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Deep transcranial magnetic stimulation for depression [PODCAST]

The Podcast by KevinMD
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July 17, 2025
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Nationally recognized psychiatrist, internist, and addiction medicine specialist Muhamad Aly Rifai discusses his article, “How deep transcranial magnetic stimulation is transforming mental health care.” He shares his experience with deep TMS (dTMS), a non-invasive neuromodulation therapy that offers rapid relief for patients with severe depression, OCD, and other conditions that have resisted conventional treatment. Muhamad explains how recent accelerated protocols can condense weeks of therapy into a single five-day period, achieving remission rates as high as 79 percent. Contrasting this with the slow progress and side effects of many medications, he highlights the safety of dTMS, which requires no anesthesia and does not cause memory impairment like ECT. Through powerful patient stories, the conversation serves as a call to action for clinicians, patients, and policymakers to overcome insurance barriers and lack of awareness, advocating for a new standard of care where rapid, profound healing is not just an aspiration, but a reality.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai, an internal medicine physician and psychiatrist. Today’s KevinMD article is “How deep transcranial magnetic stimulation is transforming mental health care.” Muhamad, welcome back to the show.

Muhamad Aly Rifai: Thank you very much for having me to talk about this timely topic on the treatment of depression and treatment-refractory depression.

Kevin Pho: All right. What’s this latest article about?

Muhamad Aly Rifai: Sure. In my article, I talk about patients who suffer from depression. About 25 million Americans suffer from depression. And despite our best pharmaceutical treatments, there are at least 50 to 60 percent of patients that end up with partial or non-response to antidepressant medications.

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And specifically, there are about 30 or 40 percent of patients who have depression who will end up with what we call treatment-resistant depression. This is where patients do not respond to antidepressants, despite multiple trials of different antidepressants, different classes of antidepressants, or multiple antidepressants, and they end up with this state of prolonged sadness.

Relentless depression drains somebody’s identity. It drains the color out of their life. They end up being disabled, jobless, their self-worth disintegrates, and this condition, severe treatment-resistant depression, had been without treatment for many years, up until the beginning of the 2000s where we started trying additional treatment modalities other than pharmaceuticals to see if we could affect the treatment of depression.

In the past, there have been other pharmaceutical treatments, but we wanted to try something different. Early on, electroconvulsive therapy was a treatment where electricity would be passed through the brain to induce a seizure, but that treatment is hospital-administered. It requires anesthesia. This newer treatment, transcranial magnetic stimulation, was FDA-cleared and approved in 2008, and we found out that if we are able to stimulate the areas of the brain that are involved with depression, we are able to induce a significant response.

So, transcranial magnetic stimulation was cleared in 2008, and the first treatment was what we call superficial transcranial magnetic stimulation, where a magnetic coil is placed on the left side of the brain, the frontal cortex, where it stimulates a magnetic field and causes changes in the frontal lobe. Later on, in 2013, this newer treatment, which is deep transcranial magnetic stimulation—which is the helmet behind me, which is like a helmet just like in the movies; people know Magneto—fits on the head and induces a magnetic field around the brain, targeting mostly, for depression, the frontal cortex. And that has been very, very helpful in terms of the treatment of depression.

Kevin Pho: Now, when you talk about treatment-resistant depression, are there any predictors that characterize those who are resistant to traditional antidepressants?

Muhamad Aly Rifai: There are some predictors. Sometimes the severity of depression, so individuals who suffer from severe depression, such as high scores initially on their treatment scales. There’s also a family history of depression or a family history of bipolar disorder. If individuals also have some genetic polymorphisms that actually predispose them to not being responsive to medications, those are usually predictors that this person is going to have treatment-resistant depression just because of their inability to tolerate the antidepressant medications that we have, or their inability to reach an appropriate and therapeutic level of these antidepressants.

This is especially true with, for example, patients who are ultra-rapid metabolizers, so whatever antidepressant you give them, their system will ultra-rapidly metabolize the antidepressant, and you will not be able to reach a therapeutic level. So those patients, sometimes when we do genomic testing, we’re able to predict that they are going to be treatment-resistant just by the fact that they cannot reach a therapeutic level of antidepressant medications. A family history of depression and severity of depression—those are all predictors for treatment-resistant depression.

And so we are hoping that we will be able, if we predict who is going to be treatment-resistant, to actually bypass multiple, painful, long trials of antidepressants and go to additional treatments such as transcranial magnetic stimulation.

Kevin Pho: And what are some of the efficacy data for those who undergo the transcranial treatment?

Muhamad Aly Rifai: Sure. The efficacy has improved significantly, as well as the utility of the treatment. When the treatment was approved in 2008, it was the figure-of-eight coil that gets applied on the frontal lobe, on the prefrontal cortex, and basically, it induced a magnetic field. The treatment length was 45 minutes, and you had to do it for five days a week for up to six weeks. That was a very lengthy treatment. You had to come to the office every day, five days a week, for about six to seven weeks to get some relief, and at that time, the treatment efficacy was around 40 to 50 percent.

Even with that, when deep transcranial magnetic stimulation, which is the helmet that’s behind me, was approved, the response rates were significant. This was partially also because the length of the treatment session decreased; it went down from 45 minutes to 20 minutes. And basically, we still did it for six weeks, but the rate of response increased significantly because we were targeting deep inside the brain with the magnetic field. The treatment responses increased significantly, so it went up to about 65 to 70 percent, and the rates of continuing in remission six months to a year after treatment went up to about 50 to 55 percent.

Then a newer treatment modality was introduced that’s called theta burst, where we actually intensify the magnetic field around the brain. This is analogous to increasing the dose of a medication. With theta burst, which was an increased dose of the magnetic field with a readjustment of the strength of the magnetic field, we were able to also shorten the treatment session length to about three to five minutes. So, significantly, from 45 minutes down to 20 minutes, now to three to five minutes.

And we were also able, over the last few years, to see if we would have the same success by shortening the treatment duration. So instead of six to eight weeks, we tried to shorten it to about two weeks. And most recently, there’s a treatment protocol that’s actually one week of several treatments a day, five days a week, and people are achieving remission from depression of about 70 to 75 percent. Which is pretty amazing.

Treat your depression in one week. We’re also looking at protocols where you actually come in and you spend the whole day getting treatments: a short treatment of three to five minutes with a rest of 25 minutes, and then you repeat the treatment. We’re hoping to see if we can get a good response with one day of treatments. So we are having the treatment down from six to eight weeks, down to two weeks, and now down to one week, and we’re hoping for one day.

You come in for treatment, you’re depressed, you’re hopeless, you feel that the weight of the world is on you with severe depression, you haven’t responded to any antidepressants, and then you get a treatment. So now it’s one week, and we think we’re going to be able to do one day of treatment to help individuals who have this severe, treatment-refractory depression.

Kevin Pho: And what do patients feel when they’re undergoing therapy?

Muhamad Aly Rifai: The patient is comfortable. With the helmet, we put a cap on the head and the helmet fits snugly on the head. The patient sits—it’s as comfortable as, say, being under a hair dryer in a hair salon. They feel a little bit of tapping on the head, but there’s no discomfort. There’s no pain, no anesthesia, and no loss of consciousness. The patient is comfortable. I have some patients who listen to music. I have some patients who read books while they are getting their treatment. Then, you remove the helmet, and the patient goes home; they drive home. So there’s no after-effect. Even the prolonged treatment where you do several treatments in a day, the patient is comfortable.

The effect is localized only on the brain, and there are very few adverse effects. Maybe a little bit of a headache, but that’s it. That’s the worst side effect that patients experience. One in 100,000, if a person has a history of seizures, they may experience a seizure. I’ve been administering this treatment to my patients for 12 years, and I haven’t had one case of seizures. So, it’s a pretty safe and effective treatment. We added it on to medications, but it could be a replacement for medications in the future.

Now, this treatment is also expanding, so it’s not just for treatment-resistant depression. There is anxious depression, so for people who have predominant anxiety with their depression, it’s also indicated. For late-life depression, so individuals, older individuals above the age of 65 whose depression is more resistant to treatment, that could be administered to them. There’s also a different type of helmet that treats individuals who have obsessive-compulsive disorder. The coil targets different areas of the brain, mostly in the parietal and temporal lobes, so the coils are in the back of the head.

And there is a different helmet that is being studied for nicotine use disorder, and we’re hoping that it’s also going to be very, very successful for opioid use disorder. So we’re expanding the magnetic treatments for depression, non-medication treatment. And that goes along with the movement—we’ve talked about that in previous talks—about how America is overmedicated, and there are a lot of people on medications, and how this treatment modality could replace medications in a natural way, which is a magnetic field.

Kevin Pho: Any potential complications or side effects?

Muhamad Aly Rifai: The side effects are just the discomfort in the forehead. And there’s no memory loss, there’s no confusion, there’s no anesthesia. The person is comfortable. They’re able to drive home after they’re done. One in 100,000, maybe a risk of seizures if somebody has a history of seizures, but I haven’t had any cases like that. People are very, very happy with the treatment and they’re amazed. They feel that they get their life back. They feel that they can see colors again. They’re more functional, they’re back to doing things that they missed before, and they’re able to be on fewer medications potentially, and potentially off medications if the treatment continues to be successful.

And we’ve had good success with cases actually continuing to show improvement after one year; 50 to 60 percent of people continue to be in remission. If somebody has a relapse of their depression, we’re able to retreat them for another session of TMS, exactly like antidepressants. But this is simple, no medications, and the patients tolerate it pretty well and can take a short time away from their work, and they’re able to return back to work and to their family with remission of their depression.

Kevin Pho: Is TMS, transcranial magnetic stimulation, covered by insurance?

Muhamad Aly Rifai: It is covered by insurance. So let’s start with the largest insurer, the Centers for Medicare Services. Medicare has covered transcranial magnetic stimulation since 2009. They have been a very strong advocate for it because a lot of individuals who are on Medicare experience depression and anxiety, and they have adjusted their coverage criteria. They allow you to start utilizing transcranial magnetic stimulation after only two trials of antidepressants. So you don’t have to try ten different medications to get to TMS. You try one antidepressant, and if that’s not successful, you switch to an antidepressant from a different class. And if those are not successful, Medicare will pay for transcranial magnetic stimulation.

And similarly, private insurers have realized that this would be a good alternative to hospitalization. So if somebody has depression and their depression is severe, you could administer transcranial magnetic stimulation and realize significant cost savings as opposed to a person being hospitalized in an inpatient psychiatry unit. This is going to be able to avoid hospitalization, keep a person out in the community, return them to work as soon as possible, return them to family, and return them as a functional member of society.

Kevin Pho: So how about in a primary care setting? If I’m seeing a patient who has symptoms of depression or if I’m treating them for depression, what are some typical scenarios where in the back of my mind I may consider transcranial magnetic stimulation as a next step for this patient? What would those patients typically look like?

Muhamad Aly Rifai: I would think about it early because a patient who suffers with depression, when they present to their primary care doctor, the symptoms have usually been going on for a little bit. They don’t present at the first sign of trouble, but usually the symptoms have been going on for several months. By the time you give them an antidepressant and bring them back in four weeks, that’s four to six months that have already passed for somebody who’s already in depression. They either have side effects to the first dose of antidepressant that you give them, or they want to switch to a different agent, and then you switch them to a different agent. And then we’re already six months into an episode of depression.

I would start thinking about referral to a psychiatrist for transcranial magnetic stimulation. These machines are available in most cities now. Psychiatrists are administering those treatments. There’s availability, different brands of machines, but the treatment is available and it’s approved by insurance. It’s much better for the patient to receive transcranial magnetic stimulation and return back to life as soon as possible rather than wait with an antidepressant that is not working.

So I encourage my colleagues in primary care to think about transcranial magnetic stimulation sooner than what they do with people doing multiple episodes of antidepressant treatment and suffering while not receiving adequate treatment and adequate response to antidepressants.

Kevin Pho: We’re talking to Muhamad Aly Rifai, an internal medicine physician and psychiatrist. Today’s KevinMD article is “How deep transcranial magnetic stimulation is transforming mental health care.” Muhamad, what are some take-home messages that you want to leave with the KevinMD audience?

Muhamad Aly Rifai: Treatment for depression and treatment-refractory depression is available. Transcranial magnetic stimulation and deep transcranial magnetic stimulation are valid options that should be considered early by our colleagues in primary care. Do not wait, trying multiple courses of antidepressant medications; refer these patients early to a psychiatrist who administers transcranial magnetic stimulation and deep transcranial magnetic stimulation for these patients to receive relief from their symptoms of depression and return to their normal life.

Kevin Pho: Muhamad, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Muhamad Aly Rifai: Thank you for having me.

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