This resource was developed by the IOCDF with guidance and input from a working group of scientists, clinicians, and experts: Joan Camprodon, MD, MPH, PhD; Rachel Davis, MD; Darin Dougherty, MD; Carolyn Rodriguez, MD, PhD; and Ryan Vidrine, MD. We also acknowledge Kelly Bedner at the University of Michigan for her many contributions to this article.
About 70% of people with OCD will experience at least some benefit from exposure and response prevention (a form of cognitive behavioral therapy), medication, or a combination of the two. These treatments are backed by research studies demonstrating their effectiveness, and have been widely used to treat OCD for over 30 years.
However, for those who don’t benefit from these treatments, or who only experience a minor reduction in symptoms, alternatives have been limited. Over the past decade, transcranial magnetic stimulation (TMS) has emerged as a new option for OCD treatment, and has progressed from a purely experimental treatment to a more widely available therapy backed by research studies demonstrating its effectiveness. Since TMS does not require surgery and is increasingly available at local clinics in many areas of the US, many people with OCD are curious about this treatment and may be wondering if it is appropriate for them.
Fast facts about TMS
- TMS is for people who have already tried first-line treatment (ERP and/or medication) and are still struggling
- TMS should be provided alongside medication or ERP as an add-on or “adjunct” to therapy
- TMS can be used to treat several mental health disorders, but effective OCD treatment involves TMS “recipes” that combine specific techniques and devices that studies have found to be helpful
Read on to learn about TMS, how it works, whether it may be right for you, and more.
What is TMS?
TMS is a non-invasive way of “stimulating” (or changing) activity in the brain using magnetic fields. During treatment, patients sit in a chair while a TMS device is pressed against the outside of their head. Inside the device is a wire coil. When an electric current is passed through this coil, it generates a magnetic field. The magnetic field passes through the hair, scalp, muscle, and skull and into the brain, where the magnetic field changes brain activity. This magnetic field can be targeted to reach and stimulate specific areas of the brain, including those involved in OCD. The patient may feel a tapping sensation on their head during treatment, but people receiving TMS are not being “shocked” by electricity. Patients are not sedated during the procedure, discomfort is typically mild, and patients can return to their normal activities immediately.
TMS for OCD
TMS technology is used to treat a wide range of mental health disorders and health problems, including major depressive disorder, migraine headaches, and tinnitus. TMS treatment differs depending on the illness being treated, because different parts of the brain need to be targeted depending on the illness, and different TMS equipment may be needed to reach those areas of the brain.
Over the past 10 to 15 years, researchers have developed TMS treatment techniques that target the parts of the brain affected in OCD, and have found that by stimulating these areas of the brain, some people experience a reduction in their OCD symptoms.
A “recipe” for treatment
The term “TMS” describes a variety of technologies and techniques, all of which involve the use of magnetic waves to change activity in the brain. You can think of TMS treatment like a “recipe” that consists of three ingredients: a specific TMS device (or coil), a setting or protocol that determines how fast the coil repeats its magnetic pulses, and an area of the brain where the pulses are directed (the target). Each “ingredient” in this recipe can be changed. Some combinations of ingredients have been found to be helpful for OCD, while others might be less effective.
The ingredients:
- A device or coil
The two types of devices that you will hear the most about when learning about TMS for OCD are rTMS and dTMS.- rTMS (repetitive TMS) devices deliver magnetic waves to the brain in a repeating series of pulses. rTMS can be used to target the areas of the brain closest to the surface, and is sometimes referred to as “surface TMS.”
- dTMS (deep TMS) also delivers a repetitive series of pulses, but the design of the dTMS coil allows for these pulses to reach deeper into the brain and target areas that are out of reach for standard rTMS devices.
- A protocol (or parameters)
The TMS “protocol” or “stimulation parameters” determines how fast the magnetic pulses generated by the TMS coil repeat. The speed that the pulses repeat is also known as their frequency. These pulses can be:
-
- High frequency
- Low frequency
- Intermittent Theta Burst (iTBS)
- Continuous Theta Burst (cTBS)
- iTBS and cTBS protocols can cut the time of treatment sessions down to just five minutes, compared to up to 40 minutes for other protocols, but these protocols are still being studied and are not as widely used at the moment.
- A target in the brain
The magnetic pulses generated by the coil can be directed at different parts of the brain, including some of those that may be affected by OCD. Research on TMS as a treatment for OCD has found that certain targets work better than others:- Using rTMS (or surface TMS) to target the dorsomedial prefrontal cortex (dmPFC), pre-supplementary motor area (pre-SMA), and bilateral and right dorsolateral prefrontal cortex (dlPFC) has been shown in some studies to have positive effects for OCD patients. [1]
However, these studies were small and negative effects have been reported as well. - Using dTMS to target the anterior cingulate cortex (ACC) and dmPFC were found to be helpful for OCD. [2]
- Using rTMS (or surface TMS) to target the dorsomedial prefrontal cortex (dmPFC), pre-supplementary motor area (pre-SMA), and bilateral and right dorsolateral prefrontal cortex (dlPFC) has been shown in some studies to have positive effects for OCD patients. [1]
The FDA-cleared TMS “recipes”
The US Food and Drug Administration (FDA) has cleared certain combinations of devices, protocols, and target areas of the brain to be used in treating OCD. The FDA cleared “recipe” for OCD treatment using TMS is:
Additionally, this treatment should be paired with exposures (or “provocations”) that trigger OCD fears right before the TMS session begins.
How to tell which recipe is being used in your treatment
If you are considering TMS for your OCD, or are currently undergoing treatment, there’s a few things you can look for and ask about that will help you understand which one of these treatment recipes you are receiving.
- Find out which type of TMS is being used in your treatment (e.g., surface TMS or deep TMS)
- Ask about the areas of the brain or the brain structures that are being targeted
- Pay attention to where the helmet or coil is placed on your head during treatment. Draw an imaginary line on the outside of your head from your nose, up between your eyes, over the top of your head and to the back of your neck. FDA cleared treatments require the helmet or coil to be placed on head so that is aligned with this imaginary center line. If the TMS device is placed on the side of your head, or off-center from this imaginary line, you might not be receiving treatment intended for OCD, and you should check with your doctor or TMS clinic about this.
What if I am not getting one of these FDA-cleared recipes? Does that mean I am getting the wrong treatment?
Not necessarily. A number of different devices, protocols and frequencies, and targets in the brain are actively being researched. Just because you aren’t receiving one of the FDA-cleared TMS recipes above doesn’t mean that the treatment you’re receiving is wrong or won’t work. Additionally, other TMS “recipes” with ingredients like surface TMS, cTBS, and iTBS are used to treat OCD “off-label.” This means that there is scientific evidence that these techniques might work in treating OCD, but government agencies like the FDA have not yet officially acknowledged them as effective treatments.
Dr. Oscar Morales, Medical Director of the TMS service at McLean Hospital, demonstrates how a deep TMS coil is positioned on the head during OCD treatment.
What’s it like to receive TMS therapy?
TMS is intended to be an add-on therapy that patients receive alongside other OCD treatments like medication or ERP.
TMS treatment is typically provided in an office setting on an outpatient basis. Treatment sessions are completed five days a week over the course of four to six weeks. The first part of each treatment session involves a short, personalized “provocation” where the patient’s OCD symptoms are intentionally triggered. Provoking OCD symptoms engages the circuit that will be targeted during the treatment. Following provocation, the actual dTMS treatment time is approximately 18 minutes. During each treatment, the patient will sit in a chair, wear ear plugs, and have the TMS device (sometimes placed inside a cushioned helmet) placed against the top of their head. [7] The patient is awake during the treatment. The machine will turn on, and during the treatment the patient can hear loud clicking sounds and feel a “tapping” sensation on their scalp.
Some patients have reported feeling some mild discomfort during and shortly after the treatment, including scalp pain. Once the treatment is completed, the patient is free to continue with their daily activities. [8]
Will TMS work for me?
Research evaluating how well deep TMS works for treating OCD has found that about 45% of patients have reduced OCD symptoms at one month following treatment. [9] Research conducted by BrainsWay, the manufacturer of one of the devices used in the FDA-cleared OCD treatment, found that this number could be over 55%. [10]
Some patients will need to return for “maintenance” treatment after a period of time. This may mean returning for single sessions every one to two weeks.
What are the side effects?
Reported side effects of TMS [11] include:
- Headache
- Scalp discomfort
- Tingling, spasms, or twitching of facial muscles
- Lightheadedness
Rare side effects:
- Seizures
- Hypomania or mania (mostly seen in patients who have bipolar disorder)
Who should not receive TMS?
It is not safe for some people to receive TMS because the magnetic field generated during the procedure may interact with metal devices or implants in their body, or metal left over from injuries. Examples include:
- Aneurysm clips or coils
- Stents in neck or brain
- Metal implants in ears or eyes
- Bullet fragments near the head
- Facial tattoos that have magnetic ink
- Implanted stimulators, like those used in deep brain stimulation (DBS)
Always check with your doctor and disclose if you have any of these, or any other metal objects, in your head or other parts of your body.
People with co-occurring mental health disorders like depression should be sure to disclose their symptoms and discuss them with their doctor before beginning TMS treatment.
How much does TMS cost?
TMS therapy costs will be different for each patient depending on how severe their OCD symptoms are and their health insurance coverage. Treatment costs can vary based on location, and it is best that you contact your insurance carrier for more specific details. Insurance companies may require you to obtain prior authorization before beginning TMS treatment for OCD, try at least one other type of OCD treatment before TMS, or that you pay at least some portion of the treatment costs. Some may not cover TMS at all. For those paying entirely out of pocket, treatment costs may total at least $15,000.
Where can I find a TMS provider?
The manufacturers of the two FDA-cleared deep TMS devices operate provider directories. You can access them here:
What other treatments are available?
Medication and ERP are the first-line treatments for OCD, and we recommend that anyone interested in OCD treatment for the first time should seek out these options before trying alternatives like TMS. If you’re on medication already, options include altering your dosage, or adding an antipsychotic medication on top of your current medication. You may wish to discuss these options with your psychiatrist before exploring TMS.
For those who have tried medication and ERP and haven’t experienced a benefit, there are a few other treatment options besides TMS. These include:
- Deep brain stimulation (DBS) — DBS is approved by the FDA for treating OCD under a Humanitarian Device Exemption
- Transcranial Direct Current Stimulation (tDCS) — experimental
- Gamma knife — experimental
- Ablative neurosurgery — experimental
These options have been used with varying degrees of success in people with treatment-resistant OCD. TMS is more readily available in the United States than many of the options listed above.
Sources:
- [1] Lusicic, A., Schruers K.R.J., Pallanti, S., & Castle D.J. Transcranial magnetic stimulation in the treatment of obsessive–compulsive disorder: current perspectives. Neuropsychiatr Dis Treat. 2018;14:1721-1736
https://doi.org/10.2147/NDT.S121140 ↩ - [2] Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D.M., Daskalakis, J., Ward, H., Lapidus, K., Goodman, W., Casuto, L., Feifel, D., Barnea-Ygael, N., Roth, Y., Zangen, A., & Zohar, J. Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial. Am J Psychiatry. 2019 Nov 1;176(11):931-938. doi: 10.1176/appi.ajp.2019.18101180. Epub 2019 May 21. PMID: 31109199. ↩
- [3] https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder ↩
- [4] Press Release MagVenture receives FDA clearance for OCD. (2020). Retrieved October 16, 2020, from https://www.magventure.com/images/PDF/NEWS/510-1101_Press_release_OCD_rev_10.pdf ↩
- [5] https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K221129 ↩
- [6] Neuro-MS/D (CloudTMS) is cleared by FDA for OCD treatment! (2023). Retrieved July 26, 2023, from https://neurosoft.com/en/news/neuro-ms-d--cloudtms--is-cleared-by-fda-for-ocd-treatment ↩
- [7] Transcranial magnetic stimulation. (2018, November 27). Retrieved October 16, 2020, from https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625 ↩
- [8] Galletta, E. E., Rao, P. R., & Barrett, A. M. (2011). Transcranial magnetic stimulation (TMS): potential progress for language improvement in aphasia. Topics in stroke rehabilitation, 18(2), 87–91. https://doi.org/10.1310/tsr1802-87 ↩
- [9] Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D.M., Daskalakis, J., Ward, H., Lapidus, K., Goodman, W., Casuto, L., Feifel, D., Barnea-Ygael, N., Roth, Y., Zangen, A., & Zohar, J. Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial. Am J Psychiatry. 2019 Nov 1;176(11):931-938. doi: 10.1176/appi.ajp.2019.18101180. Epub 2019 May 21. PMID: 31109199. ↩
- [10] Roth, Y., Tendler, A., Arikan, M.K., Vidrine, R., Kent, D., Muir, O., MacMillan, C., Casuto, L., Grammer, G., Sauve, W., Tolin, K., Harvey, S., Borst, M., Rifkin,R., Sheth, M., Cornejo, B., Rodriguez, R., Shakir, S., Porter, T., Kim, D., Peterson, B., Swofford, J., Roe, B., Sinclair, R., Harmelech, T., & Zangen, A. Real-world efficacy of deep TMS for obsessive-compulsive disorder: post-marketing data collected from twenty-two clinical sites. Journal of Psychiatric Research (2020). ISSN 0022-3956. https://doi.org/10.1016/j.jpsychires.2020.11.009. ↩
- [11] Mishra, B.R., Sarkar, S., Praharaj, S. K., Mehta, V. S., Diwedi, S., & Nizamie, S. H. (2011). Repetitive transcranial magnetic stimulation in psychiatry. Annals of Indian Academy of Neurology, 14(4), 245–251. https://doi.org/10.4103/0972-2327.91935 ↩