More and more patients now ask me about “five-day TMS for depression.” Some have read about Stanford’s protocol. Others have seen clinics advertise two-week treatment. Referring colleagues ask a version of the same question: Is accelerated transcranial magnetic stimulation better, and which protocol should patients look for?
The honest answer starts with a caveat. SAINT, now marketed as Stanford Neuromodulation Therapy (SNT), has reported higher remission rates than SWIFT, an accelerated intermittent theta-burst stimulation (iTBS) protocol delivered with the BrainsWay H1 coil. SAINT showed about 79 to 90 percent remission in a small open-label study and 50 percent remission at one month in a sham-controlled replication. SWIFT reported 87.8 percent response and 78.0 percent remission at week six. But the trials enrolled different populations, used different comparators, and measured outcomes at different time points. A head-to-head comparison is not possible.
SAINT: high dose, precision targeting
SAINT is an accelerated, high-dose iTBS protocol. Patients receive 10 sessions of 1,800 pulses a day, spaced 50 minutes apart, for five days: 50 sessions and 90,000 pulses in total. Each patient’s target is set with resting-state functional MRI. The chosen spot is the one in the left dorsolateral prefrontal cortex (DLPFC) whose activity runs most opposite to the subgenual anterior cingulate cortex (sgACC).
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The results across its trials:
- Open-label pilot: 19 of 21 completers remitted (90.5 percent; MADRS below 11). By intention to treat, 19 of 22 remitted (86.4 percent). No cognitive side effects were found.
- Double-blind, sham-controlled trial (interim analysis, n=29): MADRS scores fell 52.5 percent at four weeks with active treatment, versus 11.1 percent with sham.
- Later replication: At one month, remission was 50.0 percent versus 20.8 percent with sham, and response was 54.2 percent versus 25.0 percent.
The drop from about 90 percent in an uncontrolled pilot to about 50 percent under sham control is the most realistic estimate of SAINT’s true effect. That is still a strong result for treatment-resistant depression (TRD), and the protocol has received FDA clearance for TRD.
SWIFT: accelerated without the MRI
SWIFT applies accelerated iTBS through the H1 “deep TMS” coil. Because the H-coil stimulates a broader prefrontal area, it does not need MRI-guided targeting. In a multisite, randomized, blinded non-inferiority trial of 104 patients, participants received one of two schedules:
- Accelerated iTBS: Five sessions a day for six days over two weeks, then two sessions one day a week for four weeks
- Standard high-frequency H1-coil treatment: Daily sessions for four weeks, then tapering
The results:
- Primary outcome: HDRS-21 improvement was similar (19.02 vs. 19.79 points), which met the non-inferiority threshold.
- Response and remission at week six: 87.8 and 78.0 percent with accelerated iTBS, versus 87.5 and 87.5 percent with standard treatment.
- Speed: Remission came sooner with the accelerated protocol (median 21 vs. 28 days).
- Tolerability: Application-site discomfort and headache were more common with accelerated iTBS.
These rates are far higher than those from the H1-coil pivotal trial, which reported 37.0 percent response and 30.4 percent remission at week five. The difference likely reflects three things rather than better efficacy: a less treatment-resistant, moderate to severe population; an active-comparator design; and open, real-world-style enrollment. On those grounds, SWIFT’s numbers should not be read as better than SAINT’s.
What it costs
Published cost-effectiveness data are scarce for both protocols, but SAINT is clearly the more resource-intensive of the two. It requires functional MRI acquisition, proprietary targeting software, and neuronavigation, plus about 10 hours of clinic time a day for five days. Reviewers note that MRI-guided targeting is limited by cost and access. SAINT’s per-course price is widely reported to be considerably higher than conventional TMS, and payer coverage is still evolving.
SWIFT runs on an existing H-coil system with no MRI, which keeps costs close to a standard deep TMS course. Compressing treatment into about two weeks mainly saves patients travel and time off work. More broadly, iTBS is more cost-efficient than conventional repetitive TMS (rTMS). That favors accelerated iTBS approaches, although neither protocol has been studied economically on its own.
What real-world implementation looks like
Both protocols are feasible, but the obstacles differ. Any accelerated protocol strains chair time and staffing, because multiple daily sessions need rest periods in between. Short iTBS sessions make this more manageable.
SAINT also depends on MRI access, imaging analysis, and neuronavigation. It is best suited to academic or high-volume centers, and to severe or urgent TRD, including suicidal ideation, where fast response matters most. SWIFT fits more easily into community clinics that already own H-coil devices.
Some caveats apply to both. Evidence on how long the benefit lasts is limited, the trials were small, and independent replication is sparse. Accelerated protocols are generally safe, with seizure rates comparable to once-daily rTMS, but headache is common, at about 28 percent.
What I tell patients and colleagues
Accelerated TMS is a real advance, especially for patients who cannot wait six weeks or cannot commute daily for that long. But “faster” is not the same as “better,” and the two protocols’ numbers cannot be compared directly. For most patients, the right question is not which branded protocol to seek. It is whether the treating clinic selects patients carefully, measures outcomes, and has a plan for maintenance if depression returns.
Wider adoption will depend on payer coverage, on comparative trials of accelerated iTBS with and without MRI targeting, and on data about maintenance strategies. Until then, our job is to read these trials for what they are: promising, small, and not yet the last word.
Ravi Singareddy is the founder and medical director of Empower Psychiatry & Sleep in north metro Atlanta, where he leads an interventional psychiatry practice offering transcranial magnetic stimulation (TMS) and Spravato (esketamine) for treatment-resistant depression. Double board-certified in psychiatry and sleep medicine, he brings more than two decades of clinical and academic experience to patients who haven’t found relief with medications alone. He is affiliated with Emory Healthcare.
His interest in neuromodulation dates back to his years as associate professor of psychiatry at Penn State College of Medicine. There, he taught annually on vagus nerve stimulation and novel depression therapies, and he published on long-term combined electroconvulsive therapy and vagus nerve stimulation in the American Journal of Psychiatry. He has authored numerous peer-reviewed papers on sleep disorders, insomnia, anxiety, and depression, with work appearing in Sleep, the Journal of Clinical Sleep Medicine, and Psychiatry Research.
Singareddy is a Fellow of the American Psychiatric Association and the American Academy of Sleep Medicine and practices measurement-based care, tracking outcomes to guide every treatment decision. He shares updates on Instagram.
