TMS Therapy · Hayward, CA

Patients evaluating TMS clinics often run into a thicket of overlapping terms: iTBS, theta-burst, cTBS, Express TMS, TouchStar Theta Burst, accelerated iTBS, SAINT. Different clinics call essentially the same thing by different names, and a few clinics use one name to describe protocols that are meaningfully different. The result is real confusion at exactly the moment when patients are trying to compare options.

The short answer: iTBS (intermittent theta-burst stimulation) is a specific form of theta-burst stimulation. They are not synonyms — but in most patient-facing conversations, when a clinic says “theta-burst” they mean iTBS. “Express TMS,” “TouchStar Theta Burst,” and similar branded names almost always refer to iTBS as well.^[1]

What “theta-burst stimulation” actually means

Theta-burst stimulation (TBS) is a family of patterned TMS protocols that deliver pulses in a specific rhythm: bursts of three pulses at 50 Hz, repeated at 5 Hz (the theta rhythm). The name comes from the 5-Hz repetition rate, which falls in the theta band of brainwave frequencies.^[1]

TBS comes in two main forms:

Intermittent TBS (iTBS) — 2 seconds of theta-burst trains, followed by an 8-second pause, repeated for ~3 minutes total. This pattern produces a long-term potentiation (LTP)–like increase in cortical excitability. For depression, iTBS is delivered to the left dorsolateral prefrontal cortex (DLPFC). 600 pulses per session.^[1]

Continuous TBS (cTBS) — Theta-burst pulses delivered continuously for about 40 seconds, without the pause intervals. This pattern produces a long-term depression (LTD)–like decrease in cortical excitability. cTBS is typically used over the right DLPFC for depression (to inhibit relative hyperactivity on that side), or as an inhibitory protocol in other applications. 600 pulses per session.

So when someone says “theta-burst,” they’re usually referring to iTBS specifically — but the broader family includes both excitatory and inhibitory protocols. cTBS is less commonly used as a primary depression treatment in U.S. clinics but appears in some bilateral protocols.

What the THREE-D trial established

iTBS got FDA clearance for depression in 2018 on the strength of the THREE-D randomized non-inferiority trial, which compared 3-minute iTBS against the standard 37.5-minute 10-Hz rTMS protocol in 414 adults with treatment-resistant depression. The trial demonstrated that iTBS was non-inferior to standard rTMS on every efficacy measure: response rates around 49% iTBS versus 47% rTMS, remission around 32% versus 27%, adverse events broadly similar.^[2]

The key implication: iTBS delivers the same therapeutic dose as standard 10-Hz rTMS in one-twelfth the time. For patients who can complete the 4-6 week course, the choice between iTBS and 10-Hz comes down to session length preference, scalp-sensation tolerance (some patients find the more concentrated iTBS bursts less comfortable than the slower 10-Hz rhythm), and clinic equipment availability.^[3]

The 2024 network meta-analysis update

A 2024 network meta-analysis of 23 randomized trials comparing TBS protocols (iTBS, cTBS, bilateral TBS) against sham and against standard rTMS in depression confirmed that iTBS protocols match or slightly exceed 10-Hz rTMS for response and remission, with comparable safety profiles. Manic-switch incidence was not significantly elevated with TBS versus sham. Headache and scalp soreness rates were similar across protocols.^[4]

The conclusion: TBS protocols, particularly iTBS, are now first-line for many depression-TMS courses, displacing 10-Hz rTMS in clinics that prioritize session efficiency. The clinical efficacy is equivalent; the time savings are real.^[2][4]

What to ask your clinic if the naming feels confusing

“Is this iTBS, cTBS, or standard 10-Hz rTMS?” The answer should be specific. If the clinic only says “theta-burst” or uses a brand name, ask for the underlying protocol designation.

“How long is the active stimulation per session?” 3 minutes = iTBS. ~37.5 minutes = standard 10-Hz rTMS. ~20 minutes = Deep TMS H1. Other lengths exist for specific accelerated protocols.

“How many pulses per session?” Standard iTBS = 600 pulses. Standard 10-Hz rTMS = 3,000 pulses. The pulse count tells you what dose you’re getting.

“What FDA clearance applies?” iTBS is FDA-cleared for depression (2018). The clinic should be able to cite the specific clearance.

“Are accelerated protocols available?” Some clinics offer SAINT-style accelerated iTBS (multiple sessions per day for 5 days). Different from standard iTBS in schedule, similar in per-session protocol.^[5]

The bottom line

iTBS and theta-burst stimulation are closely related but not identical. iTBS is the specific 3-minute, excitatory, 600-pulse protocol delivered to the left DLPFC for depression — and it’s what most clinics mean when they say “theta-burst.” cTBS is the inhibitory counterpart, used less often as primary depression treatment in U.S. clinics. Branded names like “Express TMS” and “TouchStar Theta Burst” describe iTBS delivered via specific manufacturers’ equipment.

The THREE-D trial established iTBS as non-inferior to standard 10-Hz rTMS for depression, with the same therapeutic dose delivered in one-twelfth the time. For patients comparing TMS clinics, the protocol designation (iTBS, cTBS, 10-Hz rTMS, Deep TMS) matters more than the marketing name.^[2][4]

If you’re in Hayward or the East Bay and you want to understand exactly which protocol fits your schedule and your indication, that’s what a consultation is for.

Nefretiri Abat, JD, PMHNP-BC — Founder, Exxceed Wellness. Exxceed Wellness offers iTBS, standard 10-Hz rTMS, and Deep TMS at our Hayward, CA practice. Schedule a consultation at exxceedwellness.com.