The role of assessment

A focused assessment can clarify symptoms, competing explanations, functional impairment and risk. It also creates a baseline so that change is measured rather than guessed.

The role of psychotherapy

Therapy can address avoidance, routines, relationships, coping strategies and patterns that brain stimulation alone cannot teach. The approach should match the person’s diagnosis, goals and readiness.

Where rTMS may fit

When indicated, rTMS can be added to an existing treatment plan. It does not automatically require stopping medication or therapy. Coordination is important so clinicians understand what is changing and why.

What research can—and cannot—tell us

Studies of combined psychotherapy and rTMS suggest the approach is feasible and may be helpful for some people, but designs and protocols vary. The evidence supports thoughtful clinical consideration, not a guarantee that every combination improves outcomes.

Questions for an integrated plan

• What is the primary treatment target?
• How will symptoms and daily function be measured?
• Which clinician coordinates the plan?
• When will the plan be continued, changed or stopped?

Research source

Study of rTMS combined with psychotherapy.

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Reviewed by Dr. Courtney Dookie, Calgary Mind & Wellness Clinic.

How the options differ

rTMS

Treatment occurs through repeated clinic visits. It does not require anaesthesia and generally has limited systemic side effects. Common effects include temporary scalp discomfort or headache. Access, time commitment and protocol fit are practical considerations.

Medication

Medication is usually taken at home and can be effective and easier to integrate into a daily schedule. Side effects vary by medicine and person and can include sleep, digestive, sexual or weight-related effects. Medication changes require prescriber oversight.

What does the evidence say?

Meta-analytic evidence supports rTMS as an option for treatment-resistant major depression, but response is not guaranteed and estimates vary across protocols and study populations. A 2023 systematic review found active rTMS more effective than sham treatment across several commonly used protocols.

A better decision framework

• Review which treatments were tried, at what dose and for how long.
• Consider urgency, safety, side effects and practical access.
• Agree on symptom and function measures before treatment.
• Plan a review point and alternatives if progress is limited.

Research source

2023 systematic review and meta-analysis of rTMS for treatment-resistant depression.

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Reviewed by Dr. Courtney Dookie, Calgary Mind & Wellness Clinic.

Before the first session

Your clinician reviews screening information, medications, treatment goals and informed consent. The treatment position and stimulation settings are individualized rather than copied from another person.

During treatment

1. You remove magnetic items near the head and settle into the treatment chair.
2. The clinician positions the device at the planned treatment location.
3. You hear clicking and may feel tapping or muscle movement near the scalp.
4. Comfort and symptoms are checked, especially during early sessions.

Session length and the number of sessions vary by protocol. A treatment plan should state the schedule clearly before a package begins.

After the session

There is no routine sedation or recovery room. Temporary headache, scalp sensitivity or fatigue can occur. New or concerning symptoms should be reported promptly. Improvement, when it occurs, is usually assessed across a course rather than judged from one appointment.

Questions worth asking

• What goal and outcome measure will we track?
• Why was this protocol chosen?
• When will progress be reviewed?
• What happens if improvement is limited?

Research source

Clinical rTMS consensus recommendations.

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Reviewed by Dr. Courtney Dookie, Calgary Mind & Wellness Clinic.

Who may be considered for rTMS?

For depression, the strongest evidence is for adults whose symptoms have not improved sufficiently with one or more adequate treatment attempts. Candidacy is not decided by a diagnosis alone. A clinician reviews symptom severity, treatment history, medications, functional impact and the person’s goals.

What the safety screen covers

• Metal or electronic devices in or near the head
• History of seizures, significant neurological illness or brain injury
• Current medications and substances that may affect seizure threshold
• Pregnancy, recent medical changes and relevant surgical history
• Current mental-health symptoms, including urgent safety concerns

Most people experience temporary scalp discomfort or headache. Seizure is rare, but screening and protocol selection matter. International expert guidelines emphasize trained clinicians, appropriate dosing and ongoing monitoring.

What happens after screening?

If rTMS appears appropriate, the clinician explains the proposed target, schedule, expected benefits, realistic limitations and alternatives. If it is not the right fit, the consultation can still clarify next steps.

Research sources

Consensus recommendations for clinical rTMS in depression and international expert safety guidelines.

Reviewed by Dr. Courtney Dookie, Calgary Mind & Wellness Clinic.