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Q&A: Accelerated TMS Speeds Suicidal Ideation Relief, With Owen Muir, MD
SWIFT accelerated Deep TMS resolved suicidal ideation faster than standard dosing, Owen Muir, MD, says.
A secondary analysis of BrainsWay's pivotal SWIFT trial found accelerated Deep Transcranial Magnetic Stimulation (Deep TMS) resolved suicidal ideation faster than standard once-daily dosing.¹ Among 89 enrolled patients, the proportion with suicidal ideation fell from 22.5% at baseline to 6.7% after 6 weeks, a 70% relative reduction.¹ Median time to improvement was 10 days with the SWIFT protocol versus 13 days with standard dosing, a statistically significant difference.¹
Suicidal ideation remains a persistent challenge in MDD, and the US Food & Drug Administration (FDA) cleared SWIFT in September 2025 based on the same multisite randomized trial these suicidality outcomes were drawn from.¹ The trial excluded the most severely suicidal patients at baseline.
In an interview with HCPLive,Owen Muir, MD, DFAACAP, FCTMSS, co-founder and chief medical officer at Radial, said excluding patients with severe suicidality made the findings more meaningful since more severe scores tend to regress toward the mean. In this Q&A, Muir discusses the trial findings, the limitations, and next steps for research and coverage policy.
Q&A: Accelerated TMS Speeds Suicidal Ideation Relief, With Owen Muir, MD
HCPLive: What does the 3–4-day difference in time to improvement in suicidal ideation mean for a patient who is actively struggling?
Muir: Patients who aren't suicidal don't have to sit around struggling with their suicidal thoughts. There isn't a day with suicidality that I wouldn't trade for a day without it. This is a better treatment for suicidal people in that their suicidality will be gone faster, and their depression shortly thereafter.
HCPLive: Is there a possible mechanism for why anti-suicidal effects might separate from general antidepressant effects?
Muir: The paper does not answer that question. There has long been genetics suggesting that suicidality is differently mediated than depression overall, and suicidality exists in conditions other than major depressive disorder. As a clinician, I do think suicidality is related to but separate from major depressive disorder.
Is it a symptom of depression? Yes. Might it follow different time courses in different people than depression scores broadly speaking? Yes.
An important clarifier for this study is that extremely suicidal people were screened out of the trial. I had one patient screened out at my site who didn't meet criteria because she was too suicidal for the study, but in clinical practice, TMS was judged to be the safest and most effective treatment for her suicidality, and she remitted.
The full sample of the most suicidal people isn't captured in this data set, because as an FDA approval trial, the most suicidal patients were screened out. That makes these outcomes even more significant, because very high numbers tend to regress to the mean, and we lopped off the very highest in suicidality.
We only had modest suicidality in the trial, and we still saw that improvement, which is actually statistically less likely. Since we limited the sample to people who were modestly, but not severely, suicidal, and still saw the difference, it gives me even more hope that this will be effective in the more severely suicidal individuals we see in clinical practice.
HCPLive: What would it take from a trial design standpoint to isolate a true anti-suicidal effect?
Muir: We'd want to power the trial to look at anti-suicidality as the primary endpoint. You'd want to enroll everyone who had suicidality, whether from OCD, bipolar disorder, schizophrenia, depression, or borderline personality disorder. Across that broad range of diagnoses, we'd want to see reliable reductions in suicidality, ideally independent of effects on the primary diagnosis. You'd want a treatment that wouldn't be expected to affect OCD, BPD, or general depression symptomatology, but that still exhibited a profound anti-suicidal effect.
I don't know that we're going to have that, but not being suicidal does selectively happen. I have patients who are quite depressed and not suicidal after some versions of accelerated TMS treatment. I just talked to one of them this morning; the depression and anhedonia were still present, but the suicidality had completely vanished. We'd need a better understanding of who to include and exclude from that sort of trial.
HCPLive: How should clinicians interpret these suicidal ideation findings, given the cohort wasn't the most severely at-risk population?
Muir: These are some very unwell people. I don't want to say they weren't severely at risk; I'm saying they weren't so severely at risk that they couldn't be included in an FDA trial. I think this generalizes to most patients seen in clinical practice, but not necessarily all.
That said, this is an RCT compared against a standard-of-care treatment that's been deployed in the field for decades. Does TMS work in suicidal patients? At scale, we know the answer is yes.
We answered the question of whether it's possible to get suicidality to remit even faster with this more efficient dosing schedule: yes. And we know from clinical practice that very severely suicidal people can have their suicidality remit entirely.
My biggest takeaway is that if you're looking at time to remission of suicidality, accelerated TMS is the clear choice, and it might even be something you choose before inpatient psychiatric hospitalization. Most inpatient psychiatric hospitals don't have access to the SWIFT protocol because of the way their payment structures are set up, not because they shouldn't. They definitely should put a BrainsWay H1 Coil on the unit so they can start doing this.
HCPLive: Where does accelerated Deep TMS fit into your treatment algorithm for patients with MDD and active suicidal ideation?
Muir: This is a go-to, first-line treatment for patients with acute suicidality. I think accelerated SWIFT TMS is the fastest thing I can do and still be confident that I'm going to relieve suicidal ideation in a patient who's suffering. These numbers aren't directly compared to esketamine, but they're actually better than the numbers in esketamine treatment, and we'll have more large-scale data on that soon. This is the treatment in my practice for acutely suicidal individuals who are suffering, because I don't have to spend additional time getting an fMRI scan.
HCPLive: What's the next research question needed to move this from an exploratory finding to changing practice guidelines?
Muir: What really needs to change is coverage policies.
What I want is to replicate this in larger-scale data, and I think the way to get that is to have coverage policies reliably pay for accelerated TMS, with appropriate coding and billing. That would let us do a mirror-image design in the real world: look retrospectively at patients who got once-daily TMS before SWIFT, look at patients who've gotten SWIFT TMS en masse, and see if this finding replicates in that large real-world dataset. For that to happen, payers need to reliably pay and treat suicidality as something worthy of a yes-or-no decision the day the patient is evaluated, not something that takes days to weeks to adjudicate.
My dime has been on this since 2017, when we first had an open-label patient show a one-day remission with accelerated Deep TMS, and the data has only accumulated from there.
Watch our interview with Muir here: Deep TMS Reduces Suicidal Ideation by 70% in MDD, With Owen Muir, MD (part 1) and Accelerated Deep TMS for Acute Suicidality, With Owen Muir, MD (part 2)
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