Transcranial magnetic stimulation (TMS) has become one of the most effective treatments available for instances of Depression that have not responded to medication. As the technology has advanced, so have debates about the best methods for TMS coil placement—specifically, whether MRI-guided neuronavigation produces better outcomes than standard scalp-based techniques. Two pivotal studies have helped answer this question: one published in Biological Psychiatry and another in Brain Stimulation.
Both studies conclude that while MRI navigation adds complexity and cost, it does not deliver truly superior clinical results, meaning that these findings have significant implications for patients seeking effective, accessible Depression treatment. Learn more about these studies below and discover how they are changing the TMS treatment landscape for the better.
Studies Regarding MRI-Guided TMS Coil Placement: A Questioned Advantage
The Biological Psychiatry study directly examined whether MRI-guided neuronavigation improves outcomes compared to standard “5-cm rule” TMS coil placement. Meanwhile, the Brain Stimulation report specifically assessed MRI navigation versus standard placement in intermittent theta burst stimulation (iTBS).
The Biological Psychiatry Examination
A randomized, sham-controlled trial in Biological Psychiatry (2020) assessed the antidepressant efficacy of prolonged intermittent theta burst stimulation (piTBS), comparing standard 5-cm rule placement against MRI-guided neuronavigation targeting the dorsolateral prefrontal cortex (DLPFC). The results were striking: the MRI-guided method did not outperform the standard approach. In fact, those receiving standard TMS coil placement actually showed a slightly larger average symptom reduction (−40.6% vs −32.4%).
Neuronavigation vs Non-Neuronavigation (Brain Stimulation Journal)
Another well-controlled study in the Brain Stimulation Journal (2021) compared MRI-guidance versus the 5-cm rule in applying iTBS for Depression. The results were definitive, showing no benefit from neuronavigation across nearly all measured outcomes. These findings together suggest that while MRI neuronavigation enhances anatomical precision, it does not translate into improved patient outcomes in standard rTMS or iTBS protocols. This is an important consideration for patients evaluating their treatment options.
Connectivity-Guided vs MRI-Neuronavigated TMS: No Performance Advantage
Yet another recent trial from 2024 compared connectivity-guided TMS (via resting-state fMRI-based neuronavigation) with standard MRI-neuronavigated rTMS in treatment-resistant Depression. Over 26 weeks, both groups experienced significant and sustained symptom improvement, with no meaningful differences in Depression scores between the two modalities.
This finding is particularly notable because it demonstrates that even more advanced targeting strategies—like connectivity-based approaches—did not lead to better clinical results despite added cost and complexity. For patients considering TMS, what matters most is the quality of care and consistency of treatment—not the sophistication of coil placement technology.
MRI Guidance: A Costly Investment Without Proven Benefit
MRI neuronavigation incurs considerable expense that deserves careful consideration. MRI scanning, neuronavigation systems, software, and trained personnel all add significant overhead to treatment costs. Accelerated MRI-guided protocols (such as SAINT-like approaches) can cost $30,000 or more per course, compared to much lower costs for standard rTMS.
Given the lack of superior outcomes demonstrated in clinical research, the additional cost of MRI-based TMS coil placement is increasingly difficult to justify—especially when such resources could be better allocated to making proven therapies more accessible to patients who need them.
The Bottom Line: Standard TMS Coil Placement Works—and Costs Less
Multiple rigorous studies consistently find that MRI-guided coil placement yields no additional clinical benefit over conventional methods. More intricate targeting does not equal better results, and MRI-neuronavigation often increases the financial barrier to access. These findings have important implications for patients seeking effective Depression treatment without unnecessary expense.
Standard, well-validated coil placement protocols—like the 5-cm rule or Beam F3 method—deliver outcomes equivalent to MRI-guided approaches when paired with expert application, consistent training, and fidelity to evidence-based protocols. This means patients can receive effective treatment without the added cost of advanced imaging technology.
Achieving Precision Through Simplicity
Clinicians should regularly monitor advances in TMS targeting—including MRI-guided coil placement—and strive to make informed decisions about cutting-edge technologies. At Mid City TMS, we use standardized, clinically validated scalp-based coil placement, executed with care and consistency by our experienced team.
Our clinicians are highly trained, ensuring accurate and reproducible targeting for every patient who comes through our doors. Rather than investing in expensive technology that research shows provides no additional benefit, we invest in accessible treatments using cost-effective methods that deliver consistent results.
By bypassing MRI-guidance for coil placement, we’re able to keep treatments affordable and timely—without compromising outcomes. This approach allows us to focus our resources on what truly matters: providing compassionate, expert care to our patients.
Effective, Accessible, and Compassionate Treatment Protocols with Mid City TMS
Not all innovation improves outcomes—and more expensive TMS coil placement does not mean better. As the evidence clearly shows, MRI-guided TMS adds cost and complexity without improving patient results. For patients with treatment-resistant Depression, what matters most is receiving consistent, high-quality care from trained professionals using proven techniques.
At Mid City TMS, we are committed to treatments that are both evidence-based and accessible. We use standard TMS techniques backed by strong clinical data—because what matters most is getting results for our patients. Contact us today if you would like to learn more about our evidence-backed and affordable treatment protocols.
Sources:
- Hebel, T., Fell, J., & Plewnia, C. A direct comparison of neuronavigated and non-neuronavigated intermittent theta burst stimulation in the treatment of depression. Brain Stimulation. https://www.brainstimjrnl.com/article/S1935-861X(21)00018-8/fulltext Brain Stimulation Journal
- Li, C. T., Wang, S. J., Yang, C. H., Lin, W. C., Huang, S. Y., & Hsieh, J. C. Antidepressant efficacy of prolonged intermittent theta burst stimulation: A randomized, double-blind, sham-controlled study. Biological Psychiatry. https://www.biologicalpsychiatryjournal.com/article/S0006-3223(19)31583-5/fulltext
- Morriss, R., Briley, P. M., Webster, L., Abdelghani, M., Barber, S., Bates, P., Brookes, C., Hall, B., Ingram, L., Kurkar, M., Lankappa, S., Liddle, P. F., McAllister-Williams, R. H., O’Neil-Kerr, A., Pszczolkowski, S., Suazo Di Paola, A., Walters, Y., & Auer, D. P. Connectivity-guided intermittent theta burst versus repetitive transcranial magnetic stimulation for treatment-resistant depression: a randomized controlled trial. Nature Medicine. 2024;30(2):403–413. https://doi.org/10.1038/s41591-023-02764-z https://pmc.ncbi.nlm.nih.gov/articles/PMC10878976/
