A standard Deep TMS course for depression is 36 sessions: five days a week for six weeks, then a three-week taper. The OCD protocol is 29 sessions over six weeks. Daily sessions are what the trials tested and insurers cover. Missing a day or two does not reset progress. Accelerated protocols exist but are not yet standard.
The question underneath the number is usually a different one: do you really have to come every day, what happens if you miss a session, can it be done faster, and how will you know whether it is working before all 36 are done. This page answers each of those.
Who it is for
Anyone planning a TMS course needs the session count to plan work, childcare and transportation for about nine weeks. It matters most to patients who commute from outside the immediate area, to people with jobs that cannot easily absorb a daily hour-long absence, and to residents of assisted living or skilled nursing facilities whose transportation is arranged by others. It also matters to patients with OCD, whose course is shorter but more intensive per session, and to patients who have had TMS before and are considering a repeat course, which is typically the same 36 sessions. If you are weighing an accelerated protocol you have read about, this page explains where those protocols stand today and why the standard schedule remains the one we recommend.
How it works
TMS works by cumulative change, not by a single dose. Each session delivers thousands of magnetic pulses to the prefrontal cortex, which produces a short-lived increase in excitability in that circuit, on the order of hours. Repeating the stimulation the next day, before the previous day's effect has fully faded, builds on it. Over weeks, that repeated activation produces lasting change in synaptic strength, a process similar to long-term potentiation, which is the same mechanism the brain uses to learn. This is why the dose is counted in sessions and days rather than in pulses alone. Thirty daily sessions is the amount of repetition that the trials showed was enough for most responders to reach a stable improvement, and the taper phase, where sessions are spaced further apart, lets the brain consolidate the change rather than stopping abruptly.
The Deep TMS depression pivotal trial delivered 20 daily sessions over four weeks followed by twice-weekly sessions for 12 weeks; the benefit over sham was established at week five and maintained at week 16.
Source: Levkovitz et al., World Psychiatry, 2015
The Deep TMS OCD pivotal trial delivered 29 sessions over six weeks and found a response rate of 38.1 percent with active treatment versus 11.1 percent with sham.
Source: Carmi et al., American Journal of Psychiatry, 2019
In a randomized trial of 414 patients, a three-minute theta burst session was non-inferior to the standard 37.5-minute 10 Hz session over 30 treatments, with similar remission rates of about 32 percent versus 27 percent.
Source: Blumberger et al., Lancet, 2018 (THREE-D trial)
In a sham-controlled trial of the Stanford accelerated protocol, 10 sessions per day for five days produced remission in 78.6 percent of active patients versus 13.3 percent with sham, in a sample of 29 patients.
Source: Cole et al., American Journal of Psychiatry, 2022
What to expect
At Stedfast Psychiatry, your TMS evaluation happens at any of our 13 offices or by video. Treatment sessions take place at our TMS treatment centers, with Palm Beach Gardens as the primary center. The first treatment visit takes about an hour because it includes motor threshold mapping, where we find the intensity that makes your thumb twitch and set your dose from it. Each visit after that is about 20 minutes in the chair and about 30 minutes door to door. You will be scheduled at the same time each weekday. We give you a PHQ-9 every week and review it with you. Most responders notice something shifting between sessions 10 and 20, often sleep or energy first, and mood later. If nothing has moved by session 20, your psychiatrist will discuss the odds and options openly.
Benefits
- A fixed, predictable schedule: 36 sessions, about nine weeks, same time every weekday
- Each session is about 20 minutes with no recovery time, so most patients work the same day
- Weekly PHQ-9 tracking means you see progress, or its absence, in real time
- The taper phase reduces relapse compared with stopping abruptly after six weeks
- Repeat courses for prior responders use the same proven schedule and are covered by most insurers
Risks and side effects
The main risk tied to session count is incomplete treatment. Patients who stop early, usually because of scheduling or early discomfort, lose most of the benefit, since the largest gains come in weeks three through six. Missing a single day is harmless. Missing several days in a row during the first four weeks weakens the cumulative effect and may mean adding sessions at the end. Compressing sessions, for example doing two in a day to catch up, is done only on a psychiatrist's instruction and within the device's labeled parameters. Side effects do not accumulate with session count; scalp discomfort and headache are worst in week one and fade thereafter.
Cost and insurance
Medicare in Florida and South Carolina covers an acute course of up to 30 daily sessions plus a taper, which matches the 36-session Deep TMS protocol, and allows retreatment for patients who responded to a prior course. Commercial insurers authorize a similar count, typically 30 to 36 sessions, after prior authorization, and some require a progress note with PHQ-9 scores at the midpoint before releasing the second half. Additional sessions beyond the authorized count require a documented clinical reason. OCD courses of 29 sessions are covered by Medicare and a growing number of commercial plans. Our TMS coordinator confirms the authorized session count before you begin so that there is no surprise bill partway through.
The standard schedules
| Indication | Sessions | Schedule | Session length |
|---|---|---|---|
| Depression and anxious depression | 36 | 5 per week for 6 weeks, then 2 per week for 3 weeks | About 20 minutes |
| OCD | 29 | 5 per week for 5 weeks, 4 in week 6, with symptom provocation | About 20 minutes |
| Smoking cessation | 18 | 5 per week for 3 weeks, then 1 per week for 3 weeks | About 20 minutes |
| Repeat course after relapse | Usually 36 | Same as the original course | About 20 minutes |
Where the number 36 comes from
The first large sham-controlled TMS trial, in 2007, treated patients five days a week for up to six weeks. The NIMH-funded trial in 2010 used three weeks with an extension to six for patients who were improving. The Deep TMS pivotal trial in 2015 used four weeks of daily sessions followed by 12 weeks of twice-weekly continuation. Across all of them, the picture was the same: response rates rose steadily through week four and continued to rise through week six, then leveled off.
The six-session taper came later, from clinical experience and durability studies that found patients who stopped abruptly after daily treatment relapsed sooner than patients who stepped down. Thirty daily sessions plus six taper sessions is the schedule that Medicare's coverage determinations describe and that most commercial payers authorize, which is why nearly every TMS program in the country uses it.
Why daily, not weekly
A single TMS session changes cortical excitability for a few hours. If the next session arrives the following day, it builds on a brain that is still partly in the altered state, and the effect accumulates. If the next session arrives a week later, the brain has returned to baseline and the accumulation does not happen. This is the same reason physical therapy is prescribed daily rather than monthly: the mechanism is repetition-driven plasticity, and repetition has to be close enough together to compound.
The taper phase exploits the same principle in reverse. Once the circuit has changed, spacing sessions further apart lets the new state consolidate while the external drive is withdrawn gradually, rather than removing it all at once.
What happens when you miss sessions
- One day: no measurable effect. Nearly every patient misses at least one day over nine weeks.
- Two or three consecutive days: a small setback. We add the missed sessions to the end of the acute phase.
- A week during the acute phase: a meaningful setback, especially in weeks one through four. Your psychiatrist may extend the acute phase by a week.
- Stopping before session 20: most of the benefit is lost, because the largest gains come in weeks three through six.
- Missing taper sessions: less critical than missing acute sessions, but associated with earlier relapse.
The practical rule: protect the first four weeks. Schedule vacations, surgeries and travel either before the course starts or after the taper ends.
How we track whether it is working
You will complete a PHQ-9 every week. We look for a drop of five or more points by week four as an early signal. Sleep, energy and concentration often improve before mood does, and family members sometimes notice before the patient. Response, defined as a 50 percent drop in score, typically shows up between sessions 15 and 30. About one in five eventual responders shows little change until the final two weeks, which is why we complete the course for patients who are tolerating it well even when early scores are flat. If there is no change at all by session 20, your psychiatrist reviews the options: completing the course, adjusting medication alongside it, or switching to Spravato.
Accelerated and theta burst protocols
Theta burst
Intermittent theta burst stimulation, or iTBS, delivers pulses in a pattern that mimics natural hippocampal rhythms and compresses a session into about three minutes. In the THREE-D trial of 414 patients, it was non-inferior to the standard 37.5-minute session over 30 treatments. It shortens the session, not the course: patients still come five days a week for six weeks. It was FDA-cleared in 2018.
The Stanford accelerated protocol
The Stanford Neuromodulation Therapy protocol, often called SAINT or SNT, delivers 10 theta burst sessions per day, spaced 50 minutes apart, for five consecutive days, with the target chosen by functional MRI for each patient. An open-label study of 21 patients reported remission in about 90 percent, and a sham-controlled trial of 29 patients reported remission in 78.6 percent versus 13.3 percent with sham. The FDA cleared the protocol in 2022.
These results are striking and the research is legitimate. They are also small studies, the protocol requires an MRI and specialized targeting equipment, insurers have been slow to cover it, and durability beyond a few months is still being studied. Stedfast Psychiatry's TMS program uses the standard Deep TMS schedule, which is what our insurers authorize and what the largest body of evidence supports. If accelerated protocols become standard of care and covered, we will say so plainly.
Planning your nine weeks
Pick a time slot you can keep every weekday, ideally one tied to an existing routine such as before work or after dropping children at school. Clear the first four weeks of travel. Arrange a backup ride for days your usual transportation falls through. Tell your employer you have a recurring medical appointment; you do not need to say what it is. Keep your medication and therapy schedule steady so that the PHQ-9 trend reflects TMS rather than other changes. Expect the first week to be the hardest, both for scalp discomfort and for the adjustment to the routine, and expect it to get easier.
Stedfast Psychiatry's TMS program starts with an evaluation at any of our 13 offices or by video, where we confirm candidacy and map out your schedule. Treatment sessions take place at our TMS treatment centers, with Palm Beach Gardens, 11641 Kew Gardens Ave, Suite 209, as the primary center. Call (561) 437-2199 to schedule a TMS evaluation.
Frequently asked questions
Why 36 sessions and not 20 or 50?
Because that is roughly what the trials tested and what the data support. The early sham-controlled trials ran four to six weeks of daily sessions, and patients who responded mostly did so by week six. The six-session taper was added because stopping abruptly after daily treatment was associated with earlier relapse. Fewer than 20 sessions leaves a meaningful share of eventual responders untreated, and beyond 36 the additional benefit is small for most patients. Insurers authorize the count that matches this evidence.
Do I really have to come every day?
Five days a week, yes, during the six-week acute phase. Each session produces a short-lived change in cortical excitability, and the next session needs to build on it before it fades. Spreading sessions to two or three a week during the acute phase was not how the treatment was tested and appears to weaken the effect. Weekends off are fine and built into every protocol. During the three-week taper, sessions drop to two per week on purpose.
What happens if I miss a session?
One missed day is not a problem; it happens to nearly everyone over nine weeks. Two or three consecutive missed days during the acute phase is a setback but not a restart; we add the missed sessions to the end of the course. A gap of a week or more in the first month can meaningfully reduce the benefit, and your psychiatrist may recommend extending the acute phase. Tell us as soon as you know about a conflict so we can reschedule rather than skip.
How soon will I know if it is working?
Most responders notice early changes between sessions 10 and 20: sleeping better, more energy, finding things slightly less effortful. Mood itself often lags those changes. We score the PHQ-9 weekly, and a drop of five points or more by week four is a good sign. A few patients, roughly one in five eventual responders, show little change until the last two weeks, which is why we rarely stop a course early. If your score has not moved by session 20, we have an honest conversation about odds.
Can TMS be done faster?
Research protocols can. The Stanford accelerated protocol, sometimes called SAINT or SNT, delivers 50 theta burst sessions over five days and showed very high remission in small trials. It is FDA-cleared but requires MRI-guided targeting, is not yet covered by most insurers, and has not been tested at scale. Theta burst stimulation shortens each session to three minutes but still runs 30 sessions over six weeks. Stedfast Psychiatry's TMS program uses the standard Deep TMS schedule, which is what our insurers authorize and what the largest body of evidence supports.
How many sessions does the OCD protocol take?
Twenty-nine sessions over six weeks, five days a week in the first five weeks and four in the sixth. The OCD protocol uses a different coil, stimulates the medial prefrontal and anterior cingulate cortex rather than the dorsolateral prefrontal cortex, and includes a brief individualized symptom provocation before each session, which makes the target circuit active while it is stimulated. Each session is about 20 minutes. The course is not extended or tapered in the same way as the depression protocol.
If I relapse, how many sessions is a repeat course?
Usually the same 36 sessions, though some patients who responded quickly the first time respond quickly again and may stop after fewer, on their psychiatrist's judgment. Medicare and most insurers cover retreatment for patients who had a documented response to a prior course. Some patients instead choose a maintenance schedule of one or two sessions a week after the acute course; the evidence for maintenance is thinner than for retreatment, so we decide it case by case.
Can I do two sessions in one day to finish sooner?
In specific situations, with a psychiatrist's instruction, yes. Delivering two sessions a day with a break of several hours has been used safely to catch up after missed days and in research protocols. It is not how we run a standard course, because the evidence base and the insurance authorizations are built around one session per day. If your situation requires an unusual schedule, such as travel from out of the area, discuss it at the evaluation rather than planning around it.
Where this treatment is offered
Conditions this treats
If you are in crisis, call or text 988 or go to the nearest emergency room. Educational content; individual results vary. Reviewed by Dr. David Husted, board-certified psychiatrist.