You usually continue your antidepressant during TMS; registry data show better outcomes with the combination than with TMS alone. A few medications matter: benzodiazepines may blunt the response, bupropion above 300 mg and some others lower the seizure threshold, and anticonvulsants raise the stimulation dose needed. Tapering after remission is a separate decision made months later.
The real medication questions are more specific. A few drugs blunt the response and may be worth tapering. A few lower the seizure threshold and may need a dose adjustment. Changing medications in the middle of a course muddies the picture of whether TMS is working. And once you are in remission, there is a decision about whether and when to reduce medication. This page works through each of those, and the rule underneath all of them: never change a psychiatric medication on your own before or during TMS.
Who it is for
This page is for anyone starting TMS who takes psychiatric medication, which is nearly everyone, and for the family members and primary care physicians who help manage those prescriptions. It applies to patients on a single SSRI that has helped a little but not enough, to patients on complex regimens of two or three antidepressants plus an augmenting agent, to patients who have stopped medication because of side effects and are wondering whether they need to restart before TMS, and to patients on medications for other conditions, such as anticonvulsants, stimulants, opioids or sleep aids, that interact with how TMS works. It is also for patients who have finished a course, reached remission, and are asking whether they can finally stop the medication they have been on for years. Each of those situations has a different answer, and all of them are decided with your psychiatrist rather than by a general rule.
How it works
TMS and antidepressants act through different routes on overlapping circuits. Medication changes neurotransmitter signaling throughout the brain. TMS drives activity in a specific prefrontal circuit from the outside, producing lasting changes in synaptic strength. There is no pharmacological interaction, because nothing is absorbed, metabolized or excreted. The interactions that do exist are physiological. Drugs that enhance inhibitory signaling, principally benzodiazepines, reduce cortical excitability and appear to dampen the effect of stimulation. Drugs that lower the seizure threshold, including bupropion, tricyclics, clozapine and tramadol, raise the small risk that a session triggers a seizure. Anticonvulsant mood stabilizers raise the motor threshold, which means more intensity is needed to reach the target, and that is measured at the first session. Stimulants have been associated with somewhat better TMS response in some registries, though the data are preliminary. Everything else, from SSRIs to lithium to antipsychotics at usual doses, is simply continued.
In a naturalistic study of 307 TMS patients treated in ordinary clinical practice, where the large majority continued antidepressant medication, 58 percent responded and 37 percent remitted, higher than the rates seen in medication-free pivotal trials.
Source: Carpenter et al., Depression and Anxiety, 2012
In an analysis of concomitant medications among TMS patients, benzodiazepine use was associated with significantly lower remission rates, while psychostimulant use was associated with greater improvement.
Source: Hunter et al., Brain and Behavior, 2019
In a secondary analysis of the 414-patient THREE-D trial, patients taking benzodiazepines had lower response rates to both standard TMS and theta burst stimulation than patients not taking them.
Source: Kaster et al., Depression and Anxiety, 2019
Bupropion carries a dose-dependent seizure risk of about 0.1 percent at doses up to 300 mg a day of the sustained-release form, rising at higher doses, which is why TMS programs review the dose before treatment.
Source: FDA prescribing information for bupropion
What to expect
At your TMS evaluation, at any of our 13 offices or by video, bring a complete medication list including doses, over-the-counter products and supplements. The psychiatrist sorts your medications into three groups: continue as is, adjust before starting, and consider tapering. Any changes are made before the first session so that the course starts from a stable baseline. During the course, at our TMS treatment centers with Palm Beach Gardens as the primary center, we ask you to keep every medication steady unless the psychiatrist directs otherwise, so that the weekly PHQ-9 trend reflects TMS. After the course, the psychiatrist who evaluated you continues your medication management, which is where decisions about tapering are made, usually not before several months of stable remission.
Benefits
- No pharmacological interactions: TMS can be combined with any antidepressant, mood stabilizer or antipsychotic
- Augmentation with continued medication produces higher response rates than TMS alone in registry data
- No washout period: you do not stop a partly effective drug to start TMS
- Medication review before the course identifies the few drugs that blunt response or raise seizure risk
- The same psychiatrist manages your medication before, during and after the course, so decisions are coordinated
Risks and side effects
The medication-related risks of TMS are specific and manageable. Seizure risk, already roughly one in 30,000 sessions, rises with drugs that lower the seizure threshold: bupropion at doses above 300 mg a day, tricyclic antidepressants at high doses, clozapine, tramadol, high-dose stimulants and abrupt withdrawal from alcohol or benzodiazepines. We adjust these before starting or monitor more closely. Stopping a benzodiazepine abruptly is itself a seizure risk, so any taper is gradual. Changing an antidepressant mid-course can cause withdrawal symptoms or a temporary worsening that is hard to distinguish from TMS non-response. Lithium does not raise seizure risk at therapeutic levels but we confirm the level is in range. Over-the-counter products rarely matter, with the exception of high-dose caffeine and some weight-loss supplements that contain stimulants.
Cost and insurance
Continuing medication during TMS does not affect coverage, and insurers expect it: most TMS policies require documentation that you have tried medication, not that you have stopped it. Some commercial plans specifically ask that the current antidepressant be continued at a stable dose during the course. Medication management visits during and after TMS are billed separately as ordinary psychiatric visits and are covered under your usual mental health benefits. Medicare covers TMS and the associated psychiatric visits under Part B. Our TMS coordinator confirms coverage before you begin.
The short answer and the reason behind it
You keep taking your antidepressant. The FDA pivotal trials tested TMS in patients who had stopped all antidepressants, because a trial needs to isolate one variable. Those trials produced remission rates of roughly 15 to 33 percent, enough to prove the treatment works. When TMS moved into ordinary practice, where patients stayed on whatever medication they were taking, the numbers went up: 37 percent remission and 58 percent response in the largest early registry, and 60 to 75 percent response in later Deep TMS registries. Medication and TMS work through different routes and the combination does better than either alone.
So the default is to continue. The exceptions are a small number of specific drugs, covered below.
Three categories of medication
| Category | Examples | What we do |
|---|---|---|
| Continue unchanged | SSRIs, SNRIs, mirtazapine, trazodone, lithium, lamotrigine, atypical antipsychotics, buspirone, hydroxyzine, prazosin, bupropion up to 300 mg | Keep the same dose through the course |
| Review and possibly adjust | Bupropion above 300 mg, tricyclics at high dose, clozapine, tramadol, high-dose stimulants, theophylline | Reduce dose before starting if the seizure threshold effect outweighs the benefit; otherwise monitor closely |
| Consider tapering | Benzodiazepines at regular daily doses, sometimes zolpidem and related sleep aids | Gradual taper before or during the course when clinically reasonable; never abrupt |
| Affects dosing, not safety | Valproate, carbamazepine, oxcarbazepine, other anticonvulsants | Expect a higher motor threshold; stimulation intensity is set accordingly at session one |
Benzodiazepines: the medication that matters most
The most consistent finding in the literature on medications and TMS is that benzodiazepines blunt the response. A 2019 analysis of concomitant medications found that patients taking benzodiazepines had significantly lower remission rates. A secondary analysis of the 414-patient THREE-D trial found the same: lower response to both standard TMS and theta burst in benzodiazepine users. The mechanism is plausible. Benzodiazepines enhance GABA, the brain's main inhibitory signal, and TMS works by driving excitatory activity in a cortical circuit; the two are pulling in opposite directions.
The practical response is not to stop benzodiazepines abruptly, which can cause withdrawal seizures and would be more dangerous than any blunting effect. For patients on an occasional low dose, we often leave it alone. For patients on regular daily doses, the psychiatrist weighs a gradual taper, started before the course where possible, against the severity of the anxiety the benzodiazepine is treating. Some patients find that as TMS begins to reduce anxiety in weeks two to four, the taper becomes easier than expected.
Seizure threshold: the medication safety review
TMS-induced seizures are rare, on the order of one in 30,000 sessions, and most reported cases involved a known risk factor. Medications are the most common one. Bupropion is the antidepressant with the clearest dose-dependent effect: the risk is about 0.1 percent at up to 300 mg a day of the sustained-release form and rises at higher doses, which is why we review any patient above 300 mg. Tricyclics at high doses, clozapine, tramadol, high-dose stimulants and theophylline also lower the threshold. Abrupt withdrawal from alcohol or benzodiazepines lowers it sharply, which is another reason tapers are gradual.
For most patients on these drugs the answer is a modest dose adjustment before the first session or simply closer monitoring; few are excluded. Lithium at therapeutic levels is not a seizure concern, though we confirm the level. SSRIs and SNRIs have a negligible effect at usual doses.
Anticonvulsants and the stimulation dose
Valproate, carbamazepine, oxcarbazepine and similar drugs raise the motor threshold: it takes more magnetic intensity to make the thumb twitch, and therefore more to reach the prefrontal target. This is not a safety issue and not a reason to stop the drug, especially for bipolar patients for whom the mood stabilizer is a precondition for TMS. It simply means the dose set at the first session is higher. Lamotrigine has a smaller effect. We measure the threshold for every patient, so the adjustment is automatic.
Stimulants and ADHD medication
Methylphenidate and amphetamine-based stimulants are continued at usual doses. Several registries have found that patients on stimulants respond somewhat better to TMS, possibly because stimulants increase cortical excitability. High doses lower the seizure threshold and are reviewed. If you take a stimulant for ADHD, bring the dose to the evaluation; it is rarely a barrier.
Keep everything steady during the course
From the week before the first session through the end of the taper, the goal is a stable medication baseline. The weekly PHQ-9 is the instrument by which we judge whether TMS is working for you, and a medication change in the middle of the course contaminates it. An improvement in week four could be the new drug. A dip in week three could be withdrawal from the old one. When a change is unavoidable, your psychiatrist makes it and documents it so that the trend can be read with that in mind. What we ask you not to do is adjust doses on your own, skip doses because you feel better, or add a supplement without telling us.
After remission: the tapering decision
Patients who reach remission after TMS often ask whether they can finally stop the medication they have been taking for years. The honest answer is that TMS does not change the guidelines for how long to continue an antidepressant after remission. For a first episode, that is at least four to nine months. For a second episode, a year or more. For three or more episodes, or a history of severe or suicidal depression, most guidelines recommend indefinite maintenance, because each relapse makes the next more likely.
The TMS durability data point the same way. In the largest one-year follow-up, most of the patients who stayed well were continuing medication, and the relapse rate was lowest among those who kept both medication and therapy. A reasonable path for a patient who wants to reduce medication is to wait for several months of stable remission, reduce one drug at a time, go slowly, track the PHQ-9 monthly, and have a plan for what to do if scores start to climb. For many patients that plan includes a repeat TMS course, which Medicare and most insurers cover for prior responders.
A worked example
A patient arrives on sertraline 150 mg, bupropion 450 mg, clonazepam 1 mg twice daily and zolpidem at night. The sertraline continues unchanged. The bupropion is reduced to 300 mg before the first session, because 450 mg carries a meaningfully higher seizure risk and the extra 150 mg has not helped. The clonazepam is tapered over four weeks before TMS starts, with hydroxyzine as a bridge for breakthrough anxiety, because regular benzodiazepine use is the strongest predictor of blunted response. The zolpidem is continued for now and revisited if sleep improves during the course. Nothing else changes for the nine weeks of treatment. If the patient reaches remission, the sertraline stays for at least a year, and the question of reducing it is taken up then.
Every regimen is different, and the decisions above are made by a psychiatrist who knows your history. Stedfast Psychiatry's TMS program begins with a medication review and evaluation at any of our 13 offices or by video. Treatment sessions take place at our TMS treatment centers, with Palm Beach Gardens, 11641 Kew Gardens Ave, Suite 209, as the primary center. Call (561) 437-2199 to schedule a TMS evaluation and bring your full medication list.
Frequently asked questions
Do I have to stop my antidepressant to get TMS?
No. Nearly all patients continue their antidepressant, and we recommend it. The pivotal trials used medication-free patients to isolate the effect of TMS for the FDA, but real-world registries, where most patients stay on medication, report higher response rates. There is no pharmacological interaction. If your current medication is helping a little, stopping it would mean starting TMS from a lower baseline and risking withdrawal symptoms during the course. Keep taking it at the same dose unless your psychiatrist says otherwise.
I stopped my antidepressant months ago. Do I need to restart it before TMS?
Not necessarily. TMS works as monotherapy; the pivotal trials proved that. The question is whether restarting would help you more than TMS alone, and whether the reason you stopped still applies. If you stopped because of side effects, we would not restart the same drug. If you stopped because it was not working, there is little reason to restart it. If you stopped because you felt better and then relapsed, restarting alongside TMS may be the best combination. Your psychiatrist decides this at the evaluation.
Which medications interfere with TMS?
Benzodiazepines are the main one: alprazolam, lorazepam, clonazepam, diazepam and similar drugs, especially at regular daily doses, are associated with lower TMS response in several studies. Z-drugs for sleep such as zolpidem act on the same receptors and may have a smaller effect. Anticonvulsants do not interfere but raise the stimulation dose needed. SSRIs, SNRIs, mirtazapine, bupropion at usual doses, lithium, antipsychotics, stimulants and buspirone do not interfere and are continued.
Should I stop my benzodiazepine before TMS?
Possibly, but never on your own and never abruptly, because benzodiazepine withdrawal can cause seizures. If you take a low dose occasionally, it may not matter. If you take a regular daily dose, your psychiatrist may recommend a gradual taper before or during the course, or may decide that your anxiety is severe enough that the benzodiazepine should stay. Some patients find that as TMS reduces anxiety, the taper becomes easier. The decision is individual.
Is bupropion a problem with TMS?
At usual doses, no. Bupropion lowers the seizure threshold in a dose-dependent way, with risk rising above 300 mg a day of the sustained-release form and more sharply above 450 mg. Many TMS patients take bupropion at 150 to 300 mg without issue. If you are above 300 mg, your psychiatrist may reduce the dose before starting or, if the dose is clearly helping, continue it with closer monitoring. The same review applies to tricyclics, clozapine and tramadol.
Can I change medications during the TMS course?
We prefer not to. The weekly PHQ-9 is how we judge whether TMS is working, and a medication change mid-course makes the trend impossible to read: an improvement could be the new drug, a worsening could be withdrawal from the old one. If a change is medically necessary, for instance for intolerable side effects, your psychiatrist will make it and note it in the record. Otherwise, hold everything steady from the week before the first session through the end of the taper.
After TMS, can I stop my medication?
Not right away, and maybe not at all, depending on your history. Standard guidance is to continue an antidepressant for at least four to nine months after remission of a first episode and longer, often indefinitely, for people with three or more episodes. TMS does not change that math. The durability data also favor continuing medication: in the main one-year follow-up study, most patients who stayed well were on medication. If you want to taper, we discuss it after several months of stable remission, reduce slowly, and monitor the PHQ-9 monthly.
Does TMS work if medication has never helped at all?
Yes. Response to TMS does not depend on prior response to medication, and the pivotal trials enrolled patients who had failed one to four antidepressants. Patients who have never responded to any medication have somewhat lower TMS response rates than those who responded at some point, and a very long current episode lowers the odds further, but a meaningful share still respond. For these patients TMS is often used alone or with a medication that is continued mainly for sleep or anxiety.
Where this treatment is offered
Conditions this treats
If you are in crisis, call or text 988 or go to the nearest emergency room. Educational content; individual results vary. Reviewed by Dr. David Husted, board-certified psychiatrist.