Standard rTMS — the established course of treatment
The standard rTMS protocol delivers daily treatment sessions over 4 to 6 weeks. It is the most widely studied and extensively validated form of transcranial magnetic stimulation, with decades of clinical evidence supporting its use in treatment-resistant depression.
Standard repetitive Transcranial Magnetic Stimulation (rTMS) works by delivering focused magnetic pulses to the left dorsolateral prefrontal cortex — a brain region consistently implicated in mood regulation. Each pulse generates a brief electrical current in the underlying cortex, and when delivered repeatedly over a course of sessions, this stimulation gradually normalises activity in underactive neural circuits associated with depression.
The treatment was first cleared by the FDA in 2008 and has since been approved by NICE (the National Institute for Health and Care Excellence) as a treatment option for depression that has not responded adequately to antidepressant medication. Hundreds of clinical trials have demonstrated its efficacy, with response rates typically in the range of 50–60% and remission rates of 30–35% in treatment-resistant populations.
A standard course consists of 30 sessions delivered once daily, five days per week, over approximately six weeks. Each session lasts between 20 and 40 minutes depending on the specific stimulation parameters used. The treatment is non-invasive, requires no anaesthesia, and patients can return to their normal activities immediately afterwards.
Decades of clinical evidence — proven efficacy in treatment-resistant depression
Standard rTMS is one of the most thoroughly studied treatments in psychiatry. Since the first randomised controlled trials in the early 2000s, a substantial body of evidence has accumulated demonstrating its effectiveness for patients who have not responded adequately to antidepressant medication — a population historically difficult to treat.
Large-scale meta-analyses, incorporating data from thousands of patients across hundreds of trials, have consistently confirmed that active rTMS produces significantly higher response and remission rates than sham (placebo) stimulation. The treatment effect is robust, reproducible, and has been validated across diverse clinical settings and patient populations worldwide.
Importantly, standard rTMS achieves these outcomes without the systemic side effects associated with pharmacotherapy. There is no sedation, no weight change, and no impact on sexual function. The most commonly reported side effect is mild, transient scalp discomfort at the site of stimulation, which typically resolves within the first few sessions.
A typical treatment session
Each daily session follows a consistent structure. Treatment is delivered in a comfortable clinical setting and requires no preparation or recovery time.
Arrival & check-in
Brief mood and tolerability review before treatment begins.
~5 minPositioning
The treatment coil is positioned precisely over the left dorsolateral prefrontal cortex.
~5 minStimulation
Magnetic pulses are delivered at 10Hz. You remain awake and alert throughout.
20–40 minPost-session
Treatment ends. No recovery period needed — you can drive and return to normal activities.
ImmediateClinical reviews
Structured reviews at sessions 10 and 20, plus an end-of-course assessment and report.
Sessions 10, 20 & 30Who may be suitable for standard rTMS
- Treatment-resistant depression — failed to respond to at least one adequate trial of antidepressant medication
- Patients who experience intolerable side effects from antidepressants
- Those who prefer a non-pharmacological, non-invasive treatment approach
- Patients able to attend daily sessions over a 4–6 week period
A note on treatment expectations. Standard rTMS is not a single-session treatment — it works cumulatively over the course of 30 sessions. Most patients begin to notice changes from around week 2 or 3, with continued improvement through to the end of the course and often beyond. Your consultant will monitor your progress throughout and will discuss realistic expectations for your individual situation during your initial assessment.
iTBS — a faster, more efficient form of brain stimulation
Intermittent Theta Burst Stimulation (iTBS) is a newer form of rTMS that delivers stimulation in shorter, more intense bursts. It produces equivalent clinical outcomes to standard rTMS in a fraction of the treatment time — and opens the door to accelerated protocols that were previously impractical.
Standard rTMS delivers a train of single magnetic pulses at a fixed frequency — typically 10Hz for around 20 to 40 minutes per session. Intermittent Theta Burst Stimulation (iTBS) instead delivers pulses in short bursts that mimic the brain's own natural theta rhythm (5Hz), with each burst lasting just 2 seconds. The result is a session that achieves comparable cortical excitation in as little as 3 minutes.
The clinical non-inferiority of iTBS to standard rTMS was established by the landmark THREE-D trial (Blumberger et al., 2018), which demonstrated equivalent response and remission rates across over 400 patients with major depressive disorder. iTBS is now licensed and widely used as a first-line stimulation modality alongside conventional protocols.
Beyond efficiency, the shorter session time makes iTBS uniquely suited to accelerated treatment designs — where multiple sessions are delivered on the same day. This is the foundation of the intensive protocol described below.
Intensive iTBS — concentrated treatment over five days
Accelerated iTBS protocols compress the full course of brain stimulation treatment into a single week. Rather than delivering one session per day over six weeks, intensive protocols deliver multiple iTBS sessions per day for five consecutive days — dramatically reducing the overall treatment timeline while maintaining strong clinical outcomes.
This approach was pioneered at Stanford University, where researchers demonstrated that delivering multiple short iTBS sessions per day — each lasting just 3 minutes, separated by intervals to allow synaptic consolidation — could produce rapid, substantial antidepressant effects in patients with treatment-resistant depression. Since then, accelerated iTBS protocols have been replicated across multiple research groups and clinical settings worldwide, consistently showing high response and remission rates.
The evidence base for intensive iTBS protocols has grown rapidly. Randomised controlled trials and large real-world cohorts have demonstrated remission rates at least as high as those typically seen with standard daily rTMS, with effects emerging within days rather than weeks. These results represent some of the most promising outcomes seen in non-invasive psychiatric treatment.
A typical intensive treatment day
Each day of the five-day course follows a structured rhythm of brief treatment sessions separated by rest intervals to allow synaptic consolidation.
Arrival & brief check-in
Mood and tolerability reviewed before the day begins.
9:00 amSessions 1–3
Three iTBS sessions, each 3 minutes, with rest intervals between each.
MorningMidday break
Lunch break. Patients are free to rest, read, or take a short walk.
~12:30 pmSessions 4–6
Three further iTBS sessions in the afternoon with rest intervals.
AfternoonSession 7 & review
Final session of the day followed by brief clinical review and progress check.
~4:00 pmWho may be suitable for intensive iTBS
- Treatment-resistant depression — failed two or more antidepressants
- Patients who need a rapid clinical response (e.g. unable to work, severe impairment)
- Those who cannot commit to a 6-week daily treatment schedule
- Prior responders to standard rTMS seeking a more intensive retreatment
- Patients motivated to engage with an intensive 5-day programme
A note on the evidence base. Accelerated iTBS protocols have been studied in randomised controlled trials and validated in real-world clinical cohorts across multiple centres. Some protocols use personalised fMRI-guided targeting, while others use standard anatomical methods — both approaches have demonstrated strong outcomes. The evidence base continues to grow rapidly. We will discuss which approach is appropriate for you during your psychiatric assessment, and be transparent about what the evidence does and does not support for your individual situation.