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Major Depressive Disorder can be severe, chronic and disabling. In fact it is one of the  leading causes of disability worldwide. Standard methods of treatment like medications and psychotherapy are often ineffective. During management of this Treatment Resistant Depression (TRD) we follow traditional steps. First, we need to make sure that diagnosis is accurate since standard antidepressants may not work, for example in bipolar depression. Then we make sure the treatment was adequate in terms of dosage and duration. After this, we try and use an antidepressant with a different mechanism of action. And finally, we may need to switch modality of treatment (f.e brain stimulation).

Non-Invasive Brain Stimulation (NIBS) refers to stimulating neurons in the brain without surgical procedures and without the need for anesthesia. One of these methods is Repetitive Transcranial Magnetic Stimulation (rTMS), which delivers magnetic pulses that penetrate the brain painlessly and stimulate the underling tissue. rTMS is a safe and effective method for TRD. It is FDA approved for Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD). Safety and effectiveness of TMS therapy has been established in numerous randomized double blind placebo controlled trials and meta-analysis [1-3]. Clinical guidelines dictate treatment delivery [4, 5].

According to landmark STAR*D study after 3 failed medications the response and remission rates are about 5 percent [6], and this rate keeps decreasing with further medication trials. In these treatment resistant patients TMS response and remission rates shown in naturalistic settings are 58% and 37% respectively [7]. We define response as a reduction in depression rating scale scores (HDRS and PHQ-9) by 50% or more. We define remission as Hamilton Depression Rating Scale (HRDS) score <7 and Patient Health Questionnaire (PHQ-9) score <5. Even though there still is a lot of room for improvement, these rates are dramatically better than what we have in trying the next medication.

In addition to it’s efficacy, TMS is more advantageous than medications because of it’s lack of systemic side effects that are often so bothersome to patients (weight gain, headache, sexual difficulties, dry mouth, tremors etc). TMS has an advantage over other brain stimulation techniques in that it is non-invasive unlike Electroconvulsive therapy (ECT), Vagus Nerve Stimulation (VNS), Deep Brain Stimulation (DBS) etc.

The only absolute contraindication for having TMS treatment is presence of ferromagnetically sensitive metal in the head area, within 12 inches of the stimulation site.

If you are interested in learning more about TMS please click here to access a presentation.

If you are recommending this to one of your patients please click here to access a FAQ sheet for patients.



  1. O’Reardon, J.P., et al., Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry, 2007. 62(11): p. 1208-16.
  2. Levkovitz, Y., et al., Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. 14(1): p. 64-73.
  3. Blumberger, D.M., 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. 391(10131): p. 1683-1692.
  4. McClintock, S.M., et al., Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. J Clin Psychiatry, 2018. 79(1).
  5. Perera, T., et al., The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimul, 2016. 9(3): p. 336-346.
  6. Rush, A.J., et al., Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry, 2006. 163(11): p. 1905-17.
  7. Carpenter, L.L., et al., Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety, 2012. 29(7): p. 587-96.