TMS What’s New: Latest Research, Devices, and TreatmentsTranscranial magnetic stimulation (TMS) continues to evolve rapidly as both a clinical treatment and a research tool. Originally cleared for treatment-resistant depression, TMS has expanded into new therapeutic indications, refined stimulation protocols, and seen advances in device design and accessibility. This article summarizes the most important recent developments (through 2025), explains how they affect patients and clinicians, and highlights promising directions for the near future.
Overview: where TMS stands today
- TMS uses focused magnetic fields to induce electrical currents in targeted cortical regions, modulating neuronal excitability and networks without surgery.
- Clinical use has broadened beyond major depressive disorder (MDD) to include obsessive-compulsive disorder (OCD), smoking cessation, and explorations in PTSD, bipolar depression, chronic pain, and cognitive disorders.
- Research is increasingly network-focused: targeting specific functional circuits (for example, fronto-limbic or frontoparietal networks) rather than single cortical spots.
Major research advances
Precision targeting and network-based approaches
Recent studies emphasize tailoring stimulation to individual brain anatomy and functional connectivity. Instead of placing coils using scalp landmarks (like the 5-cm rule), researchers use MRI-based neuronavigation and resting-state fMRI to identify personalized targets within networks implicated in a given disorder. Early randomized and open-label trials show improved response rates when stimulation is guided by connectivity patterns associated with clinical symptoms (for example, subgenual cingulate connectivity for depression).
Accelerated and high-dose protocols
Accelerated TMS schedules condense many sessions into days (multiple sessions per day) rather than weeks, sometimes termed SAINT-like or accelerated iTBS protocols. Trials indicate faster symptom reduction and comparable or improved remission rates versus standard daily schedules for some patients with severe depression. Safety profiles have been acceptable in controlled settings, but longer-term comparative data are still accruing.
Intermittent theta-burst stimulation (iTBS)
iTBS delivers short bursts of stimulation patterned after endogenous theta rhythms and achieves similar clinical benefits in a fraction of session time (~3–10 minutes) compared to conventional repetitive TMS (rTMS) sessions that last 20–40 minutes. As a result, iTBS has become widely adopted for MDD and other indications, increasing clinic throughput and patient convenience.
Biomarkers and prediction of response
Efforts to predict who will benefit from TMS are advancing. Candidate biomarkers include:
- Neuroimaging markers (resting-state connectivity, structural features)
- EEG measures (baseline oscillatory patterns, TMS-evoked potentials)
- Clinical and genetic profiles Combining multimodal markers into prediction models has shown promise in pilot studies, potentially enabling personalized treatment plans and better allocation of resources.
Combinatorial and adjunctive treatments
Researchers are combining TMS with psychotherapy, pharmacotherapy, and noninvasive neuromodulation (e.g., tDCS) to augment effects. Timing matters: delivering TMS before or during psychotherapy can modulate plasticity and may enhance learning of therapeutic skills. Trials are ongoing; early results suggest additive benefits in some populations.
Device and technological innovations
Next-generation coils and focality improvements
Coil engineering has advanced: H-coils (deeper stimulation), controllable focal coils, and multi-channel arrays allow more precise shaping of induced fields. Improved focality reduces off-target effects and permits stimulation of deeper or distributed areas implicated in specific disorders.
Closed-loop and state-dependent stimulation
Closed-loop TMS systems monitor brain activity (EEG or other biomarkers) in real time and deliver pulses contingent on brain state (e.g., specific oscillatory phase). This approach aims to enhance efficacy by leveraging state-dependent plasticity; early human studies report feasibility and preliminary efficacy signals.
Portable and lower-cost systems
Compact and more affordable TMS devices are emerging for smaller clinics and broader access. Regulatory clearance and reimbursement remain the limiting steps for home use; current clinical practice still relies on supervised sessions in outpatient settings.
Integration with neuronavigation and AI
Commercial systems increasingly integrate neuronavigation, allowing MRI-guided coil placement and session tracking. AI tools are being developed to analyze treatment response patterns, optimize protocols, and suggest adaptive parameter adjustments—though clinical-grade, validated AI decision tools are not yet widespread.
New and expanding clinical indications
Obsessive-compulsive disorder (OCD)
FDA-cleared protocols (targeting the dorsomedial prefrontal cortex and anterior cingulate or supplementary motor area depending on device) show meaningful symptom reduction for treatment-resistant OCD. Research continues into optimal targets and combinations with behavioral therapy.
Smoking cessation and addiction
TMS targeting dorsolateral prefrontal cortex (DLPFC) and medial prefrontal circuits has shown efficacy in reducing craving and improving abstinence rates for nicotine dependence; other substances are under active investigation. FDA clearance for smoking cessation (in certain devices/protocols) marks a milestone for addiction neuromodulation.
Post-traumatic stress disorder (PTSD) and anxiety disorders
Results are mixed but encouraging. Some trials report clinically significant reductions in PTSD symptoms using right-sided DLPFC or medial prefrontal targets; others show smaller effects. Combining TMS with trauma-focused therapies is an area of active study.
Cognitive impairment and neurorehabilitation
TMS is explored for cognitive enhancement in mild cognitive impairment (MCI), post-stroke rehabilitation, and traumatic brain injury. Protocols often target frontoparietal networks to enhance attention, working memory, and motor recovery; outcomes are variable and dependent on timing, intensity, and patient selection.
Safety, tolerability, and side effects
- TMS is generally well tolerated. Common side effects: transient scalp discomfort or headache. Rare but serious: seizures (incidence low when guidelines are followed).
- Accelerated and higher-dose protocols warrant monitoring for increased transient side effects; serious adverse events remain rare in controlled settings.
- Contraindications: implanted ferromagnetic devices near the head, certain implanted stimulators, and uncontrolled epilepsy. Screening remains essential.
Practical clinical considerations
Patient selection and expectations
Ideal candidates: patients with treatment-resistant depression or those who prefer non-pharmacologic options. Clear communication about likely time course, possible need for maintenance sessions, and realistic expectations improves adherence.
Protocol selection
- Conventional rTMS vs iTBS: iTBS favors shorter sessions and is now a standard option for MDD. Choice depends on evidence for the indication, device capabilities, and local expertise.
- Accelerated protocols: appropriate for select patients, often in specialized centers with careful monitoring.
Access and cost
TMS accessibility is increasing but remains limited by availability of trained clinicians, device costs, and variable insurance coverage. Expanded indications and shorter-session protocols may improve access over time.
Future directions and research priorities
- Larger, multi-center randomized trials comparing accelerated and connectivity-guided protocols to standard care.
- Validation and clinical deployment of predictive biomarkers for treatment planning.
- FDA and regulatory pathways clarifying indications for newer protocols, closed-loop systems, and portable devices.
- Improved reimbursement models to expand equitable access.
- Deeper exploration of combined treatments (TMS + psychotherapy, pharmacologic neuromodulators, or behavioral interventions).
Takeaway
TMS is transitioning from a single-indication, one-size-fits-all therapy to a versatile, individualized neuromodulation platform. Advances in targeting, accelerated protocols, device technology, and biomarker-guided treatment promise improved outcomes and broader applications. Clinical adoption should proceed alongside rigorous trials, safety monitoring, and attention to equitable access.
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