One-Day TMS, a Deeper Look

As discussed here, there has been significant innovation in accelerated protocols. One-D TMS is a particularly interesting advance considering how dramatic the reduction in clinic visit days could be. But importantly for such convenience to be compelling, the efficacy must be retained to be clinically justifiable.

The conventional TMS protocol typically spans 6+ weeks of daily sessions, which is covered by insurance. However, the frequency does present barriers: patients need to commit to frequent appointments, coordinate with work schedules, manage transportation. All of this contributes to dropout rates and reduces accessibility for people who might benefit but can't sustain that level of commitment.

One-D TMS condenses this significantly. The preliminary research shows response rates that rival or exceed traditional protocols. For a field where even small improvements in accessibility and convenience can be the difference between someone getting treated and someone suffering untreated, it is certainly worth paying attention to.

Below is from data published by Jonathan Downar at University of Toronto, who has driven significant innovation to improve access to TMS. Reference^[1]:

What Makes the Mechanism Notable

Part of what makes the one-D protocol particularly interesting is the inclusion of d-cycloserine (DCS), a partial NMDA receptor agonist. This isn't a new drug, as DCS has been used clinically for decades, primarily as a tuberculosis antibiotic. But its neurobiological properties are an unusual but important finding: at much lower doses it acts as a partial agonist to the NMDA receptor, and has shown interesting data in a variety of neuropsychiatry studies. While these studies have not shown sufficient efficacy for approval as a commercial therapeutic, the question is whether it has sufficient efficacy to show any clinical benefit.

A few years ago, a study with DCS studied just that. When added to TMS, DCS was shown to meaningfully improve the response to TMS. In a paper published in JAMA Psychiatry^[2], a major clinical journal for the psychiatry field, the gold standard double blind placebo controlled trial demonstrated significant improvement, using MADRS (the Montgomery Asberg Depression Rating Scale, commonly used in depression clinical studies):

The Accessibility Question (and the Insurance Question)

As of this post, One-D TMS isn't yet covered by insurance plans This is partly because the approach is newer, partly because insurance companies move slowly on novel protocols, and partly because the evidence base, while promising, is still building.

We remain hopeful this will change. As the research accumulates and demonstrates sustained efficacy and safety, and as the practical benefits become more apparent—fewer appointments, faster response to treatment, reduced burden on patients' lives—there's a compelling case for coverage. Payers ultimately respond to evidence and cost-effectiveness, and a protocol that achieves comparable outcomes in a fraction of the time has both.