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Customized Transcranial Magnetic Stimulation (TMS) Protocols for Depression & Psychiatric Disorders Based on Personalized Neuroimaging (2023 Evidence)

Recent advancements in neuroimaging and brain stimulation techniques, particularly Transcranial Magnetic Stimulation (TMS), are revolutionizing the treatment of psychiatric disorders.

These technologies, leveraging our understanding of individual brain network architectures, offer the potential for highly personalized treatments.


  • Personalization of Treatment: Neuroimaging advancements allow for the personalization of brain stimulation targets, particularly in Transcranial Magnetic Stimulation (TMS), based on individual brain connectivity patterns.
  • Neuroimaging Methodologies: Cutting-edge imaging techniques like MRI have been instrumental in mapping brain connectivity, crucial for identifying individualized TMS target sites.
  • Variable Response Rates: TMS has shown varied response rates in treating conditions like depression, indicating the need for more personalized approaches.
  • Precision Medicine: The move towards personalized brain stimulation exemplifies the broader shift in healthcare towards precision medicine, tailoring treatments to individual patient characteristics.

Source: Biological Psychiatry (2023)

How TMS Works: Existing Protocols & Brain Targets

Transcranial Magnetic Stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain.

It involves placing a magnetic coil near the scalp; when activated, this coil generates a magnetic pulse that induces a small electric current in the targeted brain area, thereby influencing neural activity.

Standard TMS Protocols

Standard TMS protocols generally involve repetitive stimulation (rTMS), where repeated magnetic pulses are delivered.

The most common target in psychiatric treatments, particularly for depression, is the left dorsolateral prefrontal cortex (DLPFC).

The standard protocol typically includes daily sessions over 4-6 weeks.

Existing Targets

The DLPFC is targeted based on its involvement in mood regulation and executive functions, which are often impaired in depression.

Other targets may include the right DLPFC or other brain regions, depending on the disorder being treated.

For instance, in obsessive-compulsive disorder (OCD), the supplementary motor area or orbitofrontal cortex might be targeted.

Protocol Variations

The frequency of stimulation in TMS can vary.

High-frequency TMS (typically around 10 Hz) is thought to increase brain activity in the targeted area, while low-frequency TMS (around 1 Hz) is believed to decrease activity.

The choice of frequency depends on the treatment goals and the specific psychiatric condition.

Developing Personalized Protocols

The development of personalized TMS protocols is based on advanced neuroimaging techniques like functional MRI (fMRI), which help identify the most disrupted or functionally relevant brain areas in each individual.

This approach is still in the research phase but is rapidly evolving with the advancements in neuroimaging technology and computational methods.

Why customized TMS may be better than following a standard protocol

Tailored to Individual Brain Connectivity

Standard TMS protocols typically target predetermined brain regions, often based on population averages.

In contrast, personalized TMS considers the unique brain connectivity patterns of each individual, which can vary significantly.

This tailoring ensures that the stimulation is more accurately aligned with the patient’s specific neural architecture, potentially increasing the treatment’s effectiveness.

Variability in Treatment Response

Psychiatric disorders manifest differently in each individual, not just symptomatically but also neurologically.

Standard TMS protocols may not account for this variability, leading to inconsistent treatment outcomes.

Personalized TMS can potentially reduce this variability by adapting to the individual differences in brain structure and function, thereby improving response rates, especially in treatment-resistant cases.

Potential for Enhanced Efficacy

By targeting areas that are functionally more relevant to the individual’s disorder, personalized TMS may enhance the efficacy of the treatment.

For instance, in depression, targeting a brain region that shows more profound connectivity disruption unique to the patient could lead to better symptom relief.

Reducing Side Effects

Standard TMS protocols may inadvertently stimulate brain areas that are not optimal for the desired therapeutic effect, potentially leading to side effects.

Personalized TMS reduces this risk by precisely targeting areas identified through detailed neuroimaging, thereby potentially reducing unwanted side effects.

Optimizing Treatment Duration & Intensity

Personalized TMS allows for the optimization of treatment parameters such as duration and intensity of stimulation.

By focusing directly on the most relevant brain areas, it may be possible to achieve desired outcomes with shorter or less intense treatment sessions, enhancing patient comfort and compliance.

How Personalized TMS Would Work

Personalized TMS, as suggested by current research, would involve several key steps:

  1. Individual Neuroimaging Assessment: Patients would undergo advanced neuroimaging, like MRI, to map their brain’s connectivity patterns, focusing on areas relevant to their specific psychiatric disorder.
  2. Computational Analysis for Target Identification: Using computational algorithms, clinicians would analyze these neuroimaging data to identify the most effective stimulation sites tailored to each patient’s brain connectivity.
  3. Personalized Treatment Protocol: TMS treatment would then be administered, targeting these personalized sites, which could differ significantly from standard TMS targets.
  4. Ongoing Monitoring and Adjustment: The treatment would be monitored, and neuroimaging could be repeated to adjust the stimulation targets as necessary, ensuring the most effective treatment over time.

Personalized Circuit-Based TMS for Depression & Mental Disorders (2023 Review)

Cash & Zalesky conducted a review to highlight advancements in neuroimaging methodologies, particularly their role in mapping brain connectivity, and how these advancements have transformed our understanding of psychiatric disorders.

Researchers focused on: the development and distributed effects of brain stimulation; the employment of transcranial magnetic stimulation (TMS) in targeting and ameliorating psychiatric symptoms; and the rationale for personalized target site selection based on individual brain network architecture.


The review encompasses a broad survey of existing literature, focusing on:

  • Studies that map brain connectivity using advanced neuroimaging techniques, especially in higher-order brain regions like the prefrontal cortex.
  • Research demonstrating the variability in brain connectivity among individuals.
  • Evidence from clinical applications and basic research supporting personalized TMS targeting.


  • Transformation in Psychiatric Disorder Understanding: Enhanced neuroimaging techniques have significantly improved the understanding of psychiatric disorders and the effects of brain stimulation.
  • Variability in Brain Connectivity: There’s a notable interindividual variation in brain connectivity, especially in areas commonly targeted for psychiatric disorders, providing a basis for personalized TMS.
  • Personalized TMS Targeting: Recent advancements allow for precise, reproducible personalized TMS targeting, beneficial in treating psychiatric disorders like depression.
  • Preliminary Support & Evidence: Although preliminary support is promising, especially in depression treatment, there is a need for more comprehensive, prospective randomized clinical trials to validate these findings.


  1. Limited Large-Scale Clinical Trials: A significant limitation is the lack of extensive clinical trials to conclusively validate the effectiveness of personalized TMS targeting.
  2. Generalizability Issues: The review primarily focuses on depression, and thus, the findings’ applicability to other psychiatric disorders might be limited.
  3. Methodological Challenges: There are ongoing debates and uncertainties regarding the optimal methodologies for personalized targeting, including concerns about the reproducibility and precision of these methods.

What are some major highlights of the review?

Variability in Brain Connectivity

The review highlights that higher-order brain regions, such as the prefrontal cortex, demonstrate substantial interindividual variation in connectivity.

This variability is critical as these regions are common targets in TMS for treating psychiatric disorders.

The traditional one-size-fits-all approach in TMS may not be effective due to these variations.

Advancements in Neuroimaging

Advancements in MRI and other neuroimaging techniques have been instrumental in mapping these individual differences in brain connectivity.

This detailed mapping has provided a deeper understanding of the brain’s functional architecture and its implications in psychiatric disorders.

Personalization of TMS Targets

One of the most significant findings is the development of methods to determine reproducible, personalized TMS targets.

These methods enable the identification of stimulation sites with millimeter precision, tailored to individual brain connectivity patterns, making TMS more effective and efficient.

Preliminary Support in Depression

Initial research, primarily in the context of depression, indicates that personalized TMS targeting could significantly improve treatment outcomes.

This approach seems to address the variability in response rates seen in treatment-resistant depression, where traditional TMS methods have limited effectiveness.

Challenges & Future Directions

The review also points out the challenges and necessary future directions in this field.

While the preliminary findings are promising, there is a need for more large-scale, prospective clinical trials to establish the effectiveness of personalized TMS targeting fully.

Evidence & Research on Personalized TMS

Efficacy in Depression

Research shows promising results for personalized TMS in treating depression.

In cases of treatment-resistant depression, where standard TMS has been less effective, tailoring the stimulation sites to individual brain connectivity has led to improved response rates.

Retrospective & Prospective Studies

Both retrospective and prospective studies support the efficacy of personalized TMS. Retrospective studies, analyzing past patient data, have shown a correlation between closer proximity to personalized targets and better treatment outcomes.

Prospective studies, while fewer, are beginning to demonstrate higher response rates in patients receiving personalized TMS compared to traditional methods.

Broader Implications

The implications of personalized TMS extend beyond depression.

Preliminary research suggests potential benefits in other psychiatric and neurological conditions, although these applications are still in the early stages of investigation.

Neuroimaging-Driven Personalization

A key aspect of the research is the use of neuroimaging to drive personalization.

This approach is grounded in the understanding that different brain regions and networks are involved in various psychiatric disorders, and targeting these specific areas can enhance treatment efficacy.

Challenges & Critiques

Critiques of the current research mainly focus on the need for larger, more diverse study populations and long-term evaluations to establish the effectiveness and safety of personalized TMS.

There is also a call for standardized methodologies to ensure consistency and reproducibility in treatment protocols.

Takeaway: Customizing TMS Protocols for the Specific Patient

The concept of personalizing Transcranial Magnetic Stimulation (TMS) marks a significant advancement in the treatment of psychiatric disorders, aligning the therapy more closely with the principles of precision medicine.

By leveraging advanced neuroimaging techniques, personalized TMS tailors treatment to the individual’s unique brain connectivity, addressing the variability in brain structure and function that standard protocols may overlook.

This customization has the potential to enhance treatment efficacy, particularly in conditions like depression where response rates to conventional TMS vary.

Moreover, personalized TMS could reduce the likelihood of side effects by accurately targeting specific brain areas, thereby improving patient outcomes and comfort.

While promising, the full realization of personalized TMS in clinical practice hinges on further research, including larger, more diverse clinical trials.

Nevertheless, personalized TMS represents a forward-thinking approach, offering a glimpse into a future where psychiatric treatments are finely tuned to each patient’s neurological profile.


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