Transcranial Magnetic Stimulation (TMS) for OCD: Is it Effective?

What Is OCD?

Obsessive-compulsive disorder (OCD) is a serious mental health condition characterized by recurring, unwanted thoughts (obsessions) that lead to repetitive behaviors or mental acts (compulsions) performed to alleviate anxiety, although they often end up disrupting daily life. It affects approximately 2% of the population.¹ OCD often has wide-ranging consequences for an individual, interfering with work, school, daily responsibilities, and relationships.

OCD is characterized by:

• Obsessions: Obsessions are recurring, intrusive thoughts that usually cause distress to an individual. In most cases, obsessive thoughts involve a negative future event – e.g., an illness related to germs, a negative academic/workplace consequence, or a major social disturbance. Sometimes, however, obsessions can involve a fixation on a love interest or some other highly sought-after goal.
• Compulsions: Compulsions are repetitive, self-soothing behaviors that temporarily ease the anxiety associated with the obsessive thoughts – either because they represent a fantasized solution to one’s obsessive fear or because they offer a distraction. Such behaviors can include excessive hand-washing, checking behaviors, and counting.

What Is Transcranial Magnetic Stimulation (TMS)?

Transcranial magnetic stimulation (TMS) is a relatively safe, non-invasive procedure in which a coil that carries an electric current is placed against the head, producing a magnetic field that penetrates the scalp, skull, cerebrospinal fluid (CSF) and stimulates neurons in the brain to activate (i.e., fire). Activating groups of neurons in specific brain areas – like supplementary motor cortex for OCD – is believed to stimulate underperforming brain regions and inhibit overactive regions that underlie mental health disorders like OCD.

Despite being generally well-tolerated and FDA-approved to treat OCD, it is usually only recommended by providers and covered by insurance after traditional treatment methods (e.g., medication, psychotherapy, etc.) have been shown to be ineffective. The use of magnets and electric current preclude some people from receiving this treatment — e.g., those with epilepsy or pacemakers — but TMS providers can determine if you meet the criteria.

Side Effects of TMS

The idea of stimulating the brain with electromagnetic current can sound intimidating. However, TMS therapy is relatively safe and non-invasive, with the most common side effect being a transient headache. Headaches are the most common side effect but tend to alleviate with successive treatments and are usually treatable with over-the-counter medication. There is also a small risk of seizures, with one study estimating that 2 in 10,000 patients may experience a seizure.⁴

Possible side effects of a TMS session include:

• Headaches
• Seizures
• Dizziness
• Syncope (passing out)
• Tingling sensations
• Scalp discomfort and mild pain
• Muscle twitching
• Fatigue
• Anxiety
• Insomnia
• Jaw pain
• Back and neck pain
• Dislodging or heating of metal located in the head or neck\
• Damage to implanted device (e.g., pacemaker)
• Hearing loss (although earplugs are worn to prevent this)
• Manic episodes (in individuals with bipolar disorder)

Does TMS Work for OCD?

TMS helps relieve OCD symptoms by targeting brain areas involved in impulsivity, cognitive control, and reward processing.² It uses specific patterns and frequencies of stimulation pulses to quiet these overactive areas, which helps lessen obsessive thoughts and the need to perform compulsions.

TMS was approved by the FDA for treating OCD in 2017, yet researchers are still working to perfect how it’s used—like figuring out the exact brain areas to target and the best intensity and frequency of the pulses. Fine-tuning the treatment to match a person’s particular OCD symptoms could improve its effectiveness. For instance, different brain areas may be targeted for OCD symptoms focused on contamination compared to those that involve a persistent sense of things being incomplete.⁵

How Long Will It Take to See Results From TMS for OCD?

TMS takes time to work and is time-intensive, requiring daily sessions for weeks to months. On average, symptom improvement can take 18-20 sessions or about one month, with continued improvement extending out to 40 sessions. There is a high degree of variability between individuals, with some people first feeling relief in as little as nine sessions and others taking up to 2 months.⁶

Symptom relief tends to last at least one month. In some cases, maintenance treatment (usually once every one to two weeks) may be required. There is currently limited research on long-term success rates for TMS beyond a couple of months.

Is TMS Approved by the FDA As a Form of OCD Treatment?

While several research studies using different TMS devices and protocols have shown moderate efficacy for treating OCD, the FDA has only approved specific devices from select companies (BrainsWay, MagVenture, Cloud TMS) and protocols for this clinical therapy. The FDA’s approval only applies to treatment-resistant individuals who have already tried medication and psychotherapy.

How Effective Is TMS for OCD?

TMS is intended as an add-on therapy to traditional pharmacotherapy and/or psychotherapy for OCD, but not in place of it. Its role is to enhance therapeutic effects in people who have not achieved satisfactory results with medication or psychotherapy alone.⁷ In such cases, it seems to be helpful for about half the individuals who try it, reducing obsessive thoughts and compulsive behaviors.⁶

TMS tends to work most effectively in patients who have both OCD and depressive symptoms, which is fairly common. TMS is highly effective for depression, and reducing depressive symptoms may lead to reduced OCD symptoms and vice versa.⁵

TMS Vs. Deep TMS for OCD

Transcranial magnetic stimulation (TMS) is the general term for using electricity and the magnetic field to activate groups of neurons in the brain. Repetitive TMS (rTMS) refers to the delivery of TMS in repeating pulses, the pattern and timing of which have different effects (e.g., stimulating vs. inhibiting). Conventional rTMS devices can generate a magnetic field that typically only reaches a very shallow and focal area of the cortex.

Deep TMS devices can generate magnetic fields that reach a deeper and broader area of brain tissue, such as the anterior cingulate cortex (ACC) which is implicated in OCD. Technically, dTMS can use a single pulse or repetitive pulses (more specifically called “deep rTMS”), just like conventional rTMS, but its unique coil design allows for broader reach and fewer targeting errors.⁸

Who Should Avoid TMS for OCD?

Before receiving TMS, individuals must be screened to ensure eligibility and safety. TMS shouldn’t be used if certain conditions are present, like frequent headaches, while others, like a history of seizures or having a pacemaker, are more serious reasons to avoid them. The healthcare professional will ask a series of questions prior to treatment, and in some cases, clearance from one’s medical team is required to determine if TMS is a viable option.

Populations who should avoid TMS treatment for OCD include those who:

• Do not meet diagnostic criteria for OCD (DSM criteria for the FDA in the US; ICD criteria for the CE Marked in Europe)
• Have not already tried and shown resistance to traditional treatments (e.g., medication, psychotherapy)
• Have a history of epilepsy
• Have a history of severe headaches
• Are pregnant or nursing
• Have implanted medical and electronic devices (stents, stimulators, pacemakers, cardioverter defibrillators, cochlear implants, etc.)
• Have any other metal device or object in the body (bullet fragments, metal plate, etc.), although amalgam dental fillings are okay. Many current metal implants are non-ferrous (e.g., titanium) and may be safe as well.
• Have a history of seizures/epilepsy
• Have another medical condition that may put you at risk for a seizure
• Have brain damage from illness or injury
• Experience frequent or severe headaches (though sometimes dTMS can paradoxically be a treatment for migraine pain)

Can TMS Make OCD Worse?

Usually, OCD doesn’t get worse with TMS, but only about half of the people treated see improvement. Interestingly, for the best results in treating OCD with TMS, it often helps trigger OCD symptoms just before the session. This can make OCD symptoms stronger for a short time during treatment. There might be other short-lived side effects too.

What to Expect From TMS for OCD

TMS treatment for OCD is an intensive daily treatment that can be time-consuming and requires commitment. The treatment course may vary slightly, depending on the symptom(s) being treated, but it typically consists of daily, 20-minute sessions, five days per week, for up to 6 weeks, followed by a taper period of fewer weekly sessions for three weeks.

During a TMS for OCD session, the following may occur:

• Location: TMS usually takes place in an outpatient office or clinic setting, though it can be a hospital setting, especially for clinical research trials.
• Evaluation: Before treatment, you will be asked a series of questions to help the clinicians determine if TMS is a safe and efficacious treatment for you to receive.
• Procedure Preparation: This procedure is non-invasive and does not require any surgery, needles, or other penetration of skin, nor anesthesia. You will be awake for the entire procedure. Measurements of your head may be taken to help identify your personal target location for stimulation.
• Setting: During a treatment session, you will be seated in a comfortable chair. As the procedure involves a magnetic field, you will not be able to bring any ferrous metal (jewelry, keys, glasses) into the room. At this point, earplugs will be placed since the treatment can be loud.
• Symptom Provocation: In some cases, a symptom provocation protocol may be used, whereby OCD symptoms are intentionally triggered prior to or during stimulation to enhance treatment efficacy. Usually, this involves eliciting patient-specific obsessive thoughts while preventing the compulsive behavior that typically provides transient relief.
• Device Placement: The TMS coil in the form of a cushioned helmet or panel will be placed against your scalp at a location specified to treat your symptom(s). Once the coil is placed, it is crucial that you stay still, but you may be allowed to talk or read as long as your head doesn’t move.
• Personalized Target: As brain shape and size vary between individuals, there are several methods that the clinician may use to determine the target to stimulate. Some methods require head measurements, while others require prior neuroimaging.
• Determining Intensity: The clinician will stimulate your motor cortex to identify your “motor threshold” – i.e., the pulse intensity that will cause your hand to contract. Your treatment intensity will be relative to this value (usually 80% to 120%, depending on the condition). This threshold can change with sleep deprivation, medication, alcohol, or drug use, so it is important that you notify the clinician before a session if there’s been a change to any of these factors between sessions.⁹
• Sensations: As the treatment begins, you will hear loud, repetitive noises despite wearing earplugs. You may experience tapping or clicking sensations against your scalp. Some individuals have described this as a light, repetitive tapping or knocking on the head.
• Daily Activity: You can resume your daily activities immediately after each session, and generally, there is no recovery period or restrictions on driving or operating machinery unless a seizure occurs as a side effect.
• Subsequent Sessions: The stimulation parameters are determined during the first session and need not be repeated every session unless there have been changes to sleep or substance use (including medications) that may impact the motor threshold.⁹ Subsequent daily sessions are usually briefer than the first session.
• Monitoring Effects of Treatment: There is variation in how different people respond to treatment. With feedback, parameters may be adjusted, but generally, improvement is not felt for the first few weeks of treatment. After the final session, symptom relief may last anywhere from weeks to months. In some cases, brush-up sessions may be recommended when treatment effects wane.

How Much Will TMS for OCD Cost?

Typically, each TMS session can cost at least $250, but the total cost can vary depending on how quickly symptoms resolve, which can be very different between people. As a rough estimate based on average documented costs, the total cost can end up ranging from $3,000 to $15,000.^10,11

Will Insurance Cover TMS for OCD?

Most major insurance companies (e.g., United Healthcare, Empire, Optum, Carelon, Aetna, Medicare) will cover TMS treatment if you are eligible and have already shown resistance to a traditional treatment option like medication and/or psychotherapy. You may consider contacting your insurance company to find out what mental and behavioral health treatments are covered by your plan and what your deductible, copay, or coinsurance costs would be.

How to Find a TMS Therapist for OCD

The main company providing dTMS devices (which have shown greater efficacy than conventional TMS) is BrainsWay, which offers a directory for finding a dTMS provider near you. You may want to consult a psychiatrist to determine if TMS is a viable option for you. An online psychiatry service is an easy way to find a psychiatrist or ask your healthcare provider. Lastly, you can search a clinical trial database for research studies to participate in if you find that your clinical options are limited.

Other Treatments for OCD

While TMS is a potential add-on treatment for some, it is not for everyone. The first line of treatment for OCD is usually medication (e.g., SSRIs and SNRIs, dopamine agonists, neuroleptics) and exposure response prevention (ERP). However, 40%-60% of patients don’t respond to these treatments.^12,13

There are also treatments that can supplement medication and psychotherapy. Depending on the severity of the OCD, reasons not to use certain treatments, what’s already been tried, and what’s practical, options can include advanced methods like brain surgery or therapy with psychedelic drugs.

Other treatment options for OCD include:

• Cognitive behavioral therapy (CBT): CBT for OCD is a style of psychotherapy that is very effective for treating OCD by adapting the way one thinks about and acts on obsessive thoughts.¹⁷
• Exposure response prevention (ERP): ERP challenges the patient to resist compulsive behaviors when obsessive thoughts or fears arise. This psychotherapeutic method is highly effective for OCD and can be used in conjunction with medication and neuromodulation techniques (like TMS).
• Medications: There are several medications for OCD, with selective serotonin reuptake inhibitors (SSRIs) being the frontline choice. Other pharmaceuticals, like off-label antidepressants, benzodiazepines, and antipsychotics, may be prescribed in severe, resistant cases.
• Acceptance and commitment therapy (ACT): ACT is an offshoot of CBT that integrates aspects of transcendental meditation awareness into treatment. It approaches OCD symptoms from the view that uncomfortable thoughts and fears are a normal part of being human, but by accepting their presence and changing the way one engages with the obsessions, one can learn to live without being disrupted by them.
• Psychedelic-assisted therapy Psychedelic therapy, like ketamine and psilocybin, have recently received attention for their potential efficacy in treating OCD.^18,19 Although supporting research is currently sparse, preliminary studies have shown marked symptom relief lasting 24 hours up to 6 months post-treatment.²⁰ Relatively safe and well-tolerated for most people when administered in a controlled setting, this is an alternative treatment with great potential.
• Deep brain stimulation (DBS): DBS is an invasive neuromodulation technique (requiring surgery) whereby stimulating electrodes are placed over specific target brain areas. This method is approved by the FDA for treating OCD as per a Humanitarian Device Exemption. DBS is effective in approximately 60% of treatment-resistant cases.¹⁴
• Transcranial direct current stimulation (tDCS): As a non-invasive neuromodulation technique (no surgery necessary), weak electric current is delivered to specific brain areas through electrodes placed on the scalp surface. There are mixed results regarding its efficacy, though, as with TMS, ongoing research to fine-tune parameters (e.g., stimulation intensity, brain area targeted) may improve response rates in the future.¹