TMS is Effective for Depression Treatment
Transcranial magnetic stimulation (TMS) is an effective, evidence-based treatment for depression, particularly in patients who have not responded to adequate antidepressant trials, with response rates of 29-48% and remission rates supported by multiple high-quality studies. 1
Evidence Supporting TMS Efficacy
The American College of Physicians recommends TMS specifically for patients with major depressive disorder who have shown partial or no response to two or more adequate pharmacologic treatment trials. 1 The aggregate literature demonstrates that benefits of repetitive TMS (rTMS) for treatment-resistant depression in improving symptoms and facilitating remission outweigh the harms. 1
The number needed to treat is 3.4 to 9 patients for response and 5 to 7 patients for remission, making this a clinically meaningful intervention. 1
Comparative Effectiveness
A 2024 randomized controlled trial directly comparing rTMS to switching antidepressants in treatment-resistant depression found rTMS significantly superior, with response rates of 37.5% vs. 14.6% and remission rates of 27.1% vs. 4.9% for medication switching. 2 This represents the most recent high-quality evidence demonstrating TMS outperforms standard pharmacological approaches in moderately treatment-resistant depression. 2
Real-world effectiveness data from the first 100 consecutive patients treated post-FDA approval showed a 50.6% response rate and 24.7% remission rate at 6 weeks in a highly treatment-resistant cohort (mean 3.4 failed adequate trials). 3
Treatment Protocol Specifications
Standard rTMS Protocol
- Target: Left dorsolateral prefrontal cortex 3, 2
- Frequency: 10 Hz (high-frequency stimulation) 2, 4
- Intensity: 120% of motor threshold 4
- Duration: 3,000 pulses per session 4
- Pattern: 4-second trains with 26-second intertrain intervals 4
- Course: Up to 30 sessions over 4-6 weeks 1, 3
- Schedule: Typically 5 sessions per week 1
Theta-Burst Stimulation (TBS) Considerations
Regarding the "EXOmind TMS stick" specifically mentioned in your question: If this device uses theta-burst stimulation protocols, be aware that while TBS has shown non-inferiority to standard 10 Hz rTMS for depression treatment, there is insufficient evidence to make a recommendation for or against theta-burst stimulation according to 2022 guidelines. 1, 5
TBS protocols offer the advantage of reduced administration duration (1-3 minutes vs. 20-45 minutes for conventional rTMS), but require at least 4-6 weeks of daily treatment to induce significant clinical improvement. 1, 5
Duration of Response and Maintenance
Response rates can be maintained for 3 to 6 months following a standard acute treatment course. 1 In maintenance treatment studies, 62% of responders maintained their response status over 6 months with ongoing maintenance TMS sessions. 3
Critical caveat: At least 4-6 weeks of daily rTMS is required for significant clinical improvement—studies performing rTMS for only 3 weeks found no difference between active and sham treatment. 1
Special Populations
Bipolar Depression
TMS can be safely used in bipolar depression when combined with mood stabilizers. 4 A 2024 pilot study showed 87.1% response and 74.2% remission rates in bipolar depression treated with 10 Hz rTMS plus mood stabilizers, with no induced manic episodes. 4 Concurrent lamotrigine was associated with better outcomes, while lithium was associated with higher depression scores. 4
Post-Stroke Depression
TMS reduces symptoms of post-stroke depression with significant improvements in depression scores. 1
Important Limitations and Practical Considerations
Access challenges: TMS requires frequent onsite visits (typically 5 sessions per week for 4-6 weeks), which may limit feasibility for some patients. 1
Placebo effects: A recent RCT in veterans with high rates of comorbid PTSD and substance use disorders found no significant differences between rTMS and sham treatment, suggesting placebo effects may play an important role in certain populations. 1
Patient selection: TMS should not be excluded for patients who have failed multiple antidepressants, augmentation strategies, structured psychotherapy, or even electroconvulsive therapy (ECT). 6 However, patients who have failed deep brain stimulation (DBS) or vagus nerve stimulation (VNS) represent a different population and may be excluded from typical TMS protocols. 6
Safety Profile
TMS is well-tolerated with a discontinuation rate of only 3% in acute treatment. 3 No serious adverse events, completed suicides, or induced manic episodes were observed in large clinical cohorts. 3, 4 TMS does not have drug-drug interactions or systemic side effects. 7
Cognitive effects during treatment: High-frequency TMS (≥10 Hz) can temporarily interrupt memory and cognitive precision during active treatment sessions, but these effects are temporary. 8 Patients should be informed about possible transient cognitive difficulties during treatment. 8
Combination Approaches
TMS may be more effective when combined with behavioral interventions such as cognitive behavioral therapy (CBT). 1 The treatment can be administered adjunctively with current medications. 3