Naturalistic Outcomes with fMRI-Guided and Non-fMRI-Guided Accelerated TMS for Depression

ObjectiveTo estimate the effects of accelerated transcranial magnetic stimulation (aTMS) with and without functional MRI (fMRI) guidance in a naturalistic clinic setting. MethodsWe retrospectively analyzed data on patients who received aTMS for depression at a single subspecialty clinic between 2019 and 2025, most completing a five-day course (up to 10 treatments per day). fMRI-guided targets were selected from resting-state connectivity to the subgenual cingulate cortex. Non-fMRI-guided targeting was done using scalp-based measurement procedures. Response was defined as a Clinical Global Impression-Improvement score [≤]2 within one month post-TMS. Logistic regression evaluated predictors of response and propensity score matching was used to create comparable groups of fMRI-guided and non-fMRI-guided patients while controlling for baseline heterogeneity. Predictors included age, sex, baseline severity, past electroconvulsive therapy, past TMS, previous antidepressant trials, number of sessions, comorbidities, and fMRI guidance. ResultsOf 195 patients receiving aTMS, 115 received fMRI guidance and 80 did not. The overall response was 72.8% (77.4% with fMRI guidance, 66.3% without). Logistic regression identified fMRI guidance as the only independent predictor of response (p=0.038). In 71 pairs matched using propensity scores, response rates were 77.5% with fMRI guidance and 62.2% without (OR=2.30, 95% CI=1.05-5.41, p=0.035), yielding a number needed to treat of 6.5 to achieve one added response with fMRI guidance. ConclusionsIn this large naturalistic sample, aTMS was an effective, rapid-acting antidepressant with or without fMRI guidance. fMRI-guided targeting significantly improved outcomes.