Brain stimulation treatments use magnetic fields or electricity to change activity in brain circuits linked to mood. They are mostly used for depression that has not improved with medicines and talk therapy. Some are also used for OCD and other conditions.1
The best known are TMS (transcranial magnetic stimulation) and ECT (electroconvulsive therapy). ECT has a frightening image from old movies, but it is done very differently today. This page explains what each treatment involves, how well it works, its risks, and what older adults should know.
Key points
- ECT has the strongest guideline support of these treatments for severe depression. It is done under general anesthesia and often works within the first week. Short-term memory problems are the main downside.1,7 Strong evidence
- TMS uses a magnet held against the head. You stay awake and need no anesthesia. A usual course is daily sessions for 4 to 6 weeks.1 Moderate evidence
- Accelerated TMS such as SAINT packs 10 short sessions a day into 5 days. The FDA cleared it in 2022, but the evidence is still small.4,5 Promising
- VNS is an implanted device. It is rarely used, and Medicare covers it for depression only inside approved studies.1,8
- If you or someone you love is thinking about suicide, call or text 988 now. If someone is in immediate danger, call 911.
Who these treatments are for
Most people with depression get better with therapy, medicine or both. See treatment for depression. Brain stimulation is usually considered when two or more good treatment tries have not helped. This is often called treatment-resistant depression. See when depression doesn't get better.
ECT is also used sooner when a person needs to get better fast. Examples include a person who is not eating or drinking, has strong thoughts of suicide, or has catatonia (a state where a person barely moves, speaks or responds).1
| Treatment | How it is given | Usual course | Evidence for depression |
|---|---|---|---|
| ECT | Brief electric current under general anesthesia | 3 times a week, often 6–12 treatments | Strong evidence |
| Standard TMS | Magnetic coil on the scalp, awake | Daily on weekdays for 4–6 weeks | Moderate evidence |
| Accelerated TMS (SAINT) | Magnetic coil, guided by an MRI scan | 10 sessions a day for 5 days | Promising |
| VNS | Surgically implanted pulse device | Ongoing; months to work | Limited research |
| Deep brain stimulation | Brain surgery with implanted wires | Research only for depression | Limited research |
Sources for the table: NIMH and the VA/DoD depression guideline.1,7
Transcranial magnetic stimulation (TMS)
How it works. A technician places a padded coil against your head. The coil makes quick magnetic pulses that pass through the skull. They gently stimulate nerve cells in an area at the front of the brain that helps control mood. You are awake the whole time, and it can be done in a clinic or office.1
What a course looks like. The FDA first cleared a TMS device for depression in 2008.3 A standard course is one session a day, five days a week, for 4 to 6 weeks. Sessions last from about 3 to 40 minutes, depending on the type of TMS.1
Side effects. Most are mild. They include scalp discomfort, tapping or twitching feelings in the face or jaw, mild headache and brief lightheadedness. A seizure is possible but rare.1 Long-term safety has not been fully studied.1
How well it works. The VA and Department of Defense guideline suggests offering TMS for depression that has not responded to other treatment. It rated this a weaker recommendation than ECT.7 TMS does not help everyone. Some people need repeat courses if depression returns.
Other uses. Deep TMS, which uses a different coil, was cleared for OCD in 2018. In the main study, about 4 in 10 people on the real device improved, compared with about 1 in 10 on a fake (sham) device.3 TMS devices are also cleared for migraine, smoking cessation, depression with anxiety, and, since 2024, for teens 15 and older as an add-on treatment.1 See medicines for OCD.
TMS is usually not safe if you have metal in or near your head, such as a cochlear implant or certain aneurysm clips. Implanted devices like pacemakers and defibrillators also need careful review. Tell the TMS team about every implant, and any history of seizures or head injury.9
Accelerated TMS and the SAINT protocol
Daily TMS for six weeks is hard for many people, especially those who work or rely on rides. Accelerated TMS tries to shorten this.
SAINT (now also called Stanford neuromodulation therapy) uses a fast form of TMS called theta burst. You get 10 sessions a day for 5 days in a row. A brain MRI scan is used first to pick the exact spot to treat for each person.5
In the main trial, 29 adults with hard-to-treat depression were studied. During the month after treatment, 11 of 14 people who got real treatment reached remission (very few or no symptoms) at some point. Only 2 of 15 people on sham treatment did. Headache and tiredness were the most common side effects.5
The FDA cleared the SAINT system in September 2022. It is cleared for adults with major depression who have not improved enough with antidepressant medicine in the current episode.4
What this means for you. The early results are striking, but the main trial was small, short and done at one center. In 2022, the VA/DoD guideline said there was not yet enough evidence to recommend for or against theta burst treatment.7 Availability and insurance coverage vary. Ask how long benefits lasted for people treated at that clinic.
Electroconvulsive therapy (ECT)
How it works. ECT is done in a hospital or clinic. You get general anesthesia (medicine that puts you fully to sleep) and a muscle relaxant, so your body does not shake. A brief electric current then causes a short seizure in the brain, usually lasting less than a minute. You wake up about 5 to 10 minutes later and are usually alert within an hour.1
What a course looks like. Treatments are usually given three times a week, for a total of about 6 to 12. Many people improve within the first week, faster than with antidepressants. Some people then have "maintenance" ECT, from once a week to once every few months, to stay well.1
How well it works. The VA/DoD guideline gives ECT a strong recommendation for severe depression.7 In 2018, the FDA placed ECT devices in a lower-risk class for catatonia and for severe depressive episodes in major depression or bipolar disorder. That applies to people 13 and older whose illness has not responded to other treatment, or who need fast relief.2
Side effects. Common short-term effects include headache, upset stomach, muscle aches and confusion right after a treatment.1 The FDA also lists rarer serious risks, including heart problems, dental injury, long seizures, lung problems and, very rarely, death. It requires the device labeling to explain these risks and to list other treatment options.2
Memory. Memory loss is the side effect people worry about most. Some people have memory loss after ECT.1 Modern methods lower this risk. Placing the electrodes on one side of the head (unilateral) and using very short pulses (brief or ultrabrief pulse) cause fewer memory problems and still work well.1 Ask your team which method they plan to use and how they will check your memory.
The FDA requires ECT patient information to explain the risks and benefits and to list other treatment choices.2 You, or your legal decision-maker, should get this information and agree before treatment starts. If you want to plan ahead, see advance directives.
Vagus nerve stimulation (VNS)
The vagus nerve runs from the brain down through the neck to the chest and belly. In VNS, a surgeon places a small pulse generator under the skin of the upper left chest. A wire connects it to the vagus nerve in the neck. The device sends mild pulses on a set schedule, and its battery can last about 10 years.1
The FDA approved VNS for depression in 2005. It is for adults whose depression has lasted two years or more, is severe or keeps coming back, and has not improved after at least four other treatments. Benefits can take several months, and not everyone responds.1
Side effects include hoarseness or voice changes, cough, neck pain, trouble swallowing, shortness of breath during exercise, and surgery risks such as infection.1 The VA/DoD guideline suggests against VNS for depression outside of research.7
Medicare. Since 2019, Medicare covers VNS for treatment-resistant depression only when the person is enrolled in a Medicare-approved research study. If a person already has a VNS device, Medicare can cover a replacement when the battery runs out.8
Treatments still in research
- Deep brain stimulation (DBS) places thin wires deep in the brain, connected to a battery in the chest. It is used for Parkinson's disease and tremor. For depression, it is still experimental, and it carries brain surgery risks such as bleeding and stroke.1 The VA/DoD guideline recommends against it outside of research.7
- Magnetic seizure therapy (MST) uses strong magnetic pulses to cause a seizure under anesthesia, like ECT. Early studies suggest it may work about as well as ECT with fewer memory problems. In the U.S., it is available only in research studies.1
- Home devices. Small headsets and clip-on devices that send weak current through the scalp are sold online. Before buying one, ask your doctor what the device is authorized for and what the evidence shows. Do not stop your treatment to try one.
What older adults should know
Depression in later life is common and treatable. See depression in later life.
ECT works well in older adults. In a large study of 240 adults aged 60 and older, people received one-sided, ultrabrief ECT along with an antidepressant. Those who got well did so after about 7 treatments on average, or about two and a half weeks. Overall thinking scores showed little harm, and close to half of people knew where they were again within 10 minutes of a treatment.6 The study authors noted that remission rates were about twice those seen with antidepressants in similar groups.6
Health checks matter more. Before ECT, you will have a medical check to make sure anesthesia is safe, especially if you have heart or lung disease. You will need a ride home after each treatment. Some families plan for extra help at home during the course.
TMS and age. TMS needs no anesthesia, which appeals to many older adults. But some coverage rules treat dementia, past stroke, serious head injury and seizure history as reasons for caution.9 Pacemakers and other implants, which are more common in later life, need careful review.9
Memory worries. If a person already has memory problems or mild cognitive impairment, ask the team how they will track thinking before, during and after treatment. Severe depression itself can harm memory and daily function, so the choice is a balance. A geriatric psychiatrist can help weigh it.
Cost and insurance
For TMS, Medicare coverage rules are set by regional Medicare contractors, so they can differ by area. One regional rule, updated in 2026, covers TMS for adults with severe major depression who have not improved with medicines from at least two different drug groups, or could not tolerate them. It also requires a trial of talk therapy, and a psychiatrist must order and supervise the treatment.9 Your region's rule may differ. For ECT, ask about the costs of the treatment, anesthesia and any hospital stay. Ask the clinic to confirm coverage in writing before you start. See what Medicare covers for mental health.
Questions to ask the doctor
Which treatment fits my situation, and why?
Ask how this choice compares with medicine changes, ketamine or esketamine, and other options. Ask what happens if it does not work.
How many sessions, and how will we know it is working?
Ask about the schedule, how mood will be measured, and when you should expect to notice a change.
What are my personal risks?
Bring a list of all medicines, implants and health conditions. For ECT, ask which electrode placement and pulse type they use, and how memory will be checked.
What will it cost, and who will drive me?
Ask what insurance covers, what you will pay, and how many trips are needed. Plan transportation early.
What happens after the course ends?
Ask about maintenance treatment, therapy and medicine to help you stay well.
When to get help now
Hard-to-treat depression can be exhausting, but many people do get better, including with these treatments. If you have thoughts of suicide, call or text 988 for the 988 Suicide and Crisis Lifeline, any time. If someone is in immediate danger, call 911. You can also make a safety plan or see getting help now. Family members can read when a family member is in a mental health crisis.
Sources
- National Institute of Mental Health. Brain stimulation therapies. NIMH, 2024. NIMH
- U.S. Food and Drug Administration. Neurological devices; reclassification of electroconvulsive therapy devices (final order). Federal Register, 2018. Federal Register
- U.S. Food and Drug Administration. FDA permits marketing of transcranial magnetic stimulation for treatment of obsessive compulsive disorder. FDA, 2018. FDA
- U.S. Food and Drug Administration. 510(k) clearance K220177: Magnus Neuromodulation System with SAINT Technology. FDA, 2022. FDA
- Cole EJ, Phillips AL, Bentzley BS, et al. Stanford Neuromodulation Therapy (SNT): a double-blind randomized controlled trial. Am J Psychiatry, 2022. Journal
- Kellner CH, et al. Right unilateral ultrabrief pulse ECT in geriatric depression: phase 1 of the PRIDE study. Am J Psychiatry, 2016. Journal
- U.S. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the management of major depressive disorder, version 4.0. VA/DoD, 2022. VA
- Centers for Medicare & Medicaid Services. National coverage determination 160.18: vagus nerve stimulation. CMS, 2019. CMS
- Centers for Medicare & Medicaid Services. Local coverage determination L34641: transcranial magnetic stimulation (Wisconsin Physicians Service). CMS, 2026. CMS
Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.