Deep TMS is FDA-cleared for anxious depression, meaning depression with significant anxiety, and the standard course reduces both. It is not cleared for generalized anxiety disorder, panic disorder or social anxiety on their own; small trials are encouraging but insurers do not cover it. If your anxiety comes with depression, TMS is a covered option.
TMS is not cleared for generalized anxiety disorder, panic disorder, social anxiety disorder or any anxiety disorder on its own. The research on those conditions is promising but small, insurers do not cover it, and we do not want you to arrive expecting something the evidence does not support. This page separates what is established from what is still being studied.
Who it is for
The clearest candidate is an adult with major depressive disorder whose depression is accompanied by persistent worry, tension, restlessness or panic, who has tried at least one antidepressant without enough relief. In practice this describes most anxious patients we see for medication management: in large surveys, roughly half of people with a current depressive episode also meet criteria for an anxiety disorder, and about 40 percent of people with generalized anxiety disorder have had depression. If anxiety is your dominant complaint and a screening shows depression underneath it, you qualify under the anxious depression clearance. If you have an anxiety disorder with no depression at all, you are not a candidate under current clearances or insurance policies, and medication and cognitive behavioral therapy remain the first-line options. Off-label TMS for pure anxiety disorders is something we discuss case by case, with the limits of the evidence stated plainly.
How it works
Anxiety and depression share circuitry. The dorsolateral prefrontal cortex, the target of the depression protocol, regulates the amygdala and other limbic structures that generate fear and worry, and that top-down control is weak in both conditions. Stimulating the left prefrontal cortex at high frequency, the standard depression protocol, appears to restore some of that regulation, which is why anxiety scores fall alongside depression scores in the trials. For anxiety disorders without depression, researchers have mostly tried a different approach: low-frequency stimulation of the right prefrontal cortex, which dampens rather than excites, on the theory that right-sided overactivity drives anxiety. Both approaches have produced positive results in small trials. Deep TMS for anxious depression at Stedfast Psychiatry uses the same 36-session depression protocol with the same coil; there is no separate anxiety protocol, because the clearance was based on data from depression trials.
Nearly half of adults with a lifetime diagnosis of major depression also have a lifetime anxiety disorder, and comorbid anxiety is associated with greater severity and poorer response to antidepressants.
Source: Kessler et al., National Comorbidity Survey Replication, Archives of General Psychiatry, 2005
In the STAR*D trial, patients with anxious depression were significantly less likely to remit on citalopram and more likely to experience side effects than patients with non-anxious depression.
Source: Fava et al., American Journal of Psychiatry, 2008
Deep TMS received FDA clearance for anxious depression in 2021 based on pooled analyses of depression trial participants with comorbid anxiety symptoms, in whom active treatment reduced anxiety scores significantly more than sham.
Source: FDA 510(k) clearance, August 2021
In a sham-controlled pilot trial of 25 patients with generalized anxiety disorder, low-frequency TMS over the right prefrontal cortex produced significantly higher response and remission rates than sham, with benefits maintained at three months.
Source: Diefenbach et al., British Journal of Psychiatry, 2016
What to expect
Your evaluation can take place at any of our 13 offices or by video. A psychiatrist confirms the diagnosis with a structured interview, scores the PHQ-9 for depression and the GAD-7 for anxiety, and documents your medication history. If depression with significant anxiety is present and you meet the criteria, our TMS coordinator submits authorization under the depression indication. Treatment sessions happen at our TMS treatment centers, with Palm Beach Gardens as the primary center: 36 sessions of about 20 minutes, five days a week for six weeks and then a taper. We track both the PHQ-9 and the GAD-7 weekly. Many anxious patients notice physical tension and sleep improving first, in weeks two to four, with worry and mood following.
Benefits
- FDA-cleared for anxious depression since 2021, with insurance coverage under the depression indication
- The same 36-session course reduces both depression and anxiety scores in pooled trial data
- No sedation, dependence or withdrawal, in contrast to benzodiazepines
- No sexual, weight or activation side effects, which often limit SSRIs in anxious patients
- Can be combined with cognitive behavioral therapy and continued medication
Risks and side effects
Side effects are the same as for TMS generally: scalp discomfort and headache in the first week, facial twitching during pulses, and a rare risk of seizure of roughly one in 30,000 sessions. Anxious patients sometimes find the first session unsettling because of the noise and the sensation, and we spend extra time on the first day explaining what to expect; hearing protection and a gradual ramp-up help. One medication issue matters specifically for anxious patients: benzodiazepines such as alprazolam, lorazepam and clonazepam, especially at higher doses, are associated with reduced TMS response in several studies. We do not stop them abruptly, but we may recommend a gradual taper before or during the course.
Cost and insurance
Insurance covers TMS for anxious depression under the major depressive disorder indication, with the same requirements: a documented diagnosis, a PHQ-9 or HAM-D score in the moderate to severe range, and for commercial plans two to four failed antidepressant trials plus a psychotherapy trial. Medicare in Florida and South Carolina requires at least one failed or intolerable trial and a psychiatrist's in-person evaluation. No insurer, including Medicare, covers TMS for generalized anxiety disorder, panic disorder or social anxiety without a depression diagnosis, and we will not code a diagnosis you do not have. Off-label courses are self-pay, and our TMS coordinator can quote current rates.
Anxiety and depression: why the overlap matters
Anxiety and depression are listed as separate diagnoses, but in the clinic they are usually the same patient. Nearly half of people with major depression have a lifetime anxiety disorder, and in the STAR*D trial about half of participants had anxious depression. Those patients did worse on medication: lower remission rates, more side effects, more dropouts. That is the group the anxious depression clearance was built for.
It also means that if you came to this page thinking of yourself as an anxiety patient, there is a reasonable chance a careful evaluation finds depression too. That is not a technicality. It changes what TMS can do for you and whether insurance pays.
What is FDA-cleared
Deep TMS was cleared for anxious depression in 2021. The FDA defines the indication as major depressive disorder with comorbid anxiety symptoms, which in the trial data meant a meaningful score on the anxiety items of the Hamilton Depression Rating Scale. The clearance followed pooled analyses of patients from Deep TMS depression trials who had those symptoms. In that group, active treatment reduced anxiety scores significantly more than sham, in parallel with the drop in depression scores.
The practical consequence is that there is no separate anxiety protocol. Patients with anxious depression receive the standard 36-session depression course with the same coil, the same target and the same intensity. The anxiety benefit comes along with the depression benefit.
What is not cleared, and what the research shows
| Condition | FDA status | Evidence | Insurance |
|---|---|---|---|
| Anxious depression | Cleared (Deep TMS, 2021) | Pooled trial data; both depression and anxiety improve | Covered under the depression indication |
| Generalized anxiety disorder alone | Not cleared | Small sham-controlled pilots positive; larger trials needed | Not covered |
| Panic disorder | Not cleared | Few small studies, mixed results | Not covered |
| Social anxiety disorder | Not cleared | Very limited research | Not covered |
| PTSD | Not cleared | Mixed; some positive VA studies, one large negative Deep TMS trial | Not covered |
| OCD | Cleared (Deep TMS, 2018) | Sham-controlled pivotal trial positive | Covered by Medicare and many commercial plans |
Generalized anxiety disorder
The best-known study is a 2016 pilot from Hartford Hospital in which 25 patients with GAD were randomized to 30 sessions of low-frequency TMS over the right dorsolateral prefrontal cortex or sham. The active group had significantly higher response and remission rates, and the gains held at three months. Earlier open-label work from UCLA showed similar signals. A 2019 meta-analysis pooling anxiety and PTSD trials found a large overall effect but warned that the trials were small and used inconsistent protocols. The honest summary: the signal is real and encouraging, the evidence is not yet strong enough for clearance or coverage, and a large confirmatory trial has not been done.
Panic disorder and social anxiety
Research here is thinner. A handful of small panic disorder studies have reported mixed results, with some finding no benefit over sham. Social anxiety has barely been studied. For both conditions, cognitive behavioral therapy with exposure has strong evidence and should come first, with SSRIs as the medication of choice.
PTSD
PTSD is covered on its own page. In brief: TMS is not cleared for it, some Veterans Affairs studies have been positive, and the largest Deep TMS trial for PTSD did not beat sham. TMS is a reasonable option for the depression that frequently accompanies PTSD.
How we evaluate anxious patients for TMS
At the evaluation, a psychiatrist conducts a structured diagnostic interview covering both mood and anxiety. We score the PHQ-9 for depression and the GAD-7 for anxiety, and when an insurer requires it, the HAM-D, which includes anxiety items. We review every antidepressant and anxiety medication you have tried, with doses and durations, and any psychotherapy. We screen for the standard contraindications and pay particular attention to benzodiazepine use, because it affects both response and the taper plan.
If the evaluation shows depression with significant anxiety and you have had at least one adequate medication trial, you are a candidate and we submit authorization under the depression indication. If it shows an anxiety disorder without depression, we tell you so and recommend the treatments with the best evidence for your condition. We do not code a diagnosis you do not have to obtain coverage.
What anxious patients notice during a course
Patients with anxious depression often describe the first improvements as physical: less muscle tension, falling asleep faster, waking less. That tends to happen in weeks two to four. Worry and rumination often ease next, and mood last. Some patients notice they are less reactive, that a stressful email no longer produces an hour of dread. We track the GAD-7 alongside the PHQ-9 so that these changes are measured rather than guessed.
A few patients feel briefly keyed up after early sessions. This fades within the first week and is not a sign the treatment is making anxiety worse over the course.
Medications that matter
Benzodiazepines deserve a specific mention. Several naturalistic studies and a secondary analysis of a large randomized trial have found that patients taking benzodiazepines, especially higher doses, respond less well to TMS. The likely reason is that benzodiazepines enhance inhibitory signaling and blunt the cortical excitability TMS works through. We never stop them abruptly, since withdrawal can cause seizures. Depending on the dose, your psychiatrist may recommend a slow taper before the course, a reduction during it, or no change. SSRIs, SNRIs, buspirone, hydroxyzine and most other anxiety medications do not interfere and are continued.
The honest limits
- TMS treats anxiety that comes with depression. It is not cleared or covered for anxiety disorders alone.
- The research on GAD, panic and social anxiety is promising but small, and we would be guessing if we quoted a success rate.
- Cognitive behavioral therapy remains the most effective treatment for most anxiety disorders and should not be skipped in favor of TMS.
- About a third of patients with anxious depression do not respond to TMS, the same as for depression generally.
- Off-label TMS for pure anxiety is self-pay and offered only after a psychiatrist reviews the evidence with you.
If your anxiety comes with depression and medication has not been enough, Stedfast Psychiatry's TMS program is a covered, evidence-based option. Evaluation happens 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.
Frequently asked questions
Is TMS FDA-cleared for anxiety?
Deep TMS is FDA-cleared for anxious depression, which the FDA defines as major depressive disorder with comorbid anxiety symptoms. It is not cleared for generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobias or PTSD as standalone diagnoses. The clearance was granted in 2021 based on pooled data from depression trials showing that anxiety scores improved along with depression scores. The distinction matters for insurance: coverage follows the depression diagnosis.
I have anxiety but I am not sure I am depressed. Can I still get TMS?
Possibly. Many people who describe their main problem as anxiety screen positive for depression when asked the right questions: loss of interest, low energy, poor concentration, feeling worthless, changes in sleep and appetite. A psychiatrist at any of our offices or by video can evaluate you with a structured interview, the PHQ-9 and the GAD-7. If depression is present with your anxiety, you qualify under the anxious depression clearance. If it is genuinely absent, TMS would be off-label and self-pay.
Does TMS help panic attacks?
In patients with depression and panic symptoms, panic frequency often falls as the depression and overall anxiety improve during a TMS course. For panic disorder without depression, the evidence is limited to small studies with mixed results, and TMS is not cleared or covered. Cognitive behavioral therapy with interoceptive exposure is the best-supported treatment for panic disorder, and SSRIs are the first-line medication. We would recommend those before considering off-label TMS.
What about social anxiety or phobias?
There is very little TMS research in social anxiety disorder and almost none in specific phobias. Exposure-based cognitive behavioral therapy has strong evidence for both and remains the treatment we recommend. If social anxiety coexists with depression, which is common, the depression protocol may help both, but we would not promise it. TMS is not a substitute for exposure work in these conditions.
Will TMS make my anxiety worse at first?
Not usually. Some patients find the first session or two unsettling because of the clicking sound and the tapping sensation, and we take extra time on day one. A small number report feeling keyed up for an hour after early sessions, which fades. There is no evidence that the depression protocol worsens anxiety over a course; the pooled data show the opposite. If you are prone to claustrophobia or startle easily, tell the technician so the ramp-up can be slowed.
Can I stay on my anxiety medication during TMS?
SSRIs, SNRIs, buspirone and hydroxyzine can all be continued and do not interfere with TMS. Benzodiazepines are the exception: several studies associate regular benzodiazepine use, especially higher doses, with lower TMS response rates, probably because they dampen the cortical excitability TMS depends on. We do not stop them abruptly, which would be unsafe. Your psychiatrist may recommend a gradual taper before or during the course, or may decide the current dose is acceptable. Do not change anything on your own.
Is TMS better than medication for anxious depression?
Anxious depression is harder to treat with medication than non-anxious depression. In the STAR*D trial, patients with anxious depression were less likely to remit on an SSRI and more likely to have side effects. That makes TMS, which showed benefit in exactly this group, a sensible next step after one or two medication trials. Most patients continue their antidepressant during TMS, and the combination tends to do better than either alone. Cognitive behavioral therapy adds to both.
How do I know if my anxiety is bad enough for TMS?
The threshold is set by the depression, not the anxiety. You need a current major depressive episode of at least moderate severity, which usually means a PHQ-9 score of 10 or higher, with 15 or higher for most commercial insurers, plus a history of at least one adequate antidepressant trial. The GAD-7 documents the anxiety component but does not by itself qualify you. If your depression is mild and your anxiety is severe, therapy and medication adjustments are the right first steps.
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.