One-day accelerated TMS: how compressed protocols deliver weeks of treatment in days
Standard TMS for depression works, but it asks a lot: daily clinic visits, five days a week, for four to six weeks. For someone managing treatment-resistant depression alongside a demanding job or family responsibilities, that timeline can be a barrier in itself. Accelerated TMS protocols were developed to solve this problem, compressing the same therapeutic dose into days rather than weeks.
The most aggressive version, one-day TMS, delivers a full course of treatment in a single extended session. This article explains how the science got here, what the evidence supports, and what still needs more study.
The path from six weeks to one day
Compressed TMS didn’t appear out of nowhere. It evolved through a series of clinical milestones, each showing that the brain can handle more stimulation in a shorter window than researchers originally assumed.
Standard rTMS (established, 2008 FDA clearance): One session per day, five days a week, for four to six weeks. Each session delivers roughly 3,000 magnetic pulses over 20-40 minutes, adding up to 60,000-90,000 total pulses across 20-30 visits. This remains the most widely studied and insurance-covered protocol.
Intermittent theta-burst stimulation (iTBS, 2018 FDA clearance): A faster pulse pattern that delivers a full session in about 3 minutes instead of 37 minutes. A 2023 review in Neuropsychopharmacology described early compressed experiments using iTBS, including one by Holtzheimer et al. that delivered 15 high-frequency TMS sessions over two days and achieved a significant treatment effect by day three that held at six weeks. This was the first rigorous evidence that compression could work.
The SAINT protocol (2022 FDA clearance): The breakthrough. Stanford researchers designed a five-day intensive protocol delivering 10 iTBS sessions per day (90,000 total pulses), with functional MRI-guided targeting personalized to each patient. The FDA cleared the SAINT neuromodulation system for treatment-resistant depression in September 2022. SAINT produced the strongest remission rates ever recorded in a controlled TMS trial, and it is the scientific foundation on which one-day protocols are built.
One-day TMS (emerging): The next step in the compression timeline. One-day protocols typically deliver approximately 20 iTBS sessions over 9-10 hours in a single day, totaling roughly 36,000 pulses. The logic follows directly from the SAINT evidence: if the brain can tolerate and respond to 10 sessions in a day for five consecutive days, a concentrated single-day protocol with appropriate monitoring should also be feasible.
| Feature | Standard rTMS | SAINT (5-day) | One-day TMS |
|---|---|---|---|
| Total sessions | 20-30 | 50 (10/day x 5 days) | ~20 in one day |
| Session length | 20-40 minutes | ~3 minutes (iTBS) | ~3 minutes (iTBS) |
| Treatment span | 4-6 weeks | 5 consecutive days | 1 day (9-10 hours onsite) |
| Total pulses | 60,000-90,000 | ~90,000 | ~36,000 |
| Time off work | Daily visits for weeks | 1 week | 1-2 days |
| Evidence level | Extensive (hundreds of RCTs) | Strong (2 RCTs, FDA cleared) | Emerging (clinic-based data) |
Why compression works: the neuroscience
The brain doesn’t need 24-hour rest intervals between TMS sessions to respond. This is the central insight behind every compressed protocol.
TMS works by stimulating the left dorsolateral prefrontal cortex (DLPFC), a brain region involved in mood regulation. Magnetic pulses trigger neurons to fire, and repeated stimulation strengthens underactive neural circuits. Research suggests this process involves brain-derived neurotrophic factor (BDNF), a protein that supports the growth and survival of neurons, and promotes synaptogenesis: the formation of new connections between brain cells.
iTBS accelerated the field because it mimics the brain’s natural theta rhythms, allowing a therapeutic dose to be delivered in a fraction of the time. Once trials confirmed that a 3-minute iTBS session could produce comparable results to a 37-minute standard rTMS session, the question shifted from “can we shorten sessions?” to “can we stack sessions within a single day?”
The SAINT team answered that question definitively. Their functional MRI targeting also addressed a limitation of standard TMS: instead of estimating the stimulation site from skull landmarks (which vary by individual), SAINT maps each person’s brain connectivity to find the precise DLPFC subregion most functionally connected to mood regulation circuits.
The evidence: what we know and what we don’t
SAINT five-day protocol: strong evidence
The five-day SAINT protocol has the strongest controlled evidence of any compressed TMS approach. This is the foundation that makes one-day protocols scientifically plausible.
In a double-blind randomized controlled trial published in The American Journal of Psychiatry (2022), Cole et al. found that 78.6% of participants receiving active SAINT treatment met remission criteria at some point during the four-week follow-up period, compared to 13.3% in the sham group. The response rate was 85.7% for active versus 26.7% for sham. All 29 participants had moderate to severe treatment-resistant depression and had failed an average of five prior antidepressant treatments. At the four-week mark specifically, remission was maintained by approximately 46% of the active group.
A larger replication RCT conducted at Stanford with 48 randomized participants, published in World Psychiatry, confirmed the pattern: 50.0% of the active group achieved remission at one month versus 20.8% for sham. For comparison, standard rTMS typically yields remission rates of roughly 15% in controlled trials and up to 37% in open-label studies, according to the same research team’s analysis.
How long do the benefits last? According to Stanford Health Care, roughly 46-57% of treated participants in follow-up studies maintained remission four weeks after treatment, with some reporting sustained improvement for a year or longer. A 2025 durability study published in Brain Stimulation found that 70% of 46 participants entered remission the week following treatment, with 33% maintaining remission at 12 weeks. Periodic booster sessions may help extend the benefit for those who experience a return of symptoms.
One-day protocols: promising but earlier-stage
True single-day TMS protocols are newer, and the published evidence is not yet at the same level as SAINT’s. Most one-day data comes from clinic-based observational reports rather than sham-controlled RCTs. The clinical rationale is sound (the neuroscience of iTBS compression applies equally whether the sessions are spread across five days or concentrated into one), but the specific questions that still need controlled answers include: Is 36,000 pulses in one day as effective as 90,000 over five days? What is the optimal inter-session interval for single-day delivery? Do durability outcomes differ from the five-day approach?
What we can say is that the safety profile appears consistent with multi-day compressed protocols: mild scalp discomfort, temporary fatigue, no sedation required. And the practical appeal is significant for the right candidate.
Nushama is adding one-day TMS capability with the arrival of the Ampo device in April 2026. Our protocol design draws on the SAINT evidence base and will include the same comprehensive psychiatric assessment, personalized targeting, and post-treatment follow-up that our five-day and standard programs provide.
What treatment looks like: five-day vs. one-day
Five-day protocol timeline
Pre-treatment assessment (before Day 1): Psychiatric evaluation to confirm candidacy, review medications, and identify your optimal brain stimulation target. Some protocols include a functional MRI scan for personalized targeting.
Days 1-5: Ten iTBS sessions per day, each lasting about 3 minutes, spaced roughly 50 minutes apart. Total onsite time is approximately 4-6 hours per day.
Days 2-3 post-treatment: Some people notice early shifts in sleep quality and mood. Mild fatigue is common and typically resolves quickly.
Week 1-2 post-treatment: Mood improvements often become more noticeable. A follow-up appointment allows your clinician to assess response and adjust medications if needed.
One month post-treatment: A comprehensive follow-up to evaluate sustained improvement and discuss maintenance options.
One-day protocol timeline
Pre-treatment assessment: Same thorough psychiatric evaluation and treatment planning as the five-day protocol.
Treatment day: Approximately 20 iTBS sessions delivered over 9-10 hours onsite. Each session lasts about 3 minutes, with rest periods of 30-50 minutes between sessions. Vitals and comfort are monitored throughout the day.
Day after treatment: Most people experience mild fatigue. Light activity and rest are recommended.
Week 1-2 post-treatment: Follow-up assessment to evaluate early response and adjust medications if needed.
Side effects for both formats are generally consistent with standard TMS: mild scalp discomfort at the stimulation site and temporary fatigue. No sedation is required, and most people can drive themselves home after sessions.
Is accelerated TMS right for you?
Compressed TMS protocols may be a good fit if you:
- Are living with moderate-to-severe depression that hasn’t responded to two or more antidepressant medications
- Cannot commit to 4-6 weeks of daily treatment due to work, caregiving, or other obligations
- Are in good general medical health
- Have at least 1-2 weeks available for post-treatment follow-up, including medication adjustments if needed
The choice between a five-day and one-day protocol depends on your clinical situation and practical constraints. The five-day approach (especially SAINT) has stronger controlled evidence. One-day protocols offer maximum schedule convenience but with a smaller evidence base. Your clinician can help determine which format makes sense for you.
These protocols may not be the best starting point for everyone. People with bipolar spectrum conditions, certain medical comorbidities, active seizure disorders, or those in acute suicidal crisis may benefit from a different pathway, such as standard TMS with adjunctive support or IV ketamine therapy. A thorough psychiatric assessment before treatment helps ensure you’re matched with the right protocol.
Time, cost, and logistics
One of the most common questions we hear from professionals considering rapid TMS treatment is practical: how much time do I actually need to take off?
For a five-day protocol, plan for one full week away from intensive work. Treatment days involve 4-6 hours onsite. Most people feel well enough to return to light duties (email, calls, working from home) within 2-3 days after the final session. Full professional function, including high-stakes meetings and complex decision-making, typically resumes within a week of completing treatment.
For one-day TMS, you may need only 1-2 days off: the treatment day itself and one recovery day.
| Factor | Standard rTMS (4-6 weeks) | SAINT (5-day) | One-day protocol |
|---|---|---|---|
| Work days affected | 20-30 half-days over 4-6 weeks | 5 full days + 2-3 recovery days | 1-2 days total |
| Schedule disruption | Ongoing daily appointments | Concentrated single week | Single day + recovery |
| Approximate cost (self-pay) | $6,000-$15,000 | $30,000-$36,000 (SAINT) | Varies by provider and protocol |
| Insurance coverage | Often covered after pre-authorization | CMS began hospital reimbursement in 2025 (~$19,703) | Not yet widely covered |
For professionals in demanding roles, the concentrated timeline can be a practical advantage. Rather than weeks of daily appointments that conflict with meetings, travel, and deadlines, everything fits within a defined window. Several of our members have completed treatment during a single vacation week or planned leave.
What to look for when choosing a provider
Not all compressed TMS programs are the same. When evaluating providers, consider asking about:
Clinical assessment depth: Does the provider conduct a thorough psychiatric evaluation before treatment, including medical history and medication review?
Targeting approach: Does the protocol use brain imaging (such as functional MRI) to personalize stimulation targets, or does it rely on standard anatomical landmarks?
Evidence transparency: Is the provider clear about which protocol they use, what level of evidence supports it, and how their outcomes compare to published data?
Post-treatment support: Are medication management, follow-up assessment, and ongoing care included, or do you need separate specialists?
Integration with broader care: Can the provider coordinate with your existing therapist, psychiatrist, or primary care physician?
At Nushama, our approach to depression treatment includes thorough pre-treatment psychiatric assessment, personalized treatment planning, post-treatment medication management, and follow-up care. For people exploring whether TMS, ketamine therapy, or a combined approach might support their recovery, our care team can help clarify which pathway fits best.
Book a consultation to get started.
FAQs
What is the difference between SAINT and one-day TMS?
SAINT is an FDA-cleared five-day protocol that delivers 10 iTBS sessions per day (90,000 total pulses) with functional MRI-guided targeting. It has strong evidence from two randomized controlled trials showing remission rates of 50-79%. One-day TMS compresses treatment further into a single extended session (approximately 20 sessions, 36,000 pulses, 9-10 hours). One-day protocols draw on the same neuroscience as SAINT but have a smaller published evidence base.
How long does one-day TMS treatment take?
A single-day protocol typically involves approximately 20 iTBS sessions delivered over 9-10 hours onsite. Each individual session lasts about 3 minutes, with rest periods of 30-50 minutes between sessions.
Is accelerated TMS as effective as standard TMS?
The SAINT five-day protocol has outperformed standard rTMS in controlled trials, with 50-79% remission versus roughly 15% for standard TMS in sham-controlled studies. One-day protocols are newer and do not yet have equivalent controlled trial data, though early clinic-based results are promising. Your clinician can help you weigh the strength of evidence against practical considerations like scheduling and cost.
Does insurance cover rapid TMS treatment?
Most insurance plans do not yet cover compressed TMS protocols, though coverage for standard TMS has expanded in recent years. In 2025, the Centers for Medicare and Medicaid Services (CMS) established Category III CPT codes and hospital reimbursement for SAINT at approximately $19,703 for a full protocol, which may help expand access over time. We recommend checking with your insurance provider and our care team about specific coverage options.
Can I go back to work the day after treatment?
Most people feel well enough for light work (remote tasks, email, phone calls) within 1-2 days after completing either a five-day or one-day protocol. Full professional capacity typically returns within a week. No sedation is involved, and most people can drive themselves after sessions.
What is the SAINT protocol for TMS?
SAINT (Stanford Accelerated Intelligent Neuromodulation Therapy) is an FDA-cleared protocol that delivers 10 iTBS sessions per day over five consecutive days, totaling 90,000 pulses. It uses functional MRI to identify the optimal brain stimulation target for each person. In clinical trials published in The American Journal of Psychiatry and World Psychiatry, SAINT achieved remission rates of 50-79% in people with treatment-resistant depression. SAINT is the most rigorously studied compressed TMS protocol and the primary evidence base for newer one-day approaches.
How much does accelerated TMS cost?
Standard rTMS typically costs $6,000-$15,000 and is often covered by insurance. The SAINT five-day protocol costs $30,000-$36,000, with CMS hospital reimbursement of approximately $19,703 beginning in 2025. One-day TMS pricing varies by provider and protocol design. Our care team can help you understand the costs and explore coverage options for your specific situation.
