LORI-CAPSTONE 3
1
Capstone Part 2: Review of Literature
Student’s name: Yaneisy Loriga
Instructor: Carmen Lazo
Course: MSN Capstone Project-DBX-DL01
Date: March 31, 2026
Review of Literature
Transcranial Magnetic Stimulation for Treatment-Resistant Depression
Synthesis of Current Evidence
Major Depressive Disorder is one of the most severe and common mental illness disorders. It is defined by continuous sadness, lack of interest in all activities in life, and failure to perform normal functioning, and even suicidal thoughts in a more severe form. It has a vast impact on millions of adults worldwide and is an extensive phenomenon that influences the quality of life, productivity, and overall health outcomes (Fiorillo et al., 2025). It affects millions of grown-ups in the universe and has very far-reaching impacts on life quality, output, and the overall outcome of health. Depression is one of the difficulties that most adults encounter whenever they attempt to respond to antidepressant treatments without taking the appropriate treatment regimen.
Several studies that were conducted properly come to the conclusion of a significant decrease in the severity of depression, as well as well-validated scales like Patient Health Questionnaire-9 (PHQ-9) and Hamilton Depression Rating Scale (HDRS) (Nwachukwu, 2025). Ilhan & Arikan (2025) also determined that TMS had a greater reduction in depressive symptoms and remission rate in patients, as compared to patients who received only sham (fake) TMS and pharmacologic treatment. On the same note, a systematic review and meta-analysis study, by Saelens et al., (2025) revealed that TMS was effective in enhancing the response and remission rate of TRD. The positive outcomes are unanimous, although variability of the studies exists in the specifics of TMS, such as frequency, intensity, and duration of stimulation. High-frequency TMS has been reported to produce better results compared to low-frequency TMS in some studies, whereas in some others, there are no differences in results (Saelens et al, 2025). Moreover, the short-term effects are predictable, but the long-term effects are somewhat unpredictable, and some patients may need booster treatments to maintain TMS effects. Hutton et al (2023). TMS access may also be made available in such areas as Miami-Dade County, where there are numerous underserved patients with deficient access to mental health care. Such practice change opens the door to novel treatment modalities and achieves population health and clinical goals.
Application to PICOT Question
My PICOT question is “In adults aged 21–65 diagnosed with treatment-resistant Major Depressive Disorder in an outpatient mental health clinic in Miami-Dade County (P), how does Transcranial Magnetic Stimulation (TMS) therapy (I), compared to continued pharmacologic management alone (C), affect depressive symptom reduction and functional improvement (O) over a 12-week treatment period (T)?”. Evidence supports the PICOT question, which seeks to compare whether or not TMS, along with pharmacotherapy, is more effective than pharmacotherapy alone at 12 weeks for the treatment of depressive symptoms and capacity for independent function. Most studies focused on adult participants (21-65 years) with a diagnosis of TRD, aligning well with the intended patient population in Miami-Dade County. The studies demonstrate that TMS results in greater improvement in depressive symptoms and increases functioning in various areas, including activities of daily living, social participation, and work. These measures directly align with the planned outcomes measured in the PICOT question, such as using the PHQ-9. Many studies also involve the use of TMS in an outpatient setting, increasing the likelihood of similar settings for implementation.
Evidence Supporting Practice Change
The evidence for practice change in the dissemination of TMS is robust, backed up by efficacy, impact, and effectiveness. TMS has been compared to medication-only treatment in many randomized controlled trials and reviews in patients with treatment-resistant depression (Saelens et al., 2025). TMS has a response rate of 50% to 60%, and a remission rate of 30% to 40%, which is comparable with medication alone in treatment-resistant depressed patients (Joseph et al., 2025).
In addition, TMS has shown increased functionality. Patients treated by TMS have better cognitive metrics, quality of life, and functionality. This is crucial as TRD is often associated with both persistent depressive symptoms and dysfunction (Hutton et al., 2023). By addressing symptoms and functioning, TMS takes a comprehensive approach. TM has few side effects as far as safety is concerned. As a non-pharmacological approach, TMS has fewer side effects particularly in comparison to the side effects that are normally experienced when taking a medication, such as weight gain, drowsiness, and sexual dysfunction. TMS is safe and results in enhanced adherence to treatment and reduced drop-outs.
The next factor to consider is cost. Though there is a cost for the equipment and training for TMS, there are studies describing the cost-benefit of TMS. These patients have trialed multiple medications, had many visits to the doctors, and potentially been hospitalized. The effectiveness and low rate of relapse with TMS result in cost savings for other medical and psychiatric care. Cost-benefit studies suggest TMS yields a cost-benefit over time, particularly for those with severe, chronic depression.
Nurses, Advanced Practice Nurses (APNs) in particular, play a critical role in TMS (Hutton et al., 2023). Studies highlight nurses' coordination of care, education, and monitoring of treatment response. Nurses are instrumental in assessing for TMS, educating patients about TMS, documenting treatment protocols, and assessing TMS with a range of outcome measures (Lozano et al., 2025). The presence of nurses enhances patient satisfaction and engagement and increases patient outcomes.
Need for Practice Change
It is necessary to alter because the current ways of treating depression and especially treatment-resistant depression are not effective. Not all patients become asymptomatic on medication, which causes persistent sickness, lower quality of life scores, and high risk of hospitalization (Okesanya et al., 2025). Moreover, the burden of depression on health care system is growing and it is obvious that more efficient and more sustainable methods are required. In some parts of the state such as Miami-Dade County, this problem is exacerbated by the socioeconomic status of the people and their access to specific forms of mental health treatment. Patients are prone to further sickness and distress until alternative interventions including TMS are considered.
Current State and Gaps in Care
The typical approach to depression treatment is medications, which fail in treating treatment-resistant depression. Psychotherapies and medication are broadly administered but they are inadequate to everyone. The restrictions to the implementation of TMS include the high cost, limited time and access, and the lack of training of providers (Lozano et al., 2025). However, increasing awareness, technological advances and evidence of the effectiveness of TMS are mitigating these obstacles and make TMS adoption easier.
The Advantages and The Disadvantages of TMS.
TM has a high level of benefits such as safety, effectiveness and side effect. Its advantages are that it is a choice when a patient is not responding to other interventions, and there is an increase in the symptoms and functioning of depression (Bhattacharya et al., 2022). Such drawbacks as the necessity of several treatments, high initial price, and the possible variation in the response time are present. Maintenance interventions might be required.
Conclusion
Consistent findings exist with regard to the use of Transcranial Magnetic Stimulation in treatment-resistant depression. TMS provides superior functional and symptomatic results compared with pharmacologic therapy.
References
Bhattacharya, A., Mrudula, K., Sreepada, S. S., Sathyaprabha, T. N., Pal, P. K., Chen, R., & Udupa, K. (2022). An overview of noninvasive brain stimulation: basic principles and clinical applications. Canadian Journal of Neurological Sciences, 49(4), 479-492. https://www.cambridge.org/core/journals/canadian-journal-of-neurological-sciences/article/an-overview-of-noninvasive-brain-stimulation-basic-principles-and-clinical-applications/9D38950F1384209EFC1E524135CC65F8
Fiorillo, A., Demyttenaere, K., Martiadis, V., & Martinotti, G. (2025). Treatment resistant depression (TRD): epidemiology, clinic, burden and treatment. Frontiers in Psychiatry, 16, 1588902. https://doi.org/10.3389/fpsyt.2025.1588902
Hutton, T. M., Aaronson, S. T., Carpenter, L. L., Pages, K., Krantz, D., Lucas, L., ... & Sackeim, H. A. (2023). Dosing transcranial magnetic stimulation in major depressive disorder: relations between number of treatment sessions and effectiveness in a large patient registry. Brain Stimulation, 16(5), 1510-1521. https://doi.org/10.1016/j.brs.2023.10.001
Ilhan, R., & Arikan, M. K. (2025). The effect of repetitive and Deep Transcranial Magnetic Stimulation on quantitative electroencephalography in major depressive disorder. Frontiers in Psychiatry, 15, 1473743. https://doi.org/10.3389/fpsyt.2024.1473743
Joseph, J. T., Vishwanath, R., & Praharaj, S. K. (2025). Efficacy and safety of accelerated transcranial magnetic stimulation for obsessive-compulsive disorder: A systematic review and meta-analysis. Asian Journal of Psychiatry, 106, 104420. https://doi.org/10.1016/j.ajp.2025.104420
Lozano, A., Weinstein, E. R., Lee, T. K., Smith, J. D., Brown, C. H., & Prado, G. (2025). Implementation climate and clinic personnel attitudes in primary care towards a mental health and drug use preventive intervention for hispanic families: preliminary findings. Frontiers in health services, 5, 1619869. https://doi.org/10.3389/frhs.2025.1619869
Nwachukwu, F. O. (2025). Development and Implementation of a Nurse Practitioner-Directed Screening Method for Major Depressive Disorder in a Behavioral Health Unit Using a Standardized Rating Tool (PHQ-9) (Doctoral dissertation, Wilmington University (Delaware)). https://www.proquest.com/openview/537f16aab563d1b15bb625bd5084f28f/1?pq-origsite=gscholar&cbl=18750&diss=y
Okesanya, O. J., Oso, T. A., Adebayo, U. O., Obadofin, J. A., Abdulghaniy, R. O., Bamigbade, A. A., ... & Aban, J. L. (2025). Transforming public mental health: a review on global trends, challenges, and pathways to change. Health Care Analysis, 1-29. https://link.springer.com/article/10.1007/s10728-025-00549-8
Saelens, J., Gramser, A., Watzal, V., Zarate Jr, C. A., Lanzenberger, R., & Kraus, C. (2025). Relative effectiveness of antidepressant treatments in treatment-resistant depression: a systematic review and network meta-analysis of randomized controlled trials. Neuropsychopharmacology, 50(6), 913-919. https://www.nature.com/articles/s41386-024-02044-5
Yen, C., Valentine, E. P., & Chiang, M. C. (2024). The use of transcranial magnetic stimulation in attention optimization research: a review from basic theory to findings in attention-deficit/hyperactivity disorder and depression. Life, 14(3), 329. https://doi.org/10.3390/life14030329