently show that CBT outperforms other psychotherapies, particularly in maintaining benefits over time, with lasting effects up to a year or more post-treatment.
In contrast, other therapies and even medications often see a decline in effectiveness after treatment ends, with a higher risk of relapse.
Research clearly demonstrates that CBT surpasses other therapies and medications in both immediate and long-term outcomes for depression, with response rates ranging from 61% to 87% and consistently large effect sizes.
Be sure to ask clinics about any additional treatments they offer alongside TMS. If you're deciding between a clinic that provides only TMS and another that combines it with therapies like CBT, we recommend choosing the clinic with the integrated approach. For instance, at Cognitive FX, we offer CBT sessions to complement TMS, enhancing the overall effectiveness of the treatment.
Currently, accelerated TMS is not covered by insurance, which can be a major consideration when selecting a clinic. Only repetitive TMS (rTMS), used for depression since the 1990s, is typically covered, as many insurers deem it medically necessary for major depressive disorder (MDD) and treatment-resistant depression (TRD).
The cost of a TMS treatment course generally ranges from $6,000 to $15,000, and insurance coverage varies by provider. Some insurers require patients to have failed four antidepressant medications and psychotherapy, while others are less strict. Requirements for medication types and severity of symptoms also differ. Even with approval, patients may still face copays or deductibles, though some insurers may cover the full cost. For those needing further financial assistance, payment plans or healthcare financing options like CareCredit may help.
Advanced TMS protocols, such as iTBS and SAINT TMS, are not covered by insurance and must be paid for out of pocket. These newer methods, particularly SAINT treatment, offer significantly higher chances of getting response and remission.
If affordable, we recommend choosing a clinic offering these advanced treatments for the best chances of recovery. If relying on insurance, rTMS is still a viable option, offering equal or better results than antidepressant medication despite a longer treatment time and slightly lower response rates than accelerated TMS.
As mentioned previously, at Cognitive FX, we follow the SAINT protocol, using fMRI and neuronavigation for precise coil placement.
In contrast to traditional TMS, which takes up to six weeks to complete, our treatment plan is facilitated in just one week. Patients receive ten TMS sessions daily for five days. Each session includes ten minutes of magnetic pulses and a 50-minute break between sessions.
To improve outcomes for our patients, we also include cognitive behavioral therapy (CBT) as a part of our treatment. When combined with the traditional method of TMS (rTMS), CBT improved response and remission rates by ~8% and ~19%, respectively. Additionally, CBT is likely to produce sustained improvement over time once SAINT-iTBS has concluded.
Our TMS treatment is ideal for most patients with treatment-resistant depression. However, we do not treat patients under the age of 18 or over 65. Additionally, as a safety measure, we do not treat patients who have a history of seizures or who are currently actively suicidal and in need of crisis care.
If you are interested in receiving SAINT accelerated TMS therapy at Cognitive FX, click here to learn more.
