TMS: Accelerated Protocols

Our Access Mission and the Standard Protocol

Improving access to psychiatric care and TMS is a key goal for our practice. It is fortunate that commercial payers and medicare cover TMS treatment for patients with treatment-resistant depression.

That said, coverage remains limited to the standard protocols that are available. This standard protocol, which is typically 36 sessions for a treatment, has more history of clinical data, but accelerated protocols are now also available that have demonstrated robust clinical efficacy.

Accelerated TMS (and Very Accelerated TMS)

While accelerated protocols are not covered by insurance today, they remain an important treatment option for those patients that need to compress treatments into a shorter period of time.

Patients have more options than they have ever had before. This area is changing rapidly as clinical investigators have generated clinical data regarding the efficacy of TMS to improve patient convenience. Some of these treatments include:

• 6-Day + Taper (Deep TMS)
• 5-Day Accelerated
• Neuronavigation assisted (SAINT)
• ONE-D (One Day) Protocol

We can look at each of these protocols in turn.

Standard Accelerated

This protocol is based on recent data that was generated by Brainsway, in a multi-site clinical study enrolling 104 patients.

This research demonstrated that patients can receive multiple TMS sessions per day (typically 2-3 sessions) with a minimum interval of 20 minutes between sessions. This approach maintains clinical efficacy while reducing the overall treatment duration from 6 weeks to approximately 2-3 weeks. The accelerated protocol follows the same stimulation parameters as the standard protocol but condenses the treatment timeline. Patients still receive the full 36 sessions, but complete them in a shorter timeframe. This option is particularly beneficial for patients who cannot commit to a 6-week treatment course due to work obligations, travel constraints, or acute symptom severity requiring faster intervention.

Highlights of the data, which was announced here, reflected strong efficacy and tolerability with response rates of 87.8% and remission rates of 78.0% in the accelerated treatment group compared to 87.5% and 87.5% in the standard treatment. Time to remission was accelerated also at 21 days (median) vs. 28 days for the standard group.

The full pdf of this study is available. This study was just published this year (2025).

Our practice offers this 6-day + tapered protocol: more information can be is available on our main website.

5-Day Accelerated TMS Protocol

The 5-Day Accelerated TMS protocol represents one of the most condensed treatment approaches available today. This protocol delivers multiple TMS sessions per day (typically 10 sessions) over just five consecutive days, making it significantly more intensive than standard accelerated protocols.

This intensive approach is based on research suggesting that delivering multiple TMS sessions in a compressed timeframe may produce rapid and significant clinical improvements. The protocol typically involves 50 total sessions (10 sessions per day for 5 days), with 30-minute to 50-minute intervals between treatments.

The clinical outcomes for the 5-Day Accelerated protocol have been promising, with studies showing rapid symptom improvement that can be comparable to longer treatment courses. Patients often report noticeable mood improvements within the treatment week, though some may require maintenance sessions in the weeks following the intensive treatment period.

This protocol is particularly well-suited for patients who:

• Need rapid symptom relief due to severe depression
• Have geographic constraints that make daily visits over several weeks impractical
• Cannot take extended time away from work or family responsibilities
• Have failed to respond to standard TMS protocols
• Prefer a condensed treatment timeline for personal reasons

Integrative Mind offers this protocol (see here). While the 5-Day Accelerated protocol offers significant convenience advantages, patients should expect to be in-clinic most of the working day.

Our team conducts thorough evaluations to determine if this approach is appropriate based on the patient's medical history, symptom severity, and individual circumstances.

SAINT Protocol (Stanford Accelerated Intelligent Neuromodulation Therapy)

The SAINT protocol represents an advanced and personalized approaches to accelerated TMS treatment. Developed at Stanford University, this protocol combines several innovative elements that distinguish it from other TMS approaches:

• fMRI: SAINT uses MRI-guided precision targeting to identify the exact location for stimulation in each individual patient's brain, ensuring optimal treatment delivery. fMRI is an imaging technique to measure activity in the brain. A paper provided in Nature Methods gives a detailed protocol (this is a highly technical paper, but the pictures on page 6 give an idea of the patient experience).
• Accelerated Schedule: The protocol delivers 10 sessions per day (50 total sessions) over just 5 consecutive days, similar to the 5-Day Accelerated protocol.
• Individualized Targeting: Rather than using standardized locations, SAINT identifies the specific subregion of the dorsolateral prefrontal cortex that connects to the subgenual anterior cingulate cortex in each patient.
• Higher Pulse Frequency: SAINT typically uses a higher stimulation intensity (90% of motor threshold) and delivers more pulses per session than standard protocols.

While promising, the technology has been exclusively licensed to a private company, making it largely inaccessible (and extraordinarily expensive). fMRI also adds an extra step to the treatment, which (typically) adds additional cost. From a clinical standpoint, both approaches are targeting the same brain region.

Here is a comparison:

ONE-D (One Day) Protocol (Investigational)

The ONE-D (One-Day) Protocol is an ultra-accelerated approach that aims to deliver a complete course of TMS treatment in a single day. This innovative protocol represents the frontier of compressed TMS delivery and is currently being investigated in research settings. Key features of the 1D Protocol include:

• Single-Day Delivery: All stimulation sessions are completed within one day, typically over 8 hours with appropriate breaks.
• Co-administration of an oral neuroplastogen: an oral small molecule therapy was provided that is hypothesized to improve neural plasticity and improve the receptivity of the brain to the long term potentiation / learning changes underlying TMS

A key paper outlining this approach is here, by the Downar laboratory in University of Toronto who led this groundbreaking work. A recent followup study has been published by his group. This study demonstrated that delivering multiple sessions of intermittent theta burst stimulation within a single day could produce significant antidepressant effects while maintaining good tolerability.

This ultra-condensed approach showed promise for patients needing rapid intervention.

Conclusions

TMS remains an actively changing area. Much of the innovation is meant to improve patient convenience and lower the barriers to access. There is much to look forward to!