TMS Therapy: A Physician's Guide

Transcranial magnetic stimulation (TMS) uses brief magnetic pulses, delivered through a coil held against the scalp, to change activity in brain circuits involved in mood. Devices are FDA-cleared for depression that has not responded to medication, and some are also cleared for obsessive-compulsive disorder and smoking cessation.

This guide is written for patients and families who want the full picture, and for clinicians who refer them. It explains how TMS works, what the trials actually showed, how the newer accelerated and deep protocols differ, which conditions are still being studied, and how each major New York insurer decides coverage. Every figure is cited to the study, device label or policy it comes from, and the pages say plainly where the evidence is thin.

If you are earlier in the process, the patient's guide on mindbody7.com covers what a course feels like day to day, side effects, preparing for treatment and appealing a denial.

The science

• How TMS Works: The Neuroscience of Magnetic Stimulation for Depression
  From Faraday induction to synaptic plasticity: how a magnetic pulse makes neurons fire, why the left DLPFC is the target, and why TMS takes weeks.
• A Short History of TMS: From 1985 to Accelerated Protocols
  A dated timeline of TMS: the 1985 invention, the first depression studies, the 2008 FDA authorization, deep TMS, theta burst, SAINT and teen labels.

Protocols and devices

• Deep TMS vs Standard TMS: H-Coil and Figure-8 Compared
  H-coil vs figure-8: how deep TMS differs in physics, FDA-cleared uses, evidence, session time and safety, and why neither is clearly better for depression.
• Theta Burst Stimulation (iTBS) Explained
  iTBS delivers a TMS session in about 3 minutes. How the burst pattern works, the THREE-D evidence, comfort, guidelines and insurance coverage.
• Accelerated TMS: Protocols, Evidence and FDA Status
  Several TMS sessions a day can shorten a six-week course to days. Which accelerated protocols are FDA-cleared, how strong the evidence is, and who they suit.
• SAINT (Stanford Neuromodulation Therapy): What It Is and Is Not
  SAINT gives 50 theta-burst sessions in 5 days to an MRI-chosen target. What the trials showed, what they did not, and how it differs from SAINT-style TMS.
• One-Day Accelerated TMS: What the Early Evidence Shows
  Single-day TMS packs a whole course into one day, often with off-label drugs. The evidence so far is small, unblinded and not FDA-cleared as a schedule.
• Finding the Target: Beam F3, Neuronavigation and fMRI-Guided TMS
  Four ways to aim a TMS coil, from a tape measure to fMRI connectivity maps, and what head-to-head trials say about whether precision improves outcomes.
• Motor Threshold and TMS Dosing Explained
  Motor threshold is the personal yardstick for TMS intensity. How it is measured, why 120% is standard, and what can shift it.
• TMS Devices Compared: NeuroStar, BrainsWay, MagVenture, Magstim and Magnus
  A neutral side-by-side of the main TMS systems: coil, FDA-cleared indications with dates, protocols and session length, plus what a label cannot tell you.

The evidence

• TMS Research: The Landmark Trials and What They Showed
  Every major TMS trial in one place: size, design, how success was defined and what was found, including the negative trials and the meta-analyses.
• Response vs Remission: How TMS Success Is Measured
  There is no single TMS success rate. How response and remission are defined, which scales are used, and the questions that expose an inflated number.
• How Long Do TMS Results Last? Durability and Relapse Data
  About half to 6 in 10 TMS responders are still well at one year. What the durability studies show, how retreatment works, and what maintenance trials found.
• TMS Safety and Seizure Risk: The Real Numbers
  TMS seizures are rare: about 0.31 per 10,000 sessions in a large clinic survey. The numbers behind that figure, who is at higher risk, and how screening works.
• After Two Antidepressants: What the STAR*D Trial Tells Us (and Its Limits)
  STAR*D showed remission odds fall sharply after two antidepressant steps. What the trial found, why its 67% figure is disputed, and what it means for TMS.
• Who Responds to TMS? Predictors and Biomarkers
  No test predicts TMS response yet. The clinical predictors with real evidence, how early improvement is used, and where EEG and fMRI biomarkers stand.
• Combining TMS With Medication: Augmentation Research
  Most people stay on their antidepressant during TMS. What trials show about combining them, the D-cycloserine research, and why benzodiazepines come up.

Comparing treatments

• TMS vs ECT: Effectiveness, Memory and Who Each Suits
  ECT is more effective overall, especially for psychotic depression; TMS is gentler, with no anesthesia or memory effects. How to decide between them.
• TMS vs Spravato (Esketamine): A Side-by-Side Comparison
  Device versus drug: how TMS and Spravato (esketamine) differ in schedule, side effects, monitoring, evidence and insurance, and who tends to suit each.
• Treatment-Resistant Depression: Every Option Compared
  After two antidepressants have not worked, the options range from augmentation to TMS, esketamine, ECT and VNS. The evidence, burden and coverage of each, side by side.
• Before TMS: Ruling Out Medical Causes of "Treatment-Resistant" Depression
  What a focused medical workup looks like before TMS: which tests guidelines support, which are optional, and what the evidence says about each possible contributor.
• Pharmacogenomic Testing, Treatment Resistance and Where TMS Fits
  Pharmacogenomic tests can explain side effects and odd dose responses, but they do not pick the right antidepressant or predict TMS response. What the evidence supports.
• Inflammation, Treatment-Resistant Depression and TMS
  Raised CRP is more common in depression and loosely tied to treatment resistance, but it does not yet guide treatment. What the research shows, including for TMS.

Conditions under study

• TMS for Bipolar Depression: Evidence and Precautions
  TMS for bipolar depression is off-label, with a small average benefit across mostly negative small trials and low mania switch rates on mood stabilizers.
• TMS for PTSD: What the Research Shows
  One TMS-based system is now FDA-cleared as an adjunct for adult PTSD, but standard protocols are off-label and the trial evidence is mixed. Here is what the studies show.
• TMS for ADHD: Promising or Premature?
  No TMS device is cleared for ADHD, and the trials conflict. Right-prefrontal stimulation in adults shows a signal worth testing, but it is not ready for routine care.
• TMS for Chronic Pain and Fibromyalgia
  Motor cortex TMS has strong guideline support for neuropathic pain and weaker support for fibromyalgia. It is off-label in the US and rarely covered.
• TMS for Migraine: The Single-Pulse Device
  Migraine TMS is a hand-held, single-pulse device used at home, cleared for acute and preventive treatment. Here is the evidence and how it differs from depression TMS.
• TMS for Addiction: Alcohol, Cocaine and Beyond
  Smoking is the only cleared addiction use of TMS. Alcohol and stimulant trials mostly show reduced craving, and withdrawal raises specific seizure concerns.
• TMS for Schizophrenia: Hallucinations and Negative Symptoms
  TMS for schizophrenia is off-label. The hallucination evidence has not held up in pooled trials, and negative-symptom results conflict. Here is the honest picture.
• TMS and Autism: What the Evidence Does and Does Not Support
  TMS for autism is off-label and research-stage. What the blinded trials show, the safety issues specific to autistic people, and when TMS for co-occurring depression is reasonable.
• TMS for Alzheimer's Disease and Memory Decline
  Why the neuroAD device fell short at FDA, what newer precuneus trials show, and why late-life depression, not dementia, is where TMS usually fits.
• TMS for Tinnitus: Evidence Review
  Why TMS for tinnitus looked promising, why the larger trials disappointed, the ear-specific risks, and what guidelines recommend instead.
• TMS for Eating Disorders: Anorexia, Bulimia and Binge Eating
  What TMS trials show in anorexia, bulimia and binge eating disorder, why electrolytes and low weight matter for seizure risk, and where TMS for depression fits.
• Perimenopause, Depression and TMS
  Perimenopausal depression is real and treatable. Front-line options, the estrogen evidence, when TMS becomes reasonable, and what has not yet been studied.
• TMS for Long COVID Depression, Fatigue and Brain Fog
  What early studies show about TMS for long COVID, why post-COVID depression may respond less well, and why fatigue and brain fog are not yet TMS targets.
• TMS and Suicidal Thoughts: What Research Shows About Rapid Relief
  What sham-controlled and accelerated TMS studies show about suicidal ideation, why TMS is not a crisis treatment, and how to plan safely.

Coverage by insurer

• Medicare Coverage for TMS in New York: LCD L33398 Explained
  New York Medicare covers TMS for adults with severe major depression under LCD L33398. The criteria, the psychotherapy rule, retreatment, costs and Medicare Advantage.
• Does New York Medicaid Cover TMS? Criteria and Plan-by-Plan Rules
  NYS Medicaid covers TMS for adults with treatment-resistant depression since late 2025. The state criteria, what each managed care plan has published, and how to check.
• Aetna TMS Coverage: CPB 0469 Criteria Explained
  Aetna covers TMS for severe depression under CPB 0469. The medication and augmentation rules, teen criteria, iTBS versus accelerated protocols, exclusions and retreatment.
• Cigna TMS Coverage: EN0383 Criteria Explained
  Cigna covers 30 to 36 TMS treatments for depression from age 15 under EN0383, plus deep TMS for OCD. The criteria, exclusions and the March 2026 prior authorization change.
• Empire BCBS and Anthem TMS Coverage in New York
  Empire BlueCross BlueShield is now Anthem in New York, and its TMS criteria sit in a proprietary MCG guideline. What is public, which rules apply to your plan type, and how to get the rest.
• UnitedHealthcare and Optum TMS Coverage: The Criteria, Policy by Policy
  UnitedHealthcare routes TMS for depression to Optum's behavioral policy. Here is what it requires, what it excludes, and what Oxford, Medicare Advantage and Community Plan members should check.
• EmblemHealth and GHI TMS Coverage for NYC Employees
  EmblemHealth has not published TMS criteria for depression, and GHI-CBP became the Optum-network NYCE PPO in 2026. What is public, and how city employees can get the rest in writing.
• TMS Coverage for Veterans, TRICARE and Federal Employees
  How TRICARE, VA health care and FEHB plans handle TMS for depression: what each has published, what it has not, and the questions to ask before treatment.
• New York Mental Health Parity Laws and Your TMS Claim
  Parity law does not guarantee TMS coverage, but it gives New York patients real leverage on criteria and process. Which rules apply to your plan, and how to use them in an appeal.

Care with Dr. Lewis

• Who Delivers TMS? The Psychiatrist, the Technician and Why Oversight Matters
  The roles on a TMS team, the supervision rules New York payers apply, and what a psychiatrist adds before and during a course.
• Referring a Patient for TMS: A Guide for Therapists and Physicians
  A practical TMS referral guide for clinicians: candidate selection, safety flags, New York payer criteria, the records to send and how to stay in the loop.
• TMS in an Integrative, Precision Psychiatry Practice
  How Dr. Lewis's integrative, precision model frames TMS candidacy and aftercare, which parts are essential, and where the evidence stops.

A note on safety

TMS is not an emergency treatment. 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.

Talk to Dr. Lewis

If you are weighing TMS, read about TMS with Dr. Lewis in Brooklyn or complete the patient interest form.

Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.