TMS is not FDA-cleared for schizophrenia, and its use for either hallucinations or negative symptoms is off-label and research-stage. Two approaches have been studied since at least 2000: low-frequency (1 Hz) stimulation of the left temporoparietal cortex for persistent auditory hallucinations, and high-frequency stimulation of the left prefrontal cortex for negative symptoms such as low motivation and blunted emotion. Neither has reached the top evidence levels in the 2020 European expert guideline, which found no Level A or B evidence outside a short list that does not include schizophrenia.
For hallucinations, a 2021 meta-analysis of 27 randomized trials found no significant benefit over sham. For negative symptoms, pooled analyses lean positive, but a large multicenter trial was negative. TMS remains an add-on to be considered in research settings, not a replacement for antipsychotic treatment and psychosocial care.
Two targets, two questions
| Auditory verbal hallucinations | Negative symptoms | |
|---|---|---|
| Usual target | Left temporoparietal cortex | Left dorsolateral prefrontal cortex |
| Usual frequency | 1 Hz (low frequency) | 10 Hz (high frequency) |
| Early signal | Positive small crossover trial, 12 patients (2000) | Positive small trials pooled in meta-analyses |
| Best current evidence | Meta-analysis of 27 RCTs, 960 patients: no significant effect | Umbrella review of 20 reviews: mostly reduced scores, quality "not high" |
| Large multicenter trial | Included in the meta-analysis above | RESIS, 175 randomized: no difference from sham |
Hallucinations: early promise, weak replication
In 2000, Hoffman and colleagues gave 1 Hz TMS to that region in 12 patients with schizophrenia and auditory hallucinations and, in a double-blind crossover design, found that active stimulation reduced hallucinations relative to sham.
That result launched many trials. When a 2021 meta-analysis pooled 27 randomized trials with 960 patients, it found no significant effect of rTMS on medication-resistant auditory verbal hallucinations compared with sham (effect size −0.19, p=0.21). The 2021 IFCN expert guideline likewise describes the efficacy evidence for hallucinations as "relatively poor".
This pattern, a striking small study followed by weaker larger ones, is common in brain stimulation research. Small trials can produce large effects by chance. A similar story has played out in tinnitus, another "phantom" auditory symptom, where IFCN also rates the evidence as relatively poor.
Negative symptoms: positive pooled data, a negative landmark trial
Negative symptoms (reduced motivation, speech, pleasure and emotional expression) do not respond adequately to antipsychotic or psychosocial treatment, so any added option would matter.
A 2024 umbrella review of 20 systematic reviews and meta-analyses found that most analyses showed reduced negative-symptom scores with rTMS, "although the quality of evidence was not high".
A large multicenter trial points the other way. RESIS, a German multicenter, sham-controlled trial run from 2007 to 2011, randomized 175 patients with predominant negative symptoms; 76 received 10 Hz rTMS to the left dorsolateral prefrontal cortex and 81 received sham, five days a week for three weeks, added to their usual treatment. There was no significant difference in negative symptoms at day 21 (effect size 0.09) or through day 105, and no difference in depression or cognition. Active rTMS was well tolerated, with a small, short-lived improvement in positive symptoms. The authors noted the contrast with earlier meta-analyses.
Why the gap? The RESIS authors noted that the earlier meta-analyses were based on small proof-of-principle trials, and the 2024 umbrella review itself says the quality of evidence was "not high". A well-powered trial is a stronger test of whether a protocol works, though one negative trial does not rule out benefit from different targets, doses or patient groups.
What the guidelines say
- The 2020 European evidence-based guideline (Lefaucheur and colleagues) reached Level A only for depression, neuropathic pain and post-stroke hand recovery, and states that Level A/B evidence "is not reached concerning efficacy of rTMS in any other condition" beyond its listed indications, which do not include schizophrenia.
- The 2021 IFCN safety and recommendations guideline calls the evidence for hallucinations "relatively poor".
- Insurers generally do not cover it. Optum, for example, lists psychotic disorders among unproven TMS indications.
Older ratings for hallucinations and negative symptoms are quoted widely online, but they come from an earlier guideline edition and are not repeated here.
Safety in people with schizophrenia
TMS appears to be tolerated in schizophrenia trials; RESIS reported active treatment as well tolerated. On thinking and memory, the IFCN guideline cites a systematic review that found "no reliable evidence for cognitive side effects" across 31 randomized trials of prefrontal rTMS in depression, schizophrenia or Alzheimer's disease.
Medication is the main practical issue. The FDA's guidance for TMS devices asks for close monitoring of patients taking "neuroleptic medications, or other drugs that are known to lower the seizure threshold". The 2021 IFCN guideline is less restrictive, saying the data on low seizure rates "no longer support" a general caution about such drugs, while still recommending that all medications be documented. A treating team should know every medication and dose, plus sleep and substance use, before starting. More detail is in TMS safety and seizure risk.
Depression in someone with schizophrenia
Depression can occur alongside schizophrenia and is a separate target from psychosis. Here the practical barriers are real. Standard depression TMS criteria exclude or flag psychosis: New York Medicare lists psychotic symptoms in the current episode as a caution or limitation, and a Carelon authorization form asks clinicians to attest that the patient has no psychotic disorder. A 2018 expert consensus advises that patients with comorbid psychotic symptoms be considered for other antidepressant treatments with established efficacy, giving ECT as the example. How the two compare is covered in TMS vs ECT, and mood disorders with psychotic features in TMS for bipolar depression.
If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
If you are considering a research study
For a person living with persistent voices or disabling negative symptoms, a well-run trial can offer close monitoring and access to newer protocols. Before enrolling, it is reasonable to ask:
- Is there a sham (placebo) arm, and how is blinding protected?
- Which target and frequency are being tested, and why this one, given the mixed results so far?
- Will my current medications stay the same throughout? In the RESIS trial, TMS was added to ongoing treatment.
- Who on the study team can respond quickly if symptoms worsen, and how will my own psychiatrist be kept informed?
- What happens after the study ends if the treatment seemed to help?
Family members or other supporters can help with travel, daily sessions and noticing changes, which matters for treatments that require repeated visits over weeks.
The bottom line
TMS for schizophrenia is a legitimate research field with an honest track record of early promise and mixed replication. For persistent voices, the pooled evidence does not show a reliable benefit. For negative symptoms, pooled data lean positive but a large multicenter trial was negative. Neither use is FDA-cleared, and neither is a reason to change effective antipsychotic treatment.
For a person with treatment-resistant symptoms, a clinical trial is the most appropriate way to access TMS. Broader questions about the biology of psychosis are explored in inflammation and schizophrenia. For the wider TMS evidence, see the TMS physician's guide; for how a depression evaluation works, see the TMS service page; and for how researchers judge whether a treatment "works", see response vs remission.
Frequently asked questions
Is TMS FDA-cleared for schizophrenia?
No. TMS for hallucinations or negative symptoms of schizophrenia is off-label and research-stage in the United States.
Can TMS stop hearing voices?
An early small study suggested 1 Hz TMS reduced persistent voices, but a 2021 meta-analysis of 27 randomized trials found no significant benefit over sham for medication-resistant hallucinations.
Can I stop antipsychotic medication if I have TMS?
No. In research, TMS has been studied as an add-on to ongoing treatment, not a replacement. Any medication change should be made only with your psychiatrist.
Does TMS affect thinking or memory in schizophrenia?
The IFCN guideline cites a review of 31 randomized trials of prefrontal rTMS, including in schizophrenia, that found no reliable evidence of cognitive side effects.
How can I access TMS for schizophrenia?
The most appropriate route is a registered clinical trial. ClinicalTrials.gov lists current studies; insurers generally treat TMS for psychotic disorders as unproven.
Sources
- Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clinical Neurophysiology, 2020. europepmc.org
- Repetitive transcranial magnetic stimulation and transcranial direct current stimulation for auditory hallucinations in schizophrenia: Systematic review and meta-analysis. Journal of Psychiatric Research, 2021. europepmc.org
- 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. europepmc.org
- Efficacy of repetitive transcranial magnetic stimulation (rTMS) on negative symptoms and cognitive functioning in schizophrenia: An umbrella review of systematic reviews and meta-analyses. Psychiatry Research, 2024. europepmc.org
- Transcranial magnetic stimulation and auditory hallucinations in schizophrenia. The Lancet, 2000. pubmed.ncbi.nlm.nih.gov
- Left prefrontal high-frequency repetitive transcranial magnetic stimulation for the treatment of schizophrenia with predominant negative symptoms: a sham-controlled, randomized multicenter trial. Biological Psychiatry, 2015. pubmed.ncbi.nlm.nih.gov
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 2011. fda.gov
- Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation. Optum Behavioral Health Solutions, 2026. providerexpress.com
- LCD L33398 Transcranial Magnetic Stimulation (version 40). CMS Medicare Coverage Database, 2026. cms.gov
- Carelon Behavioral Health Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, undated. carelonbehavioralhealth.com
- Efficacy of repetitive transcranial magnetic stimulation for subjective chronic tinnitus: a randomized controlled trial meta-analysis. Frontiers in Neuroscience, 2025. europepmc.org
Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.
The information provided on this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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