Atlas›Domain IX · Biomedical, neuro & digital›Guide 017
Guide IX-017

Transcranial magnetic stimulation (rTMS, deep TMS, theta-burst, SAINT)

2008USA
A 28 · L 65 · M 713 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: US FDA device clearances as of October 2026 (per manufacturer releases and the FDA's 2018 press release), NICE interventional procedures guidance IPG542 (December 2015), the RANZCP professional practice guidelines for rTMS (approved December 2023, published 2024), Clinical TMS Society (CTMSS) clinician education material (2025), and the IFCN expert safety guidelines (Rossi et al., 2021). Stimulation settings, coil positioning and protocol schedules are deliberately not described: they belong to the prescribing psychiatrist and the treatment team.

Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation treatment that a psychotherapist does not deliver. NICE describes it as an outpatient procedure that needs no anaesthesia: a purpose-made electromagnetic coil is held against the scalp and induces small electric currents in the cerebral cortex, delivered as repeated pulses or bursts; for depression the target is one or both sides of a prefrontal region (NICE names the dorsolateral prefrontal cortex), and imaging may be used to help locate it [source: NICE IPG542]. The working idea is that repeated stimulation of brain circuits involved in mood (or, for OCD and smoking, in compulsive and craving circuits) changes their activity over a course of treatment; it is not intended to cause a seizure, unlike ECT [source: NeuroStar Safety Information; FDA 2018].

Types named in this guide (names only, no settings): conventional repetitive TMS (rTMS) with a figure-8-type coil; deep TMS (BrainsWay H-coil systems); theta-burst stimulation (a patterned form of rTMS); and the SAINT neuromodulation system (Magnus Medical), an accelerated, MRI-guided, individually targeted protocol delivered over days rather than weeks [source: CTMSS SAINT release 2022; CTMSS clinician deck 2025].

The psychotherapist's role is alongside the treating team: recognising when a TMS consultation is worth raising, psychoeducation, supporting informed consent, preparing and supporting the client through a daily course, monitoring and passing on adverse effects and mood changes (including hypomania/mania and suicidality), crisis planning, and integrating psychotherapy before, during and after. Ketamine/esketamine and ECT are covered in their own entries; psychedelic- and ketamine-assisted psychotherapy are in Domain VII.

2. Framework

2.1 Who delivers it and regulatory status

  • USA (FDA, as of October 2026). TMS devices are prescription medical devices. NeuroStar states it is available only on prescription by a licensed physician; the physician decides whether it is indicated, determines the treatment plan and remains medically responsible, and may delegate daily sessions to properly trained staff [source: NeuroStar Safety Information]. Clearances per indication and age, as sources state them:
    • Major depressive disorder, adults, after unsatisfactory response to antidepressant medication in the current episode: first TMS marketing authorisation in 2008 [source: FDA press release 2018] (NeuroStar, Neuronetics). Deep TMS (BrainsWay) for MDD: 2013 per BrainsWay; the CTMSS deck dates BrainsWay's MDD clearance to 2012 [uncertain: sources differ by a year].
    • Migraine (single-pulse portable device): 2013 for migraine with aura in adults; 2017 extended to acute and preventive treatment in people aged 12 and over [source: CTMSS clinician deck; FDA 2018]. Outside the scope of psychotherapy but sometimes confused with depression TMS.
    • Obsessive-compulsive disorder, adults: BrainsWay deep TMS authorised via the De Novo pathway, FDA press release 17 August 2018, for people who have not responded to traditional treatments; BrainsWay describes the OCD indication as adjunctive [source: FDA 2018; BrainsWay 2020 release]. NeuroStar also lists an adjunctive adult OCD indication [source: NeuroStar Safety Information] (clearance date not found [uncertain]).
    • Smoking: BrainsWay deep TMS 510(k) clearance announced 24 August 2020 "as an aid in short-term smoking cessation in adults" [source: BrainsWay 2020].
    • Anxious depression (comorbid anxiety symptoms in adults with MDD): BrainsWay clearance announced 18 August 2021 [source: The Hospitalist 2021]; NeuroStar also lists reduction of comorbid anxiety symptoms in adult MDD [source: NeuroStar Safety Information].
    • Theta-burst: the CTMSS refers to an intermittent theta-burst depression protocol cleared in 2019 [source: CTMSS SAINT release 2022] [uncertain: year and device not verified against an FDA record].
    • SAINT (accelerated, MRI-guided): Magnus Medical's SAINT Neuromodulation System cleared in September 2022 for adults with MDD who have not improved enough with antidepressant medication; clinics need specific MRI scans and neuronavigation equipment [source: CTMSS SAINT release 2022].
    • Adolescents 15 to 21 with MDD, adjunctive: NeuroStar clearance announced 25 March 2024, "as an adjunct for the treatment of MDD in adolescent patients aged 15-21" [source: Neuronetics 2024]; BrainsWay deep TMS label expansion announced 13 November 2025 as adjunct therapy for MDD in adolescents aged 15 to 21 [source: BrainsWay/SEC filing 2025]. No US TMS clearance for depression under age 15 was found [synthesis from the sources]; the migraine device's age-12 indication is a separate indication.
    • Note: NeuroStar states it has not been studied in patients who have never received antidepressant treatment [source: NeuroStar Safety Information]. Manufacturer press headlines (e.g. "first-line add-on") are marketing language; the cleared indication is adjunctive [source: Neuronetics 2024].
  • England and Wales (NICE). IPG542 (16 December 2015, replacing IPG242): rTMS for depression shows no major safety concerns and adequate short-term efficacy though clinical response is variable; it may be used with normal arrangements for clinical governance and audit; clinicians should tell patients about other treatment options and that it may not benefit them; NICE encourages more evidence on patient selection, stimulation type, maintenance and long-term outcomes [source: NICE IPG542]. NICE now also lists the same guidance under a HealthTech (HTG396) number [uncertain: renumbering seen in search results only]. Availability in the NHS varies locally [synthesis].
  • Australia and New Zealand (RANZCP 2024). A psychiatrist must screen, select and prescribe; psychiatrists must be credentialed by their institution (manufacturer training alone is insufficient); trainees and other clinicians such as psychiatric nurses may administer only under a credentialed psychiatrist's supervision. Devices must be TGA-approved (Medsafe in New Zealand); rTMS for depression is funded on the Medicare Benefits Schedule; treatment for non-approved conditions only within research. rTMS is not regulated under mental health acts [source: RANZCP 2024].
  • Operator training internationally: the IFCN guidelines summarise minimum training requirements for TMS operators [source: Rossi et al. 2021 abstract].

2.2 Phases (from the psychotherapist's side)

The phases below organise the psychotherapist's work around the team's process. The team's own steps (assessment, safety screen, consent, treatment course, outcome measures, maintenance) are as RANZCP and CTMSS describe; the mapping to psychotherapy tasks is [synthesis].

  1. Recognition and referral (any time in ongoing therapy). Goal: notice when a client's picture matches the groups for whom TMS is considered, and raise a psychiatric review. CTMSS best-practice candidates: depression after two or more failed antidepressant trials from at least two classes (with or without anxious features); OCD after failed medication trials from two classes and a trial of evidence-based psychotherapy such as ERP; smoking after failed standard medication and behavioural interventions; people with medication sensitivities or contraindications; and prior TMS responders [source: CTMSS clinician deck]. NICE adds that patient selection is "most important" because it may not suit some kinds of depression [source: NICE IPG542]. Move on when: the client agrees to a referral and a prescriber is involved.
  2. Assessment and consent (one or more appointments with the TMS service). The team does a full psychiatric assessment, medication review, structured safety screen (especially seizure risk factors and metal/implants) and seeks consent [source: RANZCP 2024]. The psychotherapist supports understanding and decision-making. Move on when: the team has accepted the client and consent is given.
  3. Acute course. Delivered in multi-week courses of repeated, typically daily weekday outpatient sessions; some OCD protocols include a symptom-provocation step before stimulation; SAINT is compressed into days [source: CTMSS clinician deck; CTMSS SAINT release]. The team monitors mental state, side effects, seizure-threshold factors and outcomes with rating scales (e.g. MADRS, HDRS, HAM-A, Y-BOCS) [source: RANZCP 2024; CTMSS clinician deck]. Psychotherapy continues alongside. Move on when: the team completes the course and does an end-of-treatment assessment.
  4. After the course: consolidation, maintenance, relapse watch. RANZCP recommends ongoing pharmacotherapy after an acute course to help prevent relapse; maintenance TMS may be considered for early relapsers or high relapse risk; retreatment is appropriate for previous good responders [source: RANZCP 2024]. The psychotherapist leads relapse-prevention work and watches for early warning signs. Ends when: therapy goals are reached or care is handed over.

Session count and format for the TMS course itself are set by the team and the device label; they are deliberately not stated here.

3. Guiding principles

  • The team prescribes and delivers; you support. Practical meaning: never suggest a device, protocol, number of sessions or medication change; route every treatment question to the psychiatrist [source: RANZCP 2024; NeuroStar Safety Information].
  • Selection matters. Practical meaning: raise TMS as an option to discuss with a psychiatrist when the history fits, not as a promise that it suits this client [source: NICE IPG542; CTMSS].
  • Honest expectations. Practical meaning: response is variable and outcomes cannot be guaranteed; help the client hold both hope and the possibility of no benefit [source: NICE IPG542; RANZCP 2024].
  • Informed choice includes alternatives and cost. Practical meaning: make sure the client has heard the other options, the time commitment and the costs, and has enough time to decide [source: NICE IPG542; RANZCP 2024].
  • Safety information is official information. Practical meaning: describe seizure risk, metal-implant contraindications and side effects only as the label or guideline states them, and point the client to the team for their own screening [source: FDA 2018; NeuroStar Safety Information].
  • Watch mood in both directions. Practical meaning: treatment-emergent hypomania/mania and suicidality are monitored throughout; you see the client in between and pass on changes the same day [source: CTMSS clinician deck; RANZCP 2024] [synthesis for the same-day reporting].
  • Combine, don't replace. Practical meaning: RANZCP states rTMS may be combined with psychological therapies; for OCD, CTMSS describes TMS as likely best used as an adjunct to exposure therapy and medication. Keep therapy going [source: RANZCP 2024; CTMSS clinician deck].
  • Off-label and research use must be transparent. Practical meaning: if a device is used outside its cleared indication or age, the client (and carer for a young person) must be told; RANZCP limits non-approved conditions to research [source: RANZCP 2024].
  • Young people need extra safeguards. Practical meaning: developmental stage, maturity, family context, capacity to consent and the child and adolescent psychiatrist's opinion all shape the decision [source: RANZCP 2024].
  • No do-it-yourself stimulation. Practical meaning: clinic TMS is a prescribed, physician-supervised procedure; discourage clients from buying or building home brain-stimulation devices and bring any such plan to the psychiatrist [synthesis; supervision requirement from NeuroStar Safety Information].
  • One shared plan. Practical meaning: with consent, agree with the team what you will monitor, how you will report and who holds crisis responsibility during the course [synthesis].

4. Intervention inventory

Part A describes how the treating team delivers TMS, at a descriptive level only. Part B is the psychotherapist's own work. Example language is illustrative throughout.

A1. How the treatment is delivered (team procedure, descriptive)

  • Purpose: give you an accurate picture so your psychoeducation matches what the client will experience.
  • Steps (as sources describe them):
    • Prescription and supervision: a psychiatrist (US: a licensed physician) assesses, prescribes, plans the course and stays medically responsible; trained staff such as nurses or technicians may run daily sessions under supervision [source: RANZCP 2024; NeuroStar Safety Information].
    • Pre-treatment: full psychiatric assessment, relevant investigations, medication review, and a structured safety screen covering seizure risk factors and metal or electronic implants [source: RANZCP 2024]. For SAINT, a brain MRI and neuronavigation are part of targeting [source: CTMSS SAINT release 2022].
    • Contraindications and cautions as sources state them: the FDA lists metallic objects or implanted stimulators in or near the head (e.g. cochlear implants, deep brain stimulators, vagus nerve stimulators, aneurysm clips or coils, stents, bullet fragments, jewellery, hair barrettes); people with a history of seizures should discuss it with their provider [source: FDA 2018]. NeuroStar: not for people with non-removable conductive metal in or near the head [source: NeuroStar Safety Information]. RANZCP lists no absolute contraindications but asks for careful risk-benefit judgement in pregnancy, children and adolescents, and seizure risk factors [source: RANZCP 2024].
    • Session: the client is awake, sits in a treatment chair, wears earplugs, and a coil is placed against the head; no anaesthesia; afterwards the client can usually return to normal activity [source: NICE IPG542; FDA 2018]. You will hear clicking sounds and feel tapping on the scalp [synthesis: common patient-information description; confirm with the local service].
    • Course: repeated outpatient sessions over several weeks (shorter, accelerated over days for SAINT); some OCD protocols start each session with a personalised symptom-provocation step [source: CTMSS clinician deck].
    • Monitoring: regular mental state, response and side-effect review; daily checks on factors that may lower the seizure threshold (medication changes, substance use, neurological or physical decline); rating scales before, during and at the end [source: RANZCP 2024].
    • Adverse effects as sources state them: commonly scalp or application-site discomfort, headache, facial twitching, fatigue, referred pain (eye, tooth, jaw), insomnia, anxiety, usually transient and easing over the first week or across the course [source: RANZCP 2024; CTMSS; NeuroStar]. NICE also lists rare hypomania, a self-limiting seizure, increasingly hostile thoughts in one patient, transient confusion or concentration/working-memory problems and transient hearing loss as reported or anecdotal [source: NICE IPG542].
    • Seizure: described as rare; CTMSS and NeuroStar state under 0.1% per course or per patient; reported seizures occurred during the session and resolved without lasting effects; risk is higher with neurological conditions, past seizures, alcohol or substance use, or seizure-threshold-lowering medication changes; services must have a seizure management protocol [source: CTMSS clinician deck; NeuroStar; RANZCP 2024; Rossi et al. 2021].
    • Hearing: earplugs are required; one permanent hearing threshold shift was reported in a patient not wearing earplugs [source: CTMSS clinician deck; FDA 2018].
    • Mood switch: CTMSS reports treatment-emergent mania rates similar for active and sham overall, with higher switch rates in bipolar than unipolar patients; RANZCP asks clinicians to recognise an emerging manic switch and have a response plan [source: CTMSS; RANZCP 2024].
    • After the course: ongoing medication to help prevent relapse; maintenance or retreatment decided by the psychiatrist [source: RANZCP 2024].
  • Example language (illustrative): "It's an outpatient treatment — you're awake, you sit in a chair with earplugs in, and a magnetic coil rests against your head. The team will tell you exactly how many visits and how long each one is."
  • Watch for: describing anything more technical than this, or contradicting the local service; when unsure, say "the team will explain that" and pass the question on.

B1. Recognising when to raise a TMS consultation and referring

  • Purpose: make sure clients who may be candidates are reviewed by a psychiatrist; TMS is not a psychotherapist's decision.
  • Steps:
    1. Review the treatment history in therapy: diagnosis, number and kind of antidepressant trials, response, side effects, prior psychotherapy (for OCD, whether ERP was tried) [source: CTMSS candidate criteria].
    2. Notice the fit: persistent depression despite medication trials; poor tolerance of medication; OCD after medication and ERP; smoking after standard medication and behavioural support; a past TMS responder who is relapsing [source: CTMSS clinician deck].
    3. Raise it as a question to take to the prescriber, not as a recommendation. With consent, write to or call the GP/psychiatrist summarising symptoms, course in therapy and why a neuromodulation review may be worth considering [synthesis].
    4. Tell the client about local availability, waiting times and funding as far as you know them, and that eligibility is decided by the service [synthesis; funding note from RANZCP 2024].
  • Example language (illustrative): "Given how many medicines you've tried, it might be worth asking your psychiatrist whether a brain-stimulation treatment such as TMS is an option for you. I can't say if it's right for you — that's their assessment — but I can help you prepare the question."
  • Watch for: the client hearing this as you "giving up" on therapy; frame it as adding, not replacing. Working when: the client brings the question to the prescriber and a referral decision is made.

B2. Psychoeducation

  • Purpose: give accurate, balanced, non-technical information that matches official sources and the local service.
  • Steps:
    1. Ask what the client has heard (internet, advertising, friends); correct confusion with ECT (TMS needs no anaesthesia and is not intended to cause a seizure) [source: NICE IPG542; NeuroStar].
    2. Explain what it is, who decides, what a course involves in general terms, common side effects and rare risks (seizure, mood switch, hearing if earplugs are not worn), using A1 [source: as A1].
    3. Explain that response varies and benefit cannot be guaranteed [source: NICE IPG542; RANZCP 2024].
    4. Distinguish types by name only (rTMS, deep TMS, theta-burst, SAINT) and say the team chooses based on the device's indications and their assessment [source: CTMSS] [synthesis for framing].
    5. Point to the service's own information leaflet and the manufacturer's official safety page; suggest writing questions down [synthesis].
  • Example language (illustrative): "The common side effects are scalp discomfort and headache, which usually ease after the first week. Seizures are rare, and the team screens for anything that might raise that risk."
  • Watch for: marketing claims ("cure", "first-line", "works in days for everyone"); gently note that labels and guidelines describe adjunctive use and variable response [source: Neuronetics 2024; NICE IPG542].

B3. Supporting informed consent and shared decision-making

  • Purpose: help the client reach a choice that is informed, voluntary and their own; the psychiatrist takes consent.
  • Steps:
    1. Check the elements RANZCP lists have been covered: method, process, possible adverse events, what to expect before/during/after, that outcomes are not guaranteed, costs, and enough time to decide; NICE adds that alternatives must be explained [source: RANZCP 2024; NICE IPG542].
    2. Help the client write questions for the consent appointment (e.g. alternatives, time commitment, what happens if it doesn't work, side effects, implants, current medicines, driving and work) [synthesis].
    3. Explore values and practical constraints (daily travel, work, childcare, cost) without steering [synthesis].
    4. Explore family or carer involvement according to the client's wishes [source: RANZCP 2024].
    5. If capacity seems impaired (e.g. severe depression, psychosis), tell the team; RANZCP states treatment without capacity requires substituted consent under local law [source: RANZCP 2024].
  • Example language (illustrative): "What would you need to know to feel this is your decision — whichever way you decide?"
  • Watch for: pressure from family, desperation leading to rushed consent, or unrealistic hope; slow the process and ask the team for more information time.

B4. Preparing the client for a daily course

  • Purpose: reduce dropout and anxiety; make the routine workable.
  • Steps:
    1. Plan logistics: travel, time off work, childcare, a backup plan for missed sessions (the team decides how to handle missed sessions) [synthesis].
    2. Rehearse the first session: what will happen, earplugs, sensations, that they can tell staff about discomfort at any time [synthesis; earplugs from FDA 2018].
    3. Encourage telling the team about all medicines, alcohol or drug use, and any metal or devices in or near the head, and about changes during the course [source: RANZCP 2024 daily seizure-threshold checks; FDA 2018].
    4. For OCD, prepare the client for a possible symptom-provocation step and link it to exposure skills they already have [source: CTMSS clinician deck] [synthesis for linking].
    5. Agree what you and the client will track between therapy sessions (mood, sleep, energy, side effects, suicidal thoughts) [synthesis].
  • Example language (illustrative): "Let's work out how the visits fit into your week and what you'll do on a day when getting there feels impossible."
  • Watch for: avoidance and anticipatory anxiety in the first week; a practical plan usually helps.

B5. Supporting the client during the course

  • Purpose: keep the client engaged, help them cope with discomfort and slow or uneven change, and keep therapy going.
  • Steps:
    1. Brief check-in each therapy session: attendance, side effects, sleep, mood, hope, thoughts of self-harm [synthesis].
    2. Normalise early discomfort as described in official information, and encourage telling staff rather than quietly dropping out [source: NeuroStar; RANZCP 2024].
    3. Help the client notice small changes (energy, activity, sleep) through a simple diary, without promising a response [synthesis].
    4. Continue the planned psychotherapy, adjusting pace to energy and fatigue [synthesis; combination supported by RANZCP 2024].
  • Example language (illustrative): "What have you noticed this week — anything better, worse or just different? Let's make sure the team hears about the side effects too."
  • Watch for: early discouragement ("it's not working"); refer the question of progress to the team, which tracks scale scores.

B6. Monitoring and passing on adverse effects and mood changes

  • Purpose: you may see changes before the team does; get them to the prescriber quickly.
  • Steps:
    1. With consent, agree a route and a timescale: who to call, how fast, what to put in writing [synthesis].
    2. Pass on the same day: signs of hypomania or mania (reduced need for sleep, racing thoughts, unusual irritability, risky behaviour), new or worsening suicidal thoughts, agitation, hostility, confusion or memory complaints, hearing changes, or any event that sounds like a seizure or faint [source: NICE IPG542 and CTMSS for the effects; RANZCP 2024 for manic-switch response planning] [synthesis for the reporting process].
    3. Pass on factors the team checks daily for seizure threshold: new or changed medicines, alcohol or substance use (including binges or withdrawal), new neurological or physical illness [source: RANZCP 2024].
    4. Pass on persistent side effects that are making the client consider stopping [synthesis].
    5. Emergency: suspected seizure, mania with risk, or imminent suicide risk goes to emergency services and the team at once [synthesis; standard practice].
  • Example language (illustrative): "You've told me you're sleeping three hours and feel unstoppable. I want the TMS team to know today — can we call them together?"
  • Watch for: clients who hide changes for fear of the course being stopped; explain that reporting keeps treatment safe.
  • Note: CTMSS reports suicidal-ideation emergence was lower with active TMS than sham in the pivotal study; RANZCP does not set specific suicidality monitoring rules. Standard suicide risk assessment still applies throughout [source: CTMSS clinician deck; RANZCP 2024] [synthesis].

B7. Crisis and safety planning for the course

  • Purpose: make sure risk is held during a period of change and frequent contact with a new team.
  • Steps:
    1. Before the course, review or write a safety plan: warning signs, coping steps, people to contact, professional and emergency contacts, and lethal-means safety (storage and removal) [synthesis; standard risk practice].
    2. Add the TMS service's contact details and agree with the team who holds clinical responsibility for crises during the course [synthesis].
    3. Include a plan for an emerging manic switch: what the client, family and you will do and who to call [source: RANZCP 2024 requires a response plan from the team] [synthesis for the shared plan].
    4. Plan for the end of the course and for non-response, when hopelessness can rise [synthesis].
  • Example language (illustrative): "If things get worse during treatment, who will you call first, and what will they do?"
  • Watch for: pinning all hope on TMS; keep other supports active.

B8. Integrating psychotherapy before, during and after

  • Purpose: add the psychological work that TMS does not provide. RANZCP states rTMS may be combined with psychological therapies; CTMSS describes TMS for OCD as likely best used as an adjunct to exposure therapy and medication [source: RANZCP 2024; CTMSS clinician deck].
  • Steps:
    1. Before: keep the existing therapy formulation; agree what the client hopes TMS might change and what therapy will work on [synthesis].
    2. During: for depression, use low-demand, active methods (activity scheduling, problem-solving, small values-based steps) matched to energy [synthesis]; for OCD, continue planned ERP alongside, coordinated with the team, especially if the protocol includes symptom provocation [source: CTMSS for adjunct framing] [synthesis for coordination]; for smoking, continue behavioural cessation support, since candidates have usually already tried it [source: CTMSS] [synthesis].
    3. After: use any improvement to consolidate skills, rebuild routines and relationships, and work on relapse prevention [synthesis].
  • Example language (illustrative): "If your energy picks up, that's a chance to start the things depression has been blocking. Let's choose one small step for this week."
  • Watch for: overloading the client during the course; keep homework light and specific.

B9. Conversations about ambivalence and adherence

  • Purpose: help the client think through doubts about starting, continuing or stopping, without advising them to change treatment.
  • Steps:
    1. Reflect both sides of the ambivalence (time, discomfort, cost, hope, fear) [synthesis; motivational interviewing style].
    2. Encourage the client to take concerns ("I want to stop", "it's not working", "it hurts") directly to the team before deciding [synthesis].
    3. Do not advise on number of sessions, stopping, restarting, maintenance or medication; refer every such question to the psychiatrist [synthesis; principle from RANZCP and NeuroStar on physician responsibility].
  • Example language (illustrative): "Part of you wants to keep going and part of you is fed up. Would it help to tell the team exactly what's getting in the way?"
  • Watch for: silent dropout; ask about attendance every session.

B10. Children and adolescents: safeguarding, consent and assent, parent or carer involvement

  • Purpose: protect young people and make sure decisions are lawful, informed and include the young person's voice.
  • Steps:
    1. Know the age limits as regulators state them: in the US, adjunctive MDD clearances for ages 15 to 21 (NeuroStar 2024; BrainsWay 2025); no depression clearance under 15 was found [source: Neuronetics 2024; BrainsWay/SEC 2025]. In Australia and New Zealand, RANZCP advises rTMS for young people only within an approved research protocol or where other options are limited and potential benefit outweighs risk; services must check the device is approved for the age group and tell patient and caregiver if use is off-label [source: RANZCP 2024].
    2. Support the assessment RANZCP describes: developmental stage, maturity, family context, capacity to consent, and the treating child and adolescent psychiatrist's opinion [source: RANZCP 2024].
    3. Consent and assent: help the young person understand the treatment in age-appropriate terms and say what they want; support parents or carers in understanding the information; legal consent rules depend on jurisdiction and are applied by the treating team [synthesis; jurisdictional rules not covered in the sources] [uncertain].
    4. Safeguarding: follow your usual safeguarding procedures for any concern (e.g. pressure or coercion, neglect, abuse, risk to self); a treatment course does not change these duties [synthesis].
    5. Monitor closely for worsening mood, agitation and suicidal thoughts, and share with parents or carers as agreed within confidentiality limits and safeguarding rules [synthesis].
    6. Keep school and family therapy work coordinated with the team; plan for missed school time [synthesis].
  • Example language (illustrative, to a 16-year-old): "Your parents and the doctor will be part of this decision, but what you think matters too. What do you want to ask them?"
  • Watch for: a young person going along with the decision to please adults; ask privately how they feel about it.

B11. After the course: relapse prevention, maintenance and retreatment conversations

  • Purpose: keep gains and recognise relapse early.
  • Steps:
    1. Review with the client what changed and what helped, and write an early-warning-signs plan [synthesis].
    2. Explain that the psychiatrist may recommend ongoing medication, maintenance TMS or later retreatment; RANZCP describes these options and sets no lifetime limit on retreatment [source: RANZCP 2024].
    3. If early warning signs return, help the client contact the prescriber promptly [synthesis].
    4. If there was no benefit, process disappointment and help the client discuss next options with the psychiatrist (e.g. other treatments the team proposes) [synthesis].
  • Example language (illustrative): "What would be the first sign that the depression is creeping back, and who will you tell?"
  • Watch for: the client attributing all change to the device and dropping skills; link gains to their own actions too.

B12. Responding to home devices, DIY stimulation and unverified claims

  • Purpose: protect clients from unsupervised or misleading neuromodulation.
  • Steps:
    1. Ask about any home or online brain-stimulation device, kit or clinic offering unproven indications [synthesis].
    2. Explain that cleared TMS is a prescription, physician-supervised treatment for specific indications and that treatment for non-approved conditions should be given only in research [source: NeuroStar; RANZCP 2024].
    3. Name general risks of unsupervised stimulation without giving any technical detail: no safety screening (seizure risk, implants), no monitoring for mood switches or side effects, no medical responsibility [synthesis based on screening and monitoring requirements in RANZCP 2024 and FDA 2018].
    4. Encourage the client to discuss the device with their doctor; consider the client's safety if they persist [synthesis].
  • Example language (illustrative): "In clinics, TMS comes with screening and monitoring for good reasons. I'd want your doctor to look at this device before you use it."
  • Watch for: financial exploitation and loss of trust in mainstream care.

5. Handling problems

  • Stuck or non-responding client (during or after the course). Response depends on the team's assessment; avoid promising more sessions will help. Help the client report honestly at reviews, keep therapy goals separate from the TMS outcome, and process disappointment. NICE notes variable response [source: NICE IPG542] [synthesis for the response].
  • Resistance or fear ("brain zapping", confusion with ECT). Explore the fear, correct facts from official sources (no anaesthesia, not intended to cause a seizure), and offer to help the client ask the team or visit the clinic first. Respect a decision to decline [source: NICE IPG542; NeuroStar] [synthesis].
  • Overwhelm from daily attendance. Problem-solve logistics, reduce therapy demands during the course, and encourage the client to tell the team; the team decides any change to the schedule [synthesis].
  • Non-adherence and missed sessions. Ask about each missed session without judgement; identify barriers (side effects, travel, depression itself, hopelessness); route the question of what to do about missed sessions to the team [synthesis].
  • Discomfort and headache. Normalise as described in official information (usually easing over the first week) and encourage reporting; RANZCP notes simple analgesia may help, which is for the team or GP to advise [source: NeuroStar; RANZCP 2024].
  • Emerging hypomania or mania. Same-day report to the prescriber; use the agreed plan; emergency services if risk is high. Higher risk in bipolar disorder [source: CTMSS; RANZCP 2024] [synthesis for the process].
  • Rising suicidality or hopelessness, including after non-response. Standard suicide risk assessment, update the safety plan, inform the team and the GP/psychiatrist; emergency pathway if imminent [synthesis].
  • Possible seizure or faint reported between sessions. Treat as a medical event: urgent medical assessment and immediate report to the team. Seizures reported in sources occurred during sessions, so an event outside a session also needs medical evaluation for other causes [source: CTMSS clinician deck] [synthesis].
  • New medicines, alcohol or drug use during the course. Encourage the client to tell the team before the next session, because these are factors checked for seizure threshold; never advise on the medicine itself [source: RANZCP 2024].
  • Rupture: client feels you are "handing them off" to a machine. Name it, repair it, and make clear that therapy continues and that you see TMS as an addition [synthesis].
  • Rupture with the TMS team or conflicting messages. With consent, contact the team to clarify; avoid criticising either party in front of the client; agree one source of truth for treatment questions [synthesis].
  • Unrealistic expectations fuelled by marketing (e.g. "cure in days"). Compare with what the label and NICE say (adjunctive indications, variable response) [source: Neuronetics 2024; NICE IPG542] [synthesis].
  • Cost and access barriers. Help the client ask about funding (e.g. NHS availability, insurance, Medicare in Australia); in Australia rTMS for depression is on the Medicare Benefits Schedule [source: RANZCP 2024] [synthesis for the rest].
  • OCD symptom provocation causing distress. Use exposure-based coping already learned, and pass on severe distress to the team [source: CTMSS for provocation step] [synthesis].
  • Pregnancy. RANZCP describes limited evidence, low theoretical risk, careful assessment, detailed consent and comparison with alternatives, and advises family involvement; support the decision and ensure the obstetric team is informed [source: RANZCP 2024] [synthesis for the last step].
  • Young person who does not want treatment but parents do (or the reverse). Make space for the young person's view, support a family conversation, involve the child and adolescent psychiatrist, and follow safeguarding procedures if coercion or risk is present [synthesis; RANZCP 2024 for assessment elements].
  • Client lacks capacity or treatment is proposed under compulsion. Raise with the team; RANZCP notes substituted consent is needed and that rTMS is not regulated under mental health acts [source: RANZCP 2024].
  • Client asks you about settings, coil position or protocol details. Explain these are decided by the psychiatrist and help the client write the question down [synthesis].

Sources

Sources:

Articles cited:

  • Rossi S, Antal A, Bestmann S, et al. (2021). Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 132(1), 269–306. doi:10.1016/j.clinph.2020.10.003 (abstract only; full text not drawn on [uncertain] for contraindication and paediatric details).
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