When Should You Consider TMS for Depression?

When Should You Consider TMS for Depression?

Medically reviewed by Ted Wirecki, MD

Many people come to their first consultation with the same question: “Am I actually a candidate, or should I keep waiting?”

Transcranial Magnetic Stimulation (TMS) is a non-invasive, FDA-cleared depression treatment. It uses magnetic pulses to stimulate the brain regions involved in mood regulation. It’s cleared specifically for people whose depression hasn’t gotten better with antidepressants, which is the actual FDA indication, not just a talking point.⁴ But that doesn’t mean you need to wait until you’ve tried everything, or feel like you’ve officially “failed” enough medications, before it’s worth having a conversation. If your symptoms are still getting in the way of your life and one or more antidepressants haven’t given you full relief, that’s already enough to ask.

It’s worth knowing that TMS for depression doesn’t require you to stop your medication. Clinical guidelines note that TMS can be given alongside antidepressants or other psychotropic medications, or on its own — no evidence that combining them raises the risk of side effects.⁴ So the two main groups this tends to help are people currently on medication who need something more added on top, and people who haven’t gotten meaningful relief from medication alone.

TMS isn’t a “last resort” — it’s common sooner than people think

A common misconception is that TMS is something you try only after exhausting years of medications and therapy. The numbers say otherwise. The NIMH-funded STAR*D trial — the largest depression treatment study ever conducted — found that roughly half of patients don’t reach full symptom relief after their very first antidepressant, and outcomes decline further with each medication tried after that.¹

So needing more than one treatment attempt isn’t rare — it’s closer to the norm. In the major clinical trials behind TMS, most patients had tried between one and four antidepressants that didn’t fully work before starting TMS. Some had tried as many as 23 over the years. There’s no fixed number required either way — it’s something a provider evaluates with you, individually.⁴ For a lot of people, TMS for depression ends up being part of the conversation eventually. The real question is usually when, not if.

Not all TMS is the same

Once you’re exploring TMS for depression, it helps to know it isn’t a single, one-size treatment. A few different protocols exist, and they mainly differ in session length and how many weeks the full course takes.

Stanford’s accelerated protocol (often called SAINT or SNT) was tested in a randomized, sham-controlled trial and produced remission in the large majority of participants with severe, treatment-resistant depression within days rather than weeks.² Researchers designed accelerated protocols specifically to shorten the standard six-week timeline while aiming to preserve — or improve on — effectiveness.³

Each protocol has different eligibility considerations, and TMS Center of Colorado offers all four. One thing worth knowing going in: only the accelerated protocol currently has strong trial evidence for its shorter schedule specifically. The other three share the same core evidence base for the traditional 4–6 week course. Choosing which TMS for depression usually comes down to your schedule, how you respond to a specific coil, and how you tolerate the sessions — something we walk through together.

On safety: the most common safety question we hear is about any seizure risk. Across the clinical trial data, seizure risk with standard TMS is estimated at less than 1 in 30,000 sessions — lower than the rate reported for some antidepressant medications — and every documented seizure happened during the treatment session itself, never afterward or at home.⁴

Can TMS be combined with medication?

Yes. Clinical guidance treats TMS as flexible on this point: it can be used as a standalone treatment for people whose medication hasn’t worked, or it can be added on top of a current medication regimen for people who are getting partial benefit but not full relief.⁴ Neither approach is considered off-label or unusual, and studies of TMS added on to ongoing medication haven’t shown a higher rate of side effects than TMS used alone.⁴

In practice, that means the decision isn’t “stop your medication and switch to TMS for depression” versus “keep struggling on medication alone.” Many patients stay on their current prescription throughout their TMS course, and some studies have specifically looked at TMS as an add-on for people who didn’t respond well to medication, or couldn’t tolerate a full dose of it.⁴ Which path makes sense — TMS for depression instead of medication, or TMS alongside it — is something we work out with you based on your history.

How we determine candidacy of TMS for depression

TMS is FDA-indicated for adults with Major Depressive Disorder who haven’t had satisfactory improvement from antidepressant medication in their current episode. In the trials that led to FDA clearance, most patients had tried one to four adequate medication courses — though there was no cap on lifetime medication history, and people who couldn’t tolerate a full medication dose due to side effects (not just those who tried and didn’t respond) also qualified.⁴

Before starting treatment, we walk through what a session actually involves. Your head stays positioned under the coil, so you won’t have much freedom of movement or a clear view of the device — most of the nervousness people feel beforehand comes from not knowing what to expect physically, not from the treatment itself. We use visual aids, and we’re glad to bring a family member into that first conversation so questions get answered up front. Written consent only happens once the process is genuinely understood.⁴

We also set realistic expectations on timing. Most people who respond do so within four to six weeks of daily sessions, though some showing partial improvement benefit from a week or two more. Throughout treatment, we track progress with a standardized questionnaire (most often the PHQ-9) rather than relying on general impressions alone — which also gives you, and your insurer if relevant, objective documentation of benefit.⁴

TMS for depression at TMS Center of Colorado

TMS isn’t something to save for after you’ve tried everything else — but it is, by design, for people whose depression hasn’t fully responded to medication, whether that means medication alone hasn’t worked, or it’s helping some but not enough. If either of those describes you, or you’re simply curious whether TMS for depression could fit into your care, that’s reason enough to ask.

Scheduling a free phone consultation with the team at one of our Denver TMS clinic locations gives you a clear path to understanding your options — protocols, insurance, and a realistic timeline for your specific situation.

Sources

1. National Institute of Mental Health. Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study.nimh.nih.gov
2. Cole, E.J., et al. “Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial.” American Journal of Psychiatry, 2022.
3. “Accelerated TMS — moving quickly into the future of depression treatment.” Neuropsychopharmacology, 2023.
4. Perera, T., George, M.S., Grammer, G., Janicak, P.G., Pascual-Leone, A., Wirecki, T. “TMS Therapy for Major Depressive Disorder: Evidence Review and Treatment Recommendations for Clinical Practice.” Clinical TMS Society White Paper, 2015.