What Should a Referring Clinician Screen For Before Making a Deep TMS Referral?

Direct Answer

Screen five domains and flag what you find rather than trying to resolve it. Implanted or magnetic-sensitive devices and metal in or near the head, which is the one genuine absolute contraindication. Seizure and neurological history, including epilepsy, stroke, significant head injury and epilepsy in a first-degree relative. Current medications, since some lower the seizure threshold. Substance use, particularly heavy alcohol use or withdrawal and stimulant use. And the client’s current state, including sleep deprivation, active psychotic symptoms and any recent shift toward mania.

None of this is a clearance decision. The treating service conducts definitive screening and the treating physician determines candidacy. What a referring clinician contributes is the longitudinal detail a one-hour intake will not surface, particularly around substance use, sleep and treatment history. Do not adjust or discontinue any medication in anticipation of a referral.

Your Job Is to Flag, Not to Clear

Referring clinicians sometimes hesitate to raise safety questions on the grounds that screening is the service’s responsibility. It is, and that is not a reason to stay quiet. Intake screening is a structured interview conducted once with someone the client has just met. You have months or years of observation and a relationship in which the client is more likely to disclose accurately.

The items most often missed at intake are the ones a client does not consider medically relevant: a concussion in high school sport, a sibling with epilepsy, drinking that has escalated quietly, a stimulant prescription obtained elsewhere, sleep that has collapsed since term started. Those belong in the referral letter.

The Absolute Contraindication Is Metal and Implanted Devices

The Medicare local coverage determination for transcranial magnetic stimulation in adults with major depressive disorder identifies as an absolute contraindication the presence of magnetic-sensitive implanted devices within 30 centimeters of the treatment coil, giving pacemakers, implantable cardioverter defibrillators, cochlear implants and metal aneurysm clips as examples.¹ The same policy lists relative contraindications including a history of seizure disorders, active psychotic symptoms in the current episode and neurological conditions such as epilepsy, cerebrovascular disease, dementia, a history of head trauma and central nervous system tumors.¹

The screening question a client will answer accurately is not “do you have any implanted devices”. It is a specific list. Ask about pacemakers and defibrillators, cochlear implants, aneurysm clips, deep brain stimulators, vagus nerve stimulators, shunts, metal plates or fragments in the head or neck and any surgery involving the skull. Dental work and most orthopedic hardware are not in the relevant zone, but the service makes that determination rather than the referrer.

Seizure Risk Is Low, and Screening Still Matters

The absolute risk is small and worth stating accurately, because clients arrive with an inflated fear of it. A literature review of transcranial magnetic stimulation safety with respect to seizures reports overall risk of under one percent, with figures varying by protocol and coil type. It cites an estimate of fewer than one in 30,000 sessions from the 2009 safety guidelines, a rate of 0.087 percent reported for the H-coil used in deep TMS and a survey finding of 0.08 seizures per 1,000 sessions.²

The same review notes something that reframes the conversation. Seizure rates associated with commonly prescribed psychotropic medications often equal or exceed the risk associated with TMS, with reported figures of 0.9 percent for olanzapine and 0.8 percent for quetiapine.² A client weighing deep TMS against continued medication is not choosing between a risky option and a safe one.

Low absolute risk is a reason to screen carefully rather than a reason to skip it, because the risk is not evenly distributed. The review identifies personal history of seizure, stroke or epilepsy, severe head trauma and traumatic brain injury, concussions, untreated epilepsy, epilepsy in a first-degree relative and demyelinating disorders such as multiple sclerosis as factors that raise it.²

The Bupropion Question Comes Up Constantly

Referring clinicians frequently assume that a client taking bupropion cannot have TMS, because bupropion lowers the seizure threshold. The safety literature does not support treating it as a bar. The same review reports that TMS-induced seizure data are not associated with any particular antidepressant and that bupropion is not a contraindication to TMS.²

The correct handling is to document it rather than to act on it. List every current medication with dose in the referral, note anything known to lower the seizure threshold and let the treating physician weigh it. Withdrawing a medication that is working, in anticipation of a referral that has not yet been accepted, creates a real risk in exchange for a theoretical one.

State-Dependent Risks Change Week to Week

Several of the factors that matter are not fixed features of a history. Sleep deprivation is identified as a particularly significant contributor, and heavy alcohol use and withdrawal, cocaine and MDMA use and severe eating disorders all appear among the behavioral and metabolic risk factors.² Every one of those is common in an emerging adult population and every one can change between the referral letter and the first appointment.

A standard course runs daily sessions five days a week for four to six weeks,⁴ which means these factors matter during treatment rather than only at screening. That argues for two things. Describe the client’s current state rather than their baseline, and say when you last observed it. And flag any pattern likely to shift, such as a client who drinks heavily on weekends or whose sleep collapses during examination periods, so the service can time the assessment rather than discover the pattern mid-course.

Yellowbrick provides neuroscience technologies and neuromodulation services through an agreement with its sister company Synchrony Brain Health, whose outpatient services include Deep TMS. Age criteria are part of screening too, since the deep TMS adolescent clearance covers ages 15 to 21 as an adjunct rather than as a standalone treatment.⁵ Screening protocols and device specifics vary between services, so confirm what a given service requires before preparing a client for what to expect.

Screening Domains and What to Ask

What to Put in the Referral Letter

• A specific device list with each item answered, rather than a line saying no contraindications identified.
• Head injury history including sport concussions and childhood injuries, with approximate dates.
• Family history of epilepsy in first-degree relatives, asked directly rather than inferred.
• The complete current medication list with doses, including anything prescribed by another provider.
• Substance use with recency and pattern, not a yes or no.
• Current sleep, described concretely, and what has changed in the last month.
• Any history of mania or hypomania, and whether a mood stabilizer is in place.
• Eating disorder history and current status.
• Date of birth, and a note if the client is under 22.
• The date you last saw the client, so the service knows how current your description is.

Key Takeaway

Screen five domains and flag rather than clear: implanted and magnetic-sensitive devices, seizure and neurological history, current medications, substance use and the client’s current state. Implanted devices near the coil are the one absolute contraindication in coverage policy, while seizure history, active psychosis and several neurological conditions are relative. Absolute seizure risk is low. It is reported at under one percent overall and at 0.087 percent for the coil used in deep TMS, comparable to or lower than rates associated with several commonly prescribed psychotropics. Bupropion is not a contraindication, so document it rather than acting on it, and never adjust medication in anticipation of a referral. The items most often missed are the ones a client does not think of as medical: an old concussion, a sibling with epilepsy, weekend drinking and collapsed sleep.

Clinical Note

This article is general guidance for referring clinicians. It is not a substitute for individual clinical judgment or an individualized assessment, it does not clear any patient for any procedure and it does not constitute medical advice. Safety screening, candidacy and device selection rest with the treating service and the treating physician. Do not adjust, withhold or discontinue any medication on the basis of this article. Contraindication lists, coverage policies and device clearances vary and change, so confirm current requirements directly with the service.

If a client is in immediate danger, direct them to emergency services. The 988 Suicide and Crisis Lifeline provides free, confidential crisis support 24 hours a day, seven days a week, by call or text to 988.³

Glossary

• Absolute contraindication: a condition under which a treatment should not be given at all.
• Relative contraindication: a factor that raises risk and requires individual weighing rather than automatically excluding treatment.
• Magnetic-sensitive implanted device: an implanted device whose function can be affected by a magnetic field, such as a pacemaker, implantable cardioverter defibrillator, cochlear implant or aneurysm clip.
• Seizure threshold: the level of neuronal excitability above which a seizure occurs, which some medications and states lower.
• H-coil: the coil design used in deep transcranial magnetic stimulation, with its own reported safety profile.
• State-dependent risk: risk arising from a condition that varies over time, such as sleep deprivation or alcohol withdrawal, as distinct from a fixed historical factor.
• Adjunct clearance: an FDA clearance for use alongside another treatment rather than as a standalone therapy.

References

1. Centers for Medicare and Medicaid Services. “LCD – Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder (L34998).” Novitas Solutions, Inc., revision effective December 11, 2022. Accessed August 25, 2026. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34998.
2. Stultz DJ, Osburn S, Burns T, Pawlowska-Wajswol S, Walton R. “Transcranial Magnetic Stimulation (TMS) Safety with Respect to Seizures: A Literature Review.” Neuropsychiatric Disease and Treatment, vol. 16, December 2020. Accessed August 25, 2026. https://www.dovepress.com/transcranial-magnetic-stimulation-tms-safety-with-respect-to-seizures–peer-reviewed-fulltext-article-NDT.
3. 988 Suicide and Crisis Lifeline. Operated in partnership with the Substance Abuse and Mental Health Services Administration and Vibrant Emotional Health. Accessed August 25, 2026. https://988lifeline.org/.
4. National Institute of Mental Health. “Brain Stimulation Therapies.” NIMH Health Topics, last reviewed March 2024. Accessed August 25, 2026. https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.
5. BrainsWay. “BrainsWay Receives FDA Clearance of Deep TMS as Adjunct Therapy for Major Depressive Disorder (MDD) in Adolescents Aged 15 to 21.” Company announcement, November 12, 2025. Accessed August 25, 2026. https://www.brainsway.com/news_events/brainsway-receives-fda-clearance-of-deep-tms-as-adjunct-therapy-for-major-depressive-disorder-mdd-in-adolescents-aged-15-to-21/.

Learn more about Yellowbrick Consultation and Treatment Center on Google.