Training and Experiential Factors Associated With Transcranial Magnetic Stimulation Referral Readiness Among Psychiatric Providers

OBJECTIVE: Transcranial magnetic stimulation (TMS) is an established treatment for patients with treatment-resistant depression (TRD); however, barriers remain in clinical practice. This study examined how psychiatric clinicians view TMS and evaluated whether training exposure and prior experience were associated with their readiness to refer patients for treatment. METHODS: We conducted a cross-sectional survey of psychiatric providers in Florida, including attending psychiatrists, psychiatry residents, and psychiatric nurse practitioners. The survey assessed beliefs about TMS effectiveness, comfort discussing and referring the treatment, familiarity with referral processes, and perceived barriers. Responses were dichotomized to reflect endorsement, and group differences were analyzed using chi-square or Fisher exact tests. RESULTS: Ninety-four clinicians completed the survey. Conceptual endorsement of TMS was high, with more than 90% agreeing that it is an effective treatment for depression. Operational readiness was more variable, particularly for referral comfort, counseling confidence, and knowledge of referral pathways. Prior TMS training and prior TMS recommendation experience were associated with greater comfort referring patients, greater confidence counseling patients, and higher awareness of referral steps. Psychiatry residents reported lower referral-pathway awareness than attending psychiatrists. Insurance coverage and treatment costs were frequently reported barriers, and lack of training was a commonly endorsed modifiable barrier. CONCLUSIONS: While psychiatric providers widely accepted TMS conceptually, operational readiness to counsel and refer was more variable. Training exposure and prior TMS recommendation experience were associated with greater confidence, comfort, and familiarity with referral pathways, although causality cannot be inferred from this cross-sectional design. These findings suggest that efforts to improve utilization should emphasize building operational competence and confidence, along with clearer referral workflows and accessible system-level processes.