TMS — What is the SAINT protocol?
Transcranial Magnetic Stimulation (TMS) for depression is typically administered once a day for 20 minutes, 5 days a week for 6 weeks, followed by a gradual taper. Termed the DASH protocol, this method has been adopted into clinical practice for many years with excellent results and is the go-to protocol for conventional TMS treatment of depression. By this method, around 50-60% of patients will achieve remission (complete resolution of depressive symptoms) while closer to 80 percent will experience an overall improvement in their symptoms.
Recently, researchers at Stanford, led by Dr. Nolan Williams, wanted to determine whether condensing the number of TMS sessions and modifying the pulse frequency could be equally or more efficacious. The protocol they studied is called the Stanford Accelerated Intelligent Neuromodulation Technique (SAINT) or, alternatively, the Stanford Neuromodulation Technique (SNT).
How is SAINT different?
The SAINT method is a type of accelerated TMS protocol that administers a full course of treatment—50 sessions—over the span of just 5 days. Patients undergo 10 sessions per day lasting ten minutes each, separated by 50-minute breaks, and each session utilizes “intermittent theta burst” (iTBS) stimulation to deliver high-frequency pulses over a short duration.
The brain area targeted by all variants of TMS is the dorsolateral prefrontal cortex (DLPFC), but SAINT utilizes a specific brain-imaging technique called resting functional connectivity MRI (fcMRI) to localize this region more precisely, which can vary from person to person by as much as several millimeters. This neuronavigationtechnique makes SAINT more expensive and resource-intensive to deliver (requiring specialized software and technicians), yet it is also thought to increase its accuracy and effectiveness compared to conventional TMS.
SAINT is not the first accelerated TMS program to be studied. Accelerated TMS refers to any TMS treatment that is administered more frequently than once per day. For at least the last decade, clinical research has supported the efficacy of both left-sided, right-sided, and intermittent theta burst accelerated TMS therapy for depression. SAINT, however, represents a unique category of accelerated TMS that combines iTBS with fcMRI neuronavigation. It has caught the attention of the scientific community not only for its robust effectiveness but also for its dramatic and rapid antidepressant effect.
What are the results of SAINT TMS?
Two large-scale studies have been published on the SAINT protocol. The first study, published in April 2020, included patients who previously failed to respond to conventional TMS and found that 90% (19 of 21 participants) achieved remission in as little as 3-5 days. The follow-up study, published in October 2021, excluded patients previously treated with TMS but confirmed the strong results, with 79% of 29 participants achieving remission within 5 days of treatment. After 5 weeks, the remission rate dropped noticeably but remained around 50%. More research is needed to assess its long-term durability, especially for those who have previously failed TMS, but it is clear that SAINT offers a dramatic antidepressant response in a fraction of the time than conventional TMS.
Is SAINT safe?
SAINT was found to be safe and well-tolerated in the two studies cited above. The only side effects reported were, fatigue and some discomfort at both the stimulation site and in the facial muscles during treatment, similar to side effects reported with conventional TMS. Neuropsychological testing demonstrated no negative cognitive side effects from SAINT. In fact, they found that participants’ ability to switch between mental tasks improved.
Summary:
The SAINT or SNT protocol developed at Stanford is a breakthrough in neuromodulation therapy due to its dramatic effect size and rapidity of action within a treatment-resistant population; 90% remission rate in 5 days is impressive no matter how you slice it. While we cannot yet conclude, lacking the requisite long-term head-to-head data, that this method is superior to conventional TMS, we can recognize that SAINT offers a practical and highly effective solution for those who need rapid relief but cannot commit to 6 weeks of daily treatments.
The FDA officially cleared the SAINT Neuromodulation System for the treatment of depression in September 2022. Although functional neuronavigation is a required element of the official SAINT protocol studied at Stanford, similar protocols can still be delivered using standard brain mapping techniques rather than fcMRI-guided targeting, which has yet to be proven as the primary driver of SAINT/SNT success. All the other ingredients of SAINT—namely, high-frequency iTBS dosing, a greater number of sessions (50 vs 36), and a denser treatment course (1 week vs 6-8 weeks) can be readily applied using conventional TMS machines and standard DLPFC-localization techniques.
Our team at Principium Psychiatry is happy to offer this accelerated TMS protocol by request. Feel free to reach out to schedule an evaluation today.
