Transcranial Magnetic Stimulation (TMS) Treatment Considerations

Introduction

TMS is a noninvasive and low risk neuromodulation treatment for a variety of psychiatric and non-psychiatric disorders. TMS induces its therapeutic effects through alternation of magnetic fields passing through the skull, causing depolarization of neurons. This is accomplished by passing current through a metal coil placed against the scalp.³ While the scientific basis behind the functions of a TMS device dates to Faraday’s Law, TMS as a potential treatment modality began in the mid-1980s with Anthony Barker and colleagues creating the first device.¹⁴ TMS rapidly became used as a mapping tool and a treatment for neurological disorders; it was then studied in the field of psychiatry. Further research led to the development of TMS (trams), a technique which produces multiple rapid alterations in magnetic fields. This rapid alteration leads to neuronal depolarization, which alters multiple neurotransmitters implicated in mental health disorders and activates neuronal pathways.^14,12 As steady progress was made, the Food and Drug Administration approved TMS for use in Major Depressive Disorder (MDD) in 2008, followed by OCD, smoking cessation, and anxious depression.^34,4 in patients ages 15 years and older.⁴

Since the inception of Transcranial Magnetic Stimulation (TMS) as a treatment for psychiatric disorders, PMH nurses have provided individualized care to patients receiving TMS. Their roles continue to develop and expand. Advanced Practice Nurses currently order and administer TMS, as well as directly manage related care.^5,28,10,20 In addition to advancing evidence-based treatment in TMS, PMH nurses are vital patient advocates, assuring that patients receive accurate information about TMS, and are involved in research efforts related to TMS and its uses.

Created by the APNA Neuromodulation Task Force and approved by the APNA Board of Directors December, 2025.

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Transcranial Magnetic Stimulation (TMS) Treatment Considerations Checklist

This checklist provides considerations for caring for patients receiving TMS for psychiatric treatment and is not intended to be all inclusive.

State Scope of Practice

Assessment for the need and ordering of TMS may be done by MDs, DOs, PMHNPs, PMHCNSs and PAs who have been specifically trained and credentialed to do so.¹⁸ Credentialed providers also determine TMS settings and parameters. TMS treatments according to specified TMS parameters may be administered by PMH-RNs and/or trained TMS technicians who have received specialized training on TMS and the TMS machine being utilized. TMS technicians are supervised by PMH-RNs.

• Review applicable state nursing, medical, drug and facility statutes and regulations to identify any existing and anticipated practice barriers.
• Verify whether the state board of nursing or other relevant board has issued a related opinion applicable to RNs and/or PMH APRNs.
• If in doubt consult the Scope of Nursing Practice Decision-Making Framework. ²³

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Treatment Recommendations

TMS is recommended for patients with treatment-resistant mental illnesses including, but not limited to, depression, depression with anxiety, and OCD. TMS has also been FDA-cleared for smoking cessation. Research also continues to evaluate the use of TMS for other mental health disorders. To date, these treatments are considered experimental.

• In general, TMS is used as an adjunct treatment for treatment resistant depression (without psychosis) with/without anxiety and treatment-resistant obsessive compulsive disorder (OCD).
• TMS treatments may be used to treat individuals 15 years old and older.⁴

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Considerations for Candidate Eligibility

Contraindications include:^4,19,16

• Absolute:
  • Metal in head/neck (within 30 cm of coil)
  • Cochlear implant
• Caution:
  • Implantable medical devices (pacemaker, defibrillator, VNS, etc.)
  • Seizure history
  • Retinal detachment

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Medical Considerations for TMS Treatment

(May require further evaluation by specialist and/or diagnostic testing.)

• Related to TMS anticipated effects:
  • Medical clearance: Usually done by TMS provider (review contraindications)
  • Specialty medical clearance (e.g., neurological, ophthalmic, cardiac) as necessary based on history.
  • Pre-procedure labs and EKG not needed.
• Outreach to Primary Psychiatric Provider in community

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Financial Considerations

• Individual should verify insurance coverage (e.g., public and private)
  • TMS for treatment resistant depression is covered by most private and public insurers
  • TMS for OCD is covered by some private and public insurers
  • Preauthorization is often required
• Private pay options may be available

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Clinic Location and Equipment

• Generally, patients drive themselves to/from appointments
• Waiting Room for patients to complete self-assessments prior to treatment.
  • Should be comfortable, private, easily accessible and near an appropriate restroom.
• Treatment room/private area with monitoring
• Required equipment:
  • TMS machine (FDA-approved device)
  • Emergency equipment readily available
    • Oxygen
    • Suction
  • Other supplies (i.e., pillows for positioning, comfortable chair or recliner often comes with machine; ear plugs)³⁵

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Documentation

• Electronic or paper record
• Procedure-specific forms, including information about pre-treatment assessments, treatment parameters used, tolerance to procedure, any reported side effects, and response to treatment. A checklist may be utilized to document pre-treatment medical clearance (if indicated by medical risk factors determined at consultation) safety screening, as well as pre-treatment nursing assessment and for treatment parameters. A nursing progress note may document assessment findings and response to treatment.
• Self-assessment tools (i.e., PHQ9, QIDs, GAD7, YBOCS etc.)^30,11,29,17
• Clinician-administered tools (HAM-D, MADRS, SLUMS, MMSE, etc.)³²
• Columbia Suicide Severity Rating Scale (C-SSRS)²⁴

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Managing Treatment Expectations¹

Pretreatment education (nursing review of what to expect)

• Efficacy – highly effective.
  • 50-70% of pts with MDD & 38-45% of pts with OCD experience a significant response⁴
• The average TMS treatment lasts between 5-40 minutes depending on the treatment parameters.⁵
• TMS does not require post-treatment monitoring and is an overall expedited procedure.⁶
• TMS has a favorable safety profile; monitoring during treatment by nursing staff leads to early identification of side effects and management of adverse events.
  • The most serious adverse event is a generalized tonic-clonic seizure; however, seizures are rare, occurring in less than 1% of cases, and remain rare even for patients with preexisting conditions such as epilepsy⁷. Close monitoring during treatment helps identify risk for seizure. Protocols should be in place for managing seizures should they occur.
  • Other potential risks include scalp pain or burning, headache, vasovagal syncope.
  • Hearing damage is a risk caused by the noise of the TMS device itself but is readily prevented through noise protection devices such as foam earplugs⁸.
• Potential need for taper/maintenance/rescue treatments⁹
• Safety precautions (suicidal ideation evaluated)
  • Review safety plans as applicable ¹⁰
• Medication changes may require rechecking motor threshold or holding treatment¹¹
• Alcohol/drug use: Recent use needs further evaluation by provider before proceeding with treatment ¹²
• Sleep will be evaluated as may change seizure threshold (in general a significant decrease in amount of sleep may require holding the treatment)¹³

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Day of Treatment/Pre-Treatment Nursing Assessment³⁵

• Medical issues since last treatment
• Medication review/reconciliation
  • Include:
    • Any medication changes (in general patients instructed to keep medication regimen stable during TMS treatment)
    • If medication changes occur, patient may need recheck of motor threshold
• Sleep assessment
• Recent drug/alcohol use
• Psych assessment at each treatment (include SI/Safety)
• Date of TMS consent (need for re-consent)
• Remove metal near coil (jewelry, hair clips)
• Identification of devices (VNS, DBS, pacemaker: evaluate need to be monitored and/or powered off during procedure)
• Insert ear plugs (patient and technician)
• Consider CBT/goal-setting plans as adjunct to TMS treatment ³⁸

*NOTE: Medication changes, acute decrease in number of hours of sleep, recent drug/alcohol use should be reviewed with treatment team prior to procedure.

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TMS Administration

• Treatment Room Time Out (for example, assure right patient, right treatment)
• Treatment Team:
  • Fully licensed/competent/credentialed by institution TMS Provider (MD, DO, APRN) for first treatment to set motor threshold and readily available for subsequent treatments
  • RN (patient assessment and review of order and/or treatment parameters for treatment, patient education and patient follow up as needed)
  • TMS Tech/MHS (working under supervision of RN)
  • Administrative Support
• Review nursing assessment and TMS Order (or therapy plan) to adjust plan of care accordingly
• Treatment Course
  • Acute course^9,19,15
    • Standard treatment protocol is usually five times per week for 4-6 weeks with taper to reduce risk of relapse (Usual course is 36 treatments as approved by insurance).¹⁵
    • Accelerated TMS (multiple treatments per day with varying protocols)²³
  • Maintenance TMS (usually not covered by insurance)³⁶
  • Rescue TMS (restarting TMS when symptoms recur)³⁶
  • Various brain targets are used and may include the following: ^4,19
    • MDD:
      • Left dorsolateral prefrontal cortex
      • Medial prefrontal cortex (mPFC)
      • Anterior cingulate cortex (ACC)
      • Limbic areas including hippocampus and amygdala
    • OCD:
      • Left dorsolateral prefrontal cortex
      • Orbitofrontal cortex (OFA)
      • Anterior cingulate cortex (ACC)
      • Dorsomedial prefrontal cortex (dmPFC)
      • Pre-supplementary motor area (pre-SMA)
      • Basal ganglia
      • Bilateral and right dorsolateral prefrontal cortex (dlPFC)
• Types of treatment
  • High frequency protocols (includes theta burst, dTMS protocols)
  • Low frequency protocols (includes cTBS, 1 Hz)
  • Motor threshold determination (determines treatment location and required energy/intensity of pulses)⁹
    • Motor threshold determination (determines treatment location and required energy/intensity of pulses)⁹
      • Determined at first treatment
      • Motor cortex
        • Thumb/toe movement (replicated 3-5 times)
        • Treatment power based on power needed to stimulate motor cortex.
  • Determination of target for treatment
    • Anatomical target
      • F3 method, 5 cm rule, 5.5 cm rule, 25% nasion to inion, cap grid.
    • Neuronavigation guided by MRI
    • Neuronavigation using anatomical landmarks and camera-capture systems
  • Number of pulses per treatment may vary
  • Intra-treatment considerations/monitoring⁹
    • Constant observation
      • Muscle movement in hand/foot
      • Grimacing
      • Loss of contact with coil
    • Mouthguard
    • Other equipment – (i.e., stress ball, fidget/popper, focal pictures)
    • Seizure prevention
    • Seizure management
      • Have emergency protocols in place
      • Suction/oxygen readily available

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Post-TMS Care Considerations³⁵

• Because there are no systemic effects, recovery time is not necessary once the treatment has concluded
• Assess side effects
  • Scalp tenderness
  • Headache
  • Jaw pain
  • Serious – retinal detachment(rare); seizures (rare)
• Consider pretreatment analgesia (consider preventative acetaminophen, ibuprofen, topical anesthetic)
• Consider use of mouthguard
• Assess response to treatment and need for provider evaluation for ongoing treatment planning
• Discharge instructions (including date/time of next appt)
• Use of call line for patient follow up/protocol for no show management

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Group Programming³⁷

• Support groups held in person or virtually
  • Provide education, encouragement and forum for support
  • Help to reduce stigma
  • Persons with lived experience provide context for living before/after/during TMS

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References

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