When medication and psychotherapy haven’t brought enough relief, transcranial magnetic stimulation — TMS — is one of the options I discuss most often. It’s not a first-line treatment, and it isn’t right for everyone, but for the right patient it can open up a path that medication trials alone haven’t.
TMS uses magnetic fields to activate nerve cells in the brain involved in mood regulation. During a session, a large magnetic coil is placed on the patient’s scalp near the forehead, where it generates electrical currents intended to stimulate the brain regions that regulate mood.
When TMS comes up
I typically bring up TMS when standard approaches — medication and psychotherapy — haven’t worked, or when medication trials have produced side effects significant enough to limit how much can realistically be tried. It’s a conversation that tends to happen after, not instead of, a genuine attempt at more conventional treatment.
How it works
The precise mechanism isn’t fully understood, in part because TMS is still a relatively young treatment — the FDA only approved it in 2008. The working theory is that the magnetic impulses stimulate the specific brain cells that govern mood regulation. It’s a different approach than electroconvulsive therapy (ECT), which is effective for severe depression but carries a risk of memory problems. TMS appears to be a gentler alternative, without that same risk profile.
What a course of treatment looks like
TMS usually requires a series of sessions to be effective, typically scheduled daily, five times a week, for four to six weeks. Each individual session has a fairly predictable rhythm:
- It’s an outpatient, office-based procedure — no anesthesia and no surgical incisions
- Patients sit comfortably, with earplugs or music available during treatment
- The active treatment portion runs about 40 minutes, with tapping sensations and possible facial twitching during dose calibration
- The full appointment runs about an hour
- Patients resume normal activities immediately afterward and don’t need someone to drive them home
Am I a candidate?
Candidacy is determined through a clinical interview with a mental health professional. Insurance companies typically require documentation of unsuccessful trials with multiple antidepressants and adjunctive medications, as well as a prior attempt at psychotherapy, before they’ll authorize coverage — which is part of why the treatment history review at a first visit matters so much.
This is also why I don’t treat TMS as a stand-alone decision. It sits alongside Spravato®, medication augmentation, and psychotherapy as one of several evidence-based paths once standard antidepressant trials genuinely haven’t worked, and part of my job is helping a patient understand which of those paths actually fits their history.
Long-term effectiveness and the need for maintenance treatment afterward are still areas where the data continues to develop. What I can say from what I’ve seen in practice is that many patients experience meaningful symptom improvement over the course of treatment, and for people with treatment-resistant depression, TMS is a genuinely valuable option worth having on the table.