TMS Sessions Reduced From 38 Minutes to 3, With Jonathan Downar, MD, PhD

Two decades of incremental advances have compressed transcranial magnetic stimulation (TMS) sessions from nearly 40 minutes down to as little as 3, expanding the treatment’s reach to far more patients with depression and other psychiatric conditions, according to Jonathan Downar, MD, PhD, associate professor of psychiatry at the University of Toronto and co-founder of Ampa One, an FDA-cleared TMS device.

Downar has practiced TMS since 2010, the same year he opened a charity TMS clinic in Toronto, now treating roughly 1000 patients annually across 10 machines. He described the field's progress as steady rather than sudden, with a meaningful development arriving every 2 to 3 years since he entered the field.

"In 2010, when I started, TMS sessions were typically 38 minutes long, and over time we were able to discover ways to get them down to about 3 minutes per session, which allowed a lot more patients to come in and made it a lot more scalable," Downar said.

Shrinking Session Time Expands Patient Access

Downar pointed to 2010 as the year the first accelerated TMS study appeared in the literature, describing a protocol delivering 15 sessions over 2 days.¹ He called reducing the number of clinic visits required to complete a course of treatment one of the field's biggest ongoing priorities.

A second theme Downar highlighted involves pharmacologically enhancing plasticity. He said certain medications acting on specific brain receptors may boost the effect of TMS, potentially extending how long a course of treatment remains effective or lowering the number of sessions needed to achieve it.

Downar also credited advances in neuroimaging, an area tied to his own early research background, with reshaping which brain circuits clinicians target. Over the past 5 to 10 years, imaging studies have generated increasingly detailed maps of the circuitry implicated in depression and other psychiatric conditions.²

The THREE-D Trial Set the Template for Shorter Protocols

Downar served as senior author on THREE-D, the 2018 trial published in The Lancet establishing a 3-minute theta-burst protocol as noninferior to older, longer stimulation regimens.³ He said the trial's legacy is visible today in the global adoption of theta-burst-based protocols, with clinicians in many regions now running sessions lasting 3 to 10 minutes instead of 37 minutes or more.

The time saved by shorter sessions has opened a new clinical question, Downar said: what to do with the extra time in a patient visit. Clinicians have begun using it to stimulate more of the brain during a single visit. A recent analysis has shown that 5x5 accelerated repetitive TMS, consisting of 5 sessions per day over 5 consecutive days, compresses overall treatment time from 6 to 1 week.⁴

"Being able to complete an effective session or treatment in 3 minutes allows you to start thinking about things like doing multiple sessions per day or targeting multiple brain areas," Downar said.

This is part 1 of a 3-part interview series with Jonathan Downar, MD, on TMS practice and his group's new meta-analysis on dosing in accelerated rTMS.

Downar has no reported disclosures.

References

1. Holtzheimer PE 3rd, McDonald WM, Mufti M, et al. Accelerated repetitive transcranial magnetic stimulation for treatment-resistant depression. Depress Anxiety. 2010;27(10):960-963. doi:10.1002/da.20731

2. Goldstein-Piekarski AN, Ball TM, Samara Z, et al. Mapping Neural Circuit Biotypes to Symptoms and Behavioral Dimensions of Depression and Anxiety. Biol Psychiatry. 2022;91(6):561-571. doi:10.1016/j.biopsych.2021.06.024

3. Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. Lancet. 2018;391(10131):1683-1692. doi:10.1016/S0140-6736(18)30295-2

4. Derman C. TMS for MDD Reimagined: Faster, Fewer Visits, and Now at Home. HCPLive. Published May 15, 2026. Accessed August 25, 2026. https://www.hcplive.com/view/tms-mdd-faster-fewer-visits-home