How Best to Utilize Transcranial Magnetic Stimulation in Sports Performance Psychiatry

Psychiatric disorders such as depression, anxiety, and substance misuse occur in athletes at rates comparable with or higher than those in the general population.^1,2 Yet, pharmacological treatment in this population can be complicated by World Anti-Doping Agency (WADA) restrictions. Under the 2025 World Anti-Doping Code, medications such as stimulants for attention-deficit/hyperactivity disorder, such as methylphenidate and amphetamine derivatives; β-blockers for performance anxiety; and systemic glucocorticoids for inflammation or mood symptoms are prohibited for athletes participating in competition.³ Even when therapeutic-use exemptions are possible, stigma, adverse effects, or administrative barriers may limit their use.

As clinicians seek safe, effective, and nonbanned interventions for athletes facing both mental and physical stressors, interest in neuromodulation has expanded. Initially developed for diagnostic neurophysiology, transcranial magnetic stimulation (TMS) has been FDA-approved for conditions such as major depressive disorder, obsessive-compulsive disorder, and smoking cessation.⁴ Through controlled electromagnetic induction, it modulates cortical excitability and mechanisms of network plasticity, relevant not only to psychiatric recovery but also to potential motor and cognitive optimization. While TMS is FDA-approved for several psychiatric and neurologic indications, its use in sports remains investigational and should be limited to therapeutic or research settings.

TMS for Performance Enhancement

TMS operates through Faraday's principle of electromagnetic induction, producing localized cortical depolarization followed by frequency-dependent neuroplasticity.⁵ High-frequency stimulation (≥5 Hz) induces long-term potentiation-like excitatory effects, whereas low-frequency (≤1 Hz) stimulation elicits long-term depression-like inhibitory effects.⁵ These mechanisms mirror those underlying motor learning and cortical reorganization during athletic skill acquisition. Qi et al framed TMS within a broader class of noninvasive brain-stimulation tools,⁶ including transcranial direct current stimulation (tDCS), transcranial alternating current stimulation, and emerging modalities such as transcranial focused ultrasound. Modulating brain-muscle connectivity through these methods can influence core attributes such as endurance, motor learning, and reaction time in competitive athletics.

High-frequency repetitive (r)TMS over the dorsolateral prefrontal cortex (DLPFC) improved motor coordination in volleyball players and reduced motor thresholds, reflecting enhanced cortical readiness.⁷
Evidence for the effects of TMS in athletic populations is emerging. Moscatelli et al reported improved interlimb synchronization after DLPFC rTMS in trained volleyball players.⁷ Conceição dos Santos et al validated a lower-limb protocol that increased muscle strength in healthy men.⁸ Keriven et al combined TMS with peripheral stimulation to accelerate recovery from delayed-onset muscle soreness, showing improved heart-rate variability, a marker of parasympathetic recovery.⁹ However, these studies are small and preliminary, highlighting the need for further research to confirm and expand upon these findings.

High-frequency stimulation (≥10 Hz) of the primary motor cortex may transiently enhance motor learning, coordination, and postexertional recovery by increasing corticospinal excitability and promoting neuroplasticity. Likewise, stimulation of the DLPFC can augment attention, motivation, and executive control, key factors in performance consistency and mental resilience.

Recovery and Concussion Care

Recovery and resilience are central to sports psychiatry and can affect performance, a key metric for coaches and club success. Concussion and postconcussive syndromes represent areas in which TMS may have both therapeutic and performance implications. Moussavi et al demonstrated that rTMS applied to the DLPFC improved mood, cognition, and fatigue in postconcussion patients within one year of injury.¹⁰ These findings parallel research into rTMS for mild traumatic brain injury, where cortical network normalization may expedite neurocognitive recovery. Hallock et al emphasized the importance of individualized concussion management and cognitive rehabilitation, which TMS may complement.¹¹ By improving attentional control, working memory, and cortical excitability, TMS could be used as a noninvasive adjunct to cognitive-motor recovery after sport-related concussions. TMS may restore prefrontal regulation after concussion, accelerating recovery of executive and motor control networks involved in both rehabilitation and athletic performance.

Performance Pressure

Athletes often underreport depression and anxiety due to stigma and performance pressures.^1,2 The International Olympic Committee’s 2019 consensus urged sports organizations to treat mental health as an integral part of performance.² Recent epidemiologic data confirm that anxiety disorders, including generalized anxiety, panic, social anxiety, and performance anxiety, affect approximately 9% of athletes, mirroring or exceeding rates in the general population. Reardon et al noted that anxiety impairs motor precision and recovery while amplifying risk for both musculoskeletal and concussive injuries.¹² Because these processes involve dysregulation within prefrontal-limbic circuits, TMS, which has already been proven to normalize cortical-subcortical connectivity in depression, may represent a nonpharmacologic tool to modulate the same networks that underlie athletic anxiety and performance inconsistency.

Anxiety symptoms in athletes are common and impair performance, with cortical circuitry overlapping TMS targets. However, payer policies generally mirror FDA-cleared indications, rTMS is typically covered for major depressive disorder (and, with specific protocols, obsessive-compulsive disorder, and smoking cessation). In contrast, off-label uses (eg, anxiety disorders or performance optimization) are inconsistently reimbursed and often require self-pay or research enrollment. In performance contexts where certain medications may be WADA-restricted, TMS remains a nonpharmacologic option, but it should be framed as an investigation for these aims.

Ethical Complications

Noninvasive brain stimulation occupies a complex ethical crossroads. Holgado et al reviewed meta-analyses of tDCS on exercise performance and found minimal, inconsistent gains after controlling publication bias.¹³ This highlights the need for cautious interpretation of any claimed ergogenic effect. As TMS technology becomes more accessible, concerns about neurodoping grow. While tDCS is marketed to consumers, clinical-grade TMS requires medical oversight. Misuse could blur boundaries between evidence-based therapy and unethical enhancement.

Recent analyses classify neuromodulation methods such as tDCS and TMS as falling within a regulatory “gray zone,” potentially performance-enhancing yet consistent with the spirit of sport when applied therapeutically and transparently.¹⁴ Clinician-guided rTMS used for psychiatric recovery or injury rehabilitation enhances authentic capability rather than conferring artificial advantage, aligning with athlete well-being and fair-play ethics.

Even well-intentioned neuromodulation can drift into enhancement territory without oversight. Clinicians must preserve clear boundaries between therapy, experimentation, and competition ethics.

Practical Integration

TMS’ safety profile is favorable in clinical practice, with transient scalp discomfort or headaches being the most common adverse effects; seizures are rare when protocols and precautions are followed.^4,5 Contraindications include metallic cranial implants, cochlear devices, or active epilepsy. Clinicians should verify payer criteria carefully, since off-label applications of TMS for anxiety or performance enhancement are rarely covered. Collaborative care across psychiatry, neurology, and sports medicine can ensure the ethical and financially realistic implementation of care (Table).

Limitations and Future Directions

Most TMS performance studies have small samples and variable stimulation parameters. As noted by Holgado et al and Qi et al,^6,13 this heterogeneity limits generalizability and calls for standardized protocols that define frequency, cortical target, and outcome metrics. Emerging accelerated paradigms such as Stanford neuromodulation therapy (formerly SAINT) deliver multiple high-frequency sessions daily and can achieve rapid clinical response in treatment-resistant depression.^15,16 Although these models are investigational, they may inform future athletic or recovery protocols that seek efficient, neuroplastic engagement. Integrating TMS with evidence-based psychotherapies for anxiety could prove synergistic. Future controlled trials should clarify whether precompetition rTMS can attenuate maladaptive cortical hyperarousal while preserving the optimal “inverted-U” arousal-performance relationship described in sports-anxiety research—where moderate arousal enhances precision and resilience, but under- or overactivation degrades performance.^5,12

Concluding Thoughts

The convergence of psychiatry and sports performance offers exciting potential and significant caution. TMS appears capable of modulating brain circuits involved in coordination, strength, recovery, and resilience. For clinicians, the mandate is clear: Employ TMS within approved therapeutic frameworks, document ancillary benefits, remain transparent about coverage limitations, and advance research through ethical collaboration. In the emerging field of performance psychiatry, TMS represents not a shortcut to success but a scientific reminder that optimal performance begins with optimal brain health.

Dr Veal is a board-certified psychiatrist and psychoanalytic candidate pursuing certification in performance psychiatry. He is the founder and CEO of Timothy M. Veal, MD, Inc. He will be expanding his practice with a new clinic in the University Towne Center area of San Diego, California, just east of La Jolla, in early 2026. His work integrates psychodynamic and psychoanalytic therapies, lifestyle medicine, and advanced neuromodulation treatments, including TMS, Magnetic e-Resonance Therapy (MeRT), and esketamine, to promote emotional recovery, brain health, and performance resilience in athletes, veterans, and high-achieving individuals.

References

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2. Reardon CL, Hainline B, Aron CM, et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med. 2019;53(11):667-699.

3. World Anti-Doping Code: International Standard Prohibited List 2025. World Anti-Doping Agency. September 2024. Accessed December 1, 2025. https://www.wada-ama.org/sites/default/files/2024-09/2025list_en_final_clean_12_september_2024.pdf

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6. Qi S, Yu J, Li L, et al. Advances in non-invasive brain stimulation: enhancing sports performance function and insights into exercise science. Front Hum Neurosci. 2024;18:1477111.

7. Moscatelli F, Toto GA, Valenzano A, et al. High-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) increase motor coordination performances in volleyball players. BMC Neurosci. 2023;24(1):30.
8. Conceição dos Santos T, Tavares dos Santos R, Oliveira HRP, et al. Transcranial magnetic stimulation protocol on lower-limb muscle strength in healthy individuals. MethodsX. 2025;14:103335.

9. Keriven H, Sánchez Sierra A, González-de-la-Flor Á, et al. Influence of combined transcranial and peripheral electromagnetic stimulation on the autonomous nerve system on delayed onset muscle soreness in young athletes: a randomized clinical trial. J Transl Med. 2025;23(1):306.

10. Moussavi Z, Suleiman A, Rutherford G, et al. A pilot randomised double-blind study of the tolerability and efficacy of repetitive transcranial magnetic stimulation on persistent post-concussion syndrome. Sci Rep. 2019;9(1):5498.

11. Hallock H, Mantwill M, Vajkoczy P, et al. Sport-related concussion: a cognitive perspective. Neurol Clin Pract. 2023;13(2):e200123.

12. Reardon CL, Gorczynski P, Hainline B, Hitchcock M, Rice S. Anxiety disorders in athletes. Clin Sports Med. 2024;43(1):33-52.

13. Holgado D, Sanabria D, Vadillo MA, Román-Caballero R. Zapping the brain to enhance sport performance? an umbrella review of the effect of transcranial direct current stimulation on physical performance. Neurosci Biobehav Rev. 2024;164:105821.

14. Pugh J, Pugh C. Neurostimulation, doping, and the spirit of sport. Neuroethics. 2021;14(suppl 2):141-158.

15. van Rooij SJH, Arulpragasam AR, McDonald WM, Philip NS. Accelerated TMS — moving quickly into the future of depression treatment. Neuropsychopharmacology. 2024;49(1):128-137.

16. Mann SK, Malhi NK. Repetitive Transcranial Magnetic Stimulation. In: StatPearls. StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/NBK568715/