For Referring Clinicians
Referring for TMS: a clinician's brief
A concise overview of TMS indications, evidence, and safety, how to introduce it to your patients, and how to refer to Muthu Brain Medicine.
Section 1
Collaborative care model
Why refer for TMS? Transcranial Magnetic Stimulation (TMS) is a non-invasive, non-systemic neuromodulation modality designed for treatment-resistant psychiatric conditions.
Collaborative co-management. Referring providers maintain primary longitudinal psychiatric and medical care. Dr. Muthu conducts the initial TMS evaluation, cortical mapping, and supervises daily protocol administration. We transition stabilized patients back to referring providers' practices for ongoing management.
Section 2
Clinical indications & coverage roadmap
Insurance-covered indications
COMMON COVERAGEMajor Depressive Disorder (MDD): severe, single or recurrent (ICD-10: F32.2, F33.2), including anxious/obsessive features.
Coverage criteria:
- Failure of ≥2 antidepressant trials across distinct classes at adequate dose/duration (or intolerable side effects).
- ≥1 trial of evidence-based psychotherapy (e.g., CBT).
FDA-cleared & extended evidence
EMERGING / OFF-LABEL- OCD: FDA-cleared (DMPFC target | H7 coil)
- Smoking cessation: FDA-cleared (Bilateral insula/PFC | H4 coil)
- Bipolar depression: emerging evidence for acute reduction
- Chronic pain / fibromyalgia: off-label neuromodulation
- Comorbid benefits: concurrently improves MDD with co-occurring OCD, PTSD, & anxiety
Section 3
Efficacy benchmark: TMS vs. the antidepressant failure cascade
Naturalistic real-world registries (Sackeim et al., 2020) demonstrate active TMS response rates of 58–83% and remission rates of 28–62%. A meta-analysis showed TMS had a Hedges' g = −0.791 for depressive symptom reduction vs. sham (Dalhuisen et al., 2022). This contrasts with STAR*D, where sequential antidepressant switches yield diminishing returns.
| Treatment step / modality | Remission | Systemic burden |
|---|---|---|
| STAR*D Level 1First monotherapy: citalopram | ~33% | High (weight, sexual, GI) |
| STAR*D Level 2Switch / augmentation | ~25–30% | High |
| STAR*D Level 3Switch / augmentation | ~12–25% | High |
| STAR*D Level 4Tranylcypromine / combination | ~7–13% | Very high |
| Active rTMS augmentation / monotherapy | 28–62% | Minimal (targeted) |
*Contextual effect sizes (g): sertraline (0.27), escitalopram (0.29), venlafaxine (0.33), mirtazapine (0.37) (Guo et al., 2020).
Section 4
ASCERTAIN-TRD trial snapshot
Head-to-head evidence in treatment-resistant depression. The 2024 ASCERTAIN-TRD study compared rTMS augmentation vs. SNRI switch and aripiprazole augmentation vs. SNRI switch in patients with TRD.
52% vs 38% vs 35%*
Response in rTMS, aripiprazole, and med switch
+30% Efficacy
rTMS had greater symptom reduction than a SNRI switch
Marked gain
Anhedonia & anxiety reduction
*p = .038 greater than predetermined statistical cutoff p = .025
Section 5
Safety profile & seizure benchmark
| Adverse event | Active | Sham | Odds ratio (95% CI) |
|---|---|---|---|
| Scalp discomfort | 23.8% | 5.2% | 8.09 (4.71–13.90) |
| Mild headache | 22.6% | 16.2% | 1.48 (1.15–1.91) |
| Local discomfort | 10.9% | 5.0% | 1.98 (1.22–3.21) |
Wang et al., 2022
- Discomfort attenuation: scalp painfulness decreases by ~37% across 10–15 sessions due to neural habituation.
- Seizure risk: extremely rare at ~1 per 30,000 sessions (<0.003%), comparable to bupropion (0.1%) or TCAs (0.1–0.4%).
- Hearing protection: standard foam earplugs eliminate transient acoustic risks.
Section 6
Long-term durability & preservation
12-month durability
62.5% of acute responders maintain response at 12 months (Dunner et al., 2014).
Preservation TMS
If symptoms recur, re-treatment response is >80% in prior responders (Lyndon et al., 2026).
Section 7
How to talk to your patients about TMS
Simple, plain-language framing helps patients feel comfortable with the referral.
“This isn't another pill.”
TMS is non-systemic. No weight gain, sexual side effects, or GI upset, and no pharmacokinetic interactions with current medications.
“It's well studied and FDA-cleared.”
TMS is FDA-cleared for depression, OCD, and smoking cessation, with response rates of 58–83% for MDD in real-world registries.
“It works by a different mechanism than medications.”
Frame TMS as targeting circuits antidepressants haven't shifted, so it's a next step rather than a last resort.
“It fits around your life.”
Short sessions (3–20 min), five days a week for four to six weeks. Patients drive themselves and return to work the same day.
“Insurance usually covers it.”
After two failed antidepressant trials and a course of psychotherapy, most commercial and Medicaid plans as well as Medicare cover TMS for depression.
“I'll stay your doctor.”
You keep managing their care. Dr. Muthu handles the TMS course and sends them back to you once they're stable.
Patients can read our clear-language guide, TMS vs Antidepressants, before their first visit.
Section 8
Quick safety check
TMS is safe for most patients. The main exclusions and cautions are:
- Ferrous metal in or near the head (aneurysm clips, fragments)
- Implanted electronic devices near the head, including cochlear implants
- A seizure history (a relative caution, not always a contraindication)
Everything else is reviewed at evaluation, and a “yes” on a screening question rarely rules out TMS. When in doubt, refer.
Section 9
How to refer
- 1Confirm the patient meets the indications above and review the quick safety check.
- 2Open the Clinician Referral Portal and fill out the referral form (takes a few minutes).
- 3Our office contacts the patient to schedule the TMS evaluation and discuss OON benefits.
- 4You receive updates during treatment, and the patient returns to your care once stabilized.
Ready to refer a patient?
Submit the referral form and our team will take it from there.
Clinician Referral Portal