Deep TMS Transformation

Muhamad Aly Rifai, MD

Welcome back to The Virtual Psychiatrist. I’m Dr. Muhamad Aly Rifai, and today, we’re diving into the fascinating journey from the earliest days of electricity in medicine to the cutting edge of Deep Transcranial Magnetic Stimulation, or dTMS. And joining me is my co-host, our TMS expert Shlomo Sirour. How are you doing?

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I’m good, thank you, Dr. Rifai. You know, it’s wild to think that what we do today with TMS actually traces back to the experiments of Volta and Galvani in the 18th century. They were shocking frog legs and, well, themselves, trying to figure out how electricity could affect living tissue. It’s a long way from frog legs to brain stimulation, right?

Muhamad Aly Rifai, MD

Absolutely. And then you had Aldini, who, I think, actually tried his voltaic pile on himself before using it on patients. He described this jolt in his head and insomnia for days. Not exactly the most comfortable experience, but it set the stage for using electricity in medicine. Fast forward to the 20th century, and we get ECT—electroconvulsive therapy—which, for all its effectiveness, has always carried a lot of stigma. I mean, movies like “One Flew Over the Cuckoo’s Nest” didn’t help.

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No, not at all. ECT is still a valuable tool, but the idea of inducing a seizure in the whole brain, with anesthesia and all the side effects, made people wary. What really changed things was when researchers realized you could target specific brain regions. That’s where Anthony Barker comes in, right? In 1985, he developed the first TMS device and showed you could noninvasively stimulate the motor cortex with magnetic fields.

Muhamad Aly Rifai, MD

Exactly. And the real breakthrough for psychiatry was when we moved from global brain stimulation to functional targeting. The left dorsolateral prefrontal cortex became the focus for depression, based on imaging studies showing its role in mood regulation. That shift—from treating the whole brain to targeting a specific circuit—was huge. It’s what made TMS, and later dTMS, a real contender in mental health treatment.

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And it’s interesting, because as we discussed in earlier episodes, psychiatry has always evolved with technology. But this was the first time we could modulate brain activity without surgery or medication, and with much less stigma than ECT. It’s a real paradigm shift.

Muhamad Aly Rifai, MD

So, let’s talk about what makes Deep TMS different. The big technical leap was the H-Coil, developed by BrainsWay. Unlike the traditional figure-8 coil, which only reaches about 0.7 centimeters below the skull, the H-Coil can go much deeper—up to 3 centimeters, depending on the model. That means we can stimulate broader and deeper brain regions, which is especially important for conditions like depression, OCD, and smoking addiction.

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Right, and the way it works is actually pretty elegant. The coil generates a pulsed magnetic field, which passes through the scalp and skull without resistance. That field induces an electric current in the targeted brain area, causing neurons to depolarize. Over repeated sessions, this promotes neuroplasticity—basically, it helps the brain rewire itself and normalize dysfunctional networks. It’s like physical therapy for the brain, but with magnets.

Muhamad Aly Rifai, MD

That’s a good analogy. And, you know, a lot of patients worry about safety. But the data are really reassuring. The most common side effect is a mild headache, usually in the first few sessions, and it’s easily managed with Tylenol or Motrin. The risk of seizure is extremely low—less than 1 in 10,000 sessions. And unlike ECT, there’s no anesthesia, no memory loss, and no systemic side effects. I spend a lot of time debunking myths about TMS. It’s noninvasive, safe, and well-tolerated.

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I get the same questions. People hear “brain stimulation” and think it’s scary, but it’s really just a series of magnetic pulses. And the helmet design of the H-Coil makes it comfortable and reliable. It’s a big step forward in making neuromodulation accessible and acceptable.

Muhamad Aly Rifai, MD

Let’s get into what dTMS is actually approved to treat. The FDA has cleared it for major depressive disorder, including late-life depression, anxious depression, OCD, and even smoking addiction. That’s a pretty broad range, and it’s expanding as more research comes in.

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And the protocols are evolving, too. For depression, a typical course is 36 sessions—five days a week for four to six weeks, sometimes with maintenance sessions after. But what’s really exciting is the rise of accelerated protocols. These condense weeks of treatment into just five days, with multiple sessions per day. Clinical trials have shown remission rates as high as 79% with these accelerated approaches, which is honestly remarkable compared to traditional medication trials.

Muhamad Aly Rifai, MD

Yeah, and for OCD, the H7 coil targets the medial prefrontal cortex and anterior cingulate, with a protocol that includes symptom provocation before each session. For smoking addiction, the H4 coil targets the insula and prefrontal cortex, and the protocol involves a brief craving provocation before each session. The outcomes are impressive—over a third of OCD patients respond, and about 28% of highly addicted smokers achieve four weeks of abstinence, which is better than most medications or behavioral therapies alone.

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And for late-life depression, dTMS is the first and only TMS device cleared for patients up to age 86. That’s a population that’s often left out of clinical trials, so it’s a big deal to have a safe, effective option for them.

Muhamad Aly Rifai, MD

You know, the science is great, but what really sticks with me are the patient stories. I’ll never forget Sarah—a 45-year-old teacher with severe, treatment-resistant depression. She’d tried everything: multiple antidepressants, therapy, nothing worked. She was desperate. We started her on accelerated dTMS, and after just one week, she told me, “I feel alive again.” It was like watching someone come back to life.

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That’s so powerful. I’ve seen similar cases. There was Mark, a lawyer who’d lost hope after years of failed medications. With dTMS, he started feeling better within days. And for older adults, the turnaround can be just as dramatic. I remember an elderly patient who’d been depressed for years—after dTMS, he was smiling, reconnecting with family, just living again.

Muhamad Aly Rifai, MD

And it’s not just depression. For OCD, I’ve seen patients who were stuck in endless rituals finally get relief. And with smoking cessation, people who’d tried everything else were able to quit. The statistics are impressive, but seeing those changes in real people—that’s what keeps me passionate about this work.

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It’s true. The numbers—like 38% response rates for OCD, or 28% abstinence for smokers—are important, but every one of those is a person whose life has changed. That’s why we do this.

Muhamad Aly Rifai, MD

Let’s shift gears to the practical side. Before starting dTMS, we do a thorough evaluation—medical, psychiatric, and screening for any implants or contraindications. Safety is always the top priority. We check for things like a history of seizures, metal in the head or neck, and certain medications that might lower the seizure threshold.

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And once patients are cleared, we walk them through what to expect. Sessions are usually about 20 minutes, and we monitor them throughout. We use symptom rating scales—like the PHQ-9 for depression or Y-BOCS for OCD—to track progress. Informed consent is a must, and we talk about side effects, even though they’re usually mild.

Muhamad Aly Rifai, MD

Insurance coverage is another big piece. Most commercial insurers and Medicare cover dTMS for depression, and coverage for OCD and smoking cessation is growing. But it’s not always straightforward—sometimes you need prior authorization, and maintenance sessions aren’t always covered. Billing uses specific codes: 90867 for the initial session, 90868 for subsequent sessions, and 90869 if you need to re-determine the motor threshold. And setting up a TMS clinic requires space, trained staff, and the right equipment. It’s a commitment, but the impact is worth it.

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Yeah, and for anyone thinking about starting a TMS practice, it’s important to have protocols in place for emergencies, like the rare chance of a seizure. But overall, it’s a safe, patient-friendly procedure that can be integrated into many outpatient settings.

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The science of targeting is moving fast. Traditionally, we used scalp-based methods, like the 5-cm rule or the Beam F3 method, to find the left DLPFC. But now, there’s a push toward MRI-based and even fMRI-guided targeting, which can personalize treatment based on each person’s brain connectivity. It’s a big step toward precision psychiatry.

Muhamad Aly Rifai, MD

And the acceleration protocols are a game changer. Stanford’s accelerated theta-burst protocol, for example, delivers multiple sessions per day and has shown remission rates up to 79% in treatment-resistant depression. That’s compressing weeks of therapy into just five days. It’s not just about speed—it’s about giving people their lives back faster.

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For OCD, network-based targeting is showing promise, too. Devices are being developed to stimulate specific circuits involved in compulsive behaviors. And as the technology advances, we’re seeing more individualized approaches—using imaging and even machine learning to optimize where and how we stimulate.

Muhamad Aly Rifai, MD

It’s exciting to see how quickly the field is moving. Every year, we get closer to truly personalized brain stimulation.

Muhamad Aly Rifai, MD

So, where does dTMS fit in the bigger picture? I really believe we’re in the middle of a neuromodulation revolution. Just like the psychopharmacology boom in the 20th century, neuromodulation is becoming a core part of psychiatric care—alongside medication and therapy. But there are still barriers: access, stigma, and insurance hurdles. We need to keep pushing for integration into mainstream care.

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I agree. And, you know, for me, working on TMS in Israel during difficult times has been a way to bring hope—not just to my patients, but to myself. Mental health challenges are everywhere, and the more tools we have, the better. I started in this field because I wanted to make a difference, and TMS has given me a way to do that, even when the world feels uncertain.

Muhamad Aly Rifai, MD

That’s beautifully said. It’s about hope, resilience, and giving people options when they feel out of them. We have to keep advocating—for our patients, for better coverage, and for reducing stigma. The more we talk about these treatments, the more accepted they’ll become.

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Looking ahead, the technology is only getting better. New coil designs and stimulation algorithms are being developed to make treatments more effective and even shorter. There’s a lot of excitement around integrating artificial intelligence and machine learning—using individual brain imaging data to personalize targeting and dosing for each patient.

Muhamad Aly Rifai, MD

And ongoing clinical trials are expanding the indications for dTMS—beyond depression, OCD, and smoking, we’re seeing research into PTSD, schizophrenia, cognitive impairment, and more. The protocols are being optimized for different conditions, and the hope is that we’ll be able to offer rapid, effective treatment for a much wider range of neuropsychiatric disorders.

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It’s an exciting time to be in this field. The pace of innovation is incredible, and I think we’re just scratching the surface of what’s possible with neuromodulation.

Muhamad Aly Rifai, MD

Absolutely. And that’s a good place to wrap up for today. Thanks for joining us on The Virtual Psychiatrist. We’ll be back soon with more stories and science from the front lines of mental health. Take care, and thank you, my friend, for sharing your insights.

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Thank you, Dr. Rifai. Always a pleasure. Goodbye, everyone—stay hopeful, and we’ll talk to you next time.