TMS for MDD Reimagined: Faster, Fewer Visits, and Now at Home

Linda Carpenter, MD, professor of psychiatry and human behavior at Brown University, used to arrive at the clinic early to deliver transcranial magnetic stimulation (TMS). If a patient couldn’t make it at the 8 am opening time, she and her colleagues would come at 7:30 am. If a patient could only do 6 pm, Carpenter would stay late for 3 months straight.

“We often made these crazy accommodations for people,” Carpenter told HCPLive.

Even if Carpenter was willing to accommodate patients with their availability, she had to make sure everyone on the team was on board with adjusted start and end times. Carpenter would not go into the clinic every day, so there had to be someone else willing to treat this patient.

But for patients who live close to a not-so-accommodating office, getting TMS may not be a realistic option. For instance, one patient may want to try TMS but can’t take 6 weeks of morning appointments without risking their job. So, they decline. They relapse.

That scenario may feel familiar to many clinicians. Although TMS has been FDA-cleared since 2008 and is supported by nearly 2 decades of evidence, its traditional delivery schedule (~36 sessions, once daily, 6 – 8 weeks) can still be difficult for patients to sustain.1 For patients managing jobs, childcare, and transportation, the time-consuming nature of TMS is often a dealbreaker. TMS may be an effective depression treatment for most patients who complete it, but far too few ever do.

“You have other people who are like, ‘I live an hour and a half away,’ and at the beginning there were a few patients who would still make that ridiculous drive,” Carpenter said. “Luckily, more and more TMS clinics have sprung [up], so people maybe can find them closer to them, but there's still so many people that can't, and it's disappointing.”

The Acceleration Wave of TMS

In the past 12 months, multiple studies showed that the standard 6-week course can be compressed into just days without compromising outcomes. A retrospective analysis published in March 2026 compared a 5x5 accelerated repetitive TMS, consisting of 5 sessions per day over 5 consecutive days (n = 40), with a conventional, daily 6-week protocol (n = 135).2

“[This study] … shows that it's not necessary to have patients come in daily for 6 or 8 weeks,” Andrew Leuchter, MD, a professor and director of the neuromodulation division at UCLA TMS Clinical and Research Services, told HCPLive. “We can actually compress the entire course of TMS treatment down to just 1 week.”

The study showed no significant difference in efficacy between accelerated vs conventional TMS (P =.07). Mean Patient Health Questionnaire-9 (PHQ-9) scores dropped from 17.68 to 10.98 in the accelerated group and from 17.83 to 8.97 in the conventional group by the end of treatment. 2 The conventional TMS group had greater response and remission rates: 58.5% vs 37.5% and 24% vs 22.5%, respectively.

Leuchter noted a delayed response. Among patients showing minimal early response at day 5, improvement rates jumped from 8% to 36% at 2- to 4-week follow-up (P =.001).2

“It is important to let patients know upfront that while they may feel great after just a couple of days or 5 days of treatment, at the end of five days, they may not yet have felt the benefits,” Leuchter said. “Going into treatment, this is something I tell all our patients: At the end of five days, I'm going to talk with you. We’ll see how you're doing. If you're not feeling [the] benefit, don't be disappointed. I'll talk to you again in 2 weeks, and at that point, the benefits will almost certainly have started to kick in.”

Although accelerated TMS shows promise, the costs stand in the way of patients receiving these treatments. Insurance does not yet reimburse for accelerated protocols. As of now, Medicare covers up to 2 sessions per day, not 5.

A study published in March 2026 found that an accelerated course of deep TMS delivered over 6 days produced comparable clinical outcomes to standard multiweek treatment in patients with major depressive disorder (MDD).3 The accelerated regimen, known as the SWIFT protocol, included 5 daily sessions of intermittent theta burst stimulation (110% rMT, H1 coil) for 6 days, plus 1 additional day per week with 2 sessions over 4 weeks. The standard protocol used high-frequency stimulation (120% rMT, H1 coil) with once-daily sessions for four weeks (20 sessions), followed by 2 sessions per week for an additional 2 weeks (4 sessions).

Response and remission outcomes for accelerated vs standard treatment were 7.8% vs 87.5% and 78.0% vs 87.5%, respectively. 3 The mean time to remission was 21 days (accelerated) vs 28 days (standard). Accelerated deep TMS demonstrated faster symptom reduction by week 2 (median HDRS change, −11.70 vs. −8.590).

Despite differences in devices, designs, and stimulation approaches, both the 5x5 accelerated protocol and the SWIFT deep TMS regimen point to a consistent conclusion: the 6-week treatment course may not be necessary.

The acceleration of in-clinic TMS represents a major advancement. Another is removing the clinic altogether.

Brain Neuromodulation Therapy at Home

On January 12, 2026, the US Food & Drug Administration (FDA) approved the first prescription, physician-directed at-home brain modulation therapy for MDD.4 The treatment was indicated for adults who did not achieve satisfactory improvement from ≥ 1 prior antidepressant.

ProlivRx delivers focal, multichannel external Combined Occipital and Trigeminal Afferent Stimulation (eCOT-AS), which uses gentle, noninvasive electrical pulses to target neural pathways associated with depression.4 The system consists of a headset with 3 pairs of integrated electrodes positioned against the scalp.

“When we talk about TMS, we're talking about a top-down kind of treatment… but with this one… all these nerves come together down deep in the brain stem, and then they have an upward effect regulating all sorts of pathways that are involved in serotonin, dopamine, norepinephrine, and immune regulation,” Carpenter said.

Carpenter and colleagues studied ProlivRx as an adjunctive therapy to antidepressants in the randomized, controlled, multicenter MOOD trial. Participants (aged 22 to 70 years) were randomized 1:1 to the active or sham arm for 8 weeks, followed by an 8-week open-label phase.4

Patients receiving ProlivRx had significantly greater remission rates (21.3% vs 6.0%; P =.027). During the open-label phase, participants in the ProlivRx arm had a mean reduction of 9.78 points from baseline on the HDRS17 (P <.0001) and achieved a remission rate of 32%. The treatment had no serious adverse events.4

Carpenter said that clinician oversight is central to the model, particularly because psychiatrists need visibility into all concurrent treatments and potential adverse effects. She always has patients use ProlivRx in the clinic for the first time, to make sure they use the device and smartphone application properly, and then she asks about how the treatment felt.

She also explored the uncertain reimbursement landscape following FDA approval, with insurers still evaluating coverage and cost structures. Some patients currently pay several thousand dollars out of pocket.

“I hope people will advocate with their insurance companies and say, ‘Hey, I want coverage for that,’ so they can get it.”

The Future Direction of TMS

More work is needed before TMS moves up the treatment algorithm, including prospective RCTs confirming 5x5 noninferiority, greater clarity on the optimal number of sessions per day, and defined insurance pathways for accelerated protocols. Carpenter pointed out that insurance does not pay for TMS maintenance. If a patient improves but later relapses, they must wait until their depression becomes severe again to meet insurance coverage criteria.

As TMS protocols gain traction in clinical psychiatry, investigators are continuing to explore the biological mechanisms underlying the therapy’s antidepressant effects. Although repetitive TMS and accelerated intermittent theta burst stimulation (aiTBS) have demonstrated efficacy in MDD, particularly among patients with treatment-resistant disease, the cellular and circuit-level changes associated with these interventions have remained poorly understood.

New preclinical findings provide insight into how accelerated TMS may restore stress-disrupted neural circuitry.5,6 In a mouse model of chronic stress, investigators reported that aiTBS selectively repaired synaptic structures and restored activity within intratelencephalic neurons in the prefrontal cortex, changes that were associated with sustained improvements in depression-related behaviors.

Although the findings remain preclinical, the study adds a mechanistic context to the growing clinical interest in accelerated neuromodulation strategies. Investigators suggested the work could help inform future efforts to refine stimulation parameters, personalize treatment approaches, and expand circuit-based neuromodulation applications across neuropsychiatric disorders.

“It's remarkable that it's actually having distinct effects on distinct cell types. What would be really cool is if it turns out that we can tune the TMS treatment to target specific circuits and cell types,” said Scott Wilke, MD, PhD, assistant professor of psychiatry and the Penske Family Chair in Neuromodulation at UCLA Health, in an interview with HCPLive.

The 6-week commitment that made TMS a treatment many patients declined is no longer the only path. The field's obligation now is to make sure clinicians know that and that payers catch up.

“This is not an experimental approach at this point. It's not a last-ditch effort to get people better. This is a legitimate treatment that probably should be considered in the future, something you should do earlier when people are depressed,” Wilke said. “TMS is really the best next step for someone who has not responded to antidepressant medications. This is a field that is rapidly evolving now, and I think there's going to be a lot of exciting changes in the coming years that will make this an even more attractive route for patients.”

References

1. Yan J. FDA Approves New Option to Treat Major Depression. Psychiatry Online. 2008;43(22):2-17. doi:https://doi.org/10.1176/pn.43.22.0002

2. Leuchter A. Accelerated 5×5 rTMS Matches Standard Protocols in TRD, With Andrew Leuchter, MD. HCPLive. Published on March 24, 2026. Accessed May 15, 2026. https://join.hcplive.com/view/accelerated-5-5-rtms-matches-standard-protocols-trd-andrew-leuchter-md

3. Derman C. Accelerated Deep TMS Matches Standard Outcomes in TRD in 6 Days. HCPLive. Published on March 18, 2026. Accessed May 15, 2026. https://www.hcplive.com/view/accelerated-deep-tms-matches-standard-outcomes-trd-6-days

4. Derman C. FDA Approves ProlivRx, First At-Home Neuromodulation Device for MDD. HCPLive. Published on January 13, 2026. Accessed May 15, 2026. https://www.hcplive.com/view/fda-approves-proliv-rx-first-home-neuromodulation-mdd

5. Wilke S. Accelerated TMS Moves Toward Circuit-Based Depression Treatment. HCPLive. Published on May 14, 2026. Accessed May 15, 2026. https://www.hcplive.com/view/accelerated-tms-circuit-based-depression-treatment

6. Scientists finally see inside the “black box” of depression treatment. Uclahealth.org. Published May 7, 2026. Accessed May 14, 2026. https://www.uclahealth.org/news/release/scientists-finally-see-inside-black-box-depression-treatment