About two thirds of patients who respond to TMS are still well a year later; the rest relapse, usually within the first six months. Relapse is treated with a repeat course, which works for most prior responders and is covered by Medicare and most insurers. Continuing an antidepressant and therapy after TMS, with monthly PHQ-9 monitoring, reduces the risk.
This page sets out the relapse data, the options for maintaining a response, what we recommend about medication and therapy after the course, how insurance handles re-treatment, and the monitoring routine we use at our Palm Beach Gardens office to catch a returning episode early, when it is easiest to treat.
Who it is for
This page is for patients finishing or recently finished with a TMS course, for those who responded to TMS in the past and are noticing symptoms return, and for anyone deciding whether to start TMS who wants to know what the long-term plan looks like. It covers the depression protocol primarily; the principles for OCD are similar, with less long-term data. If you had TMS at another clinic and have relapsed, the re-treatment options here apply to you, and we can obtain your prior records to document response.
How it works
TMS works by strengthening activity and connectivity in prefrontal mood circuits over repeated sessions, and the changes persist after stimulation stops, which is why benefit continues through the taper and beyond. Depression is a recurrent illness, however, and the same vulnerabilities that produced the episode remain: genetics, stress, sleep disruption, medical illness. Over months, some patients' circuits drift back toward the depressed pattern. A maintenance strategy aims to catch that drift early, either with scheduled booster sessions, with a prompt repeat course when symptoms begin to climb, or, most often, with continued medication and therapy that stabilize the gains while the brain consolidates them.
In a 12-month follow-up of 257 patients after acute TMS, 62.5 percent of responders maintained response throughout the year, and 36.2 percent received a repeat course, most of whom responded again.
Source: Dunner et al., Journal of Clinical Psychiatry, 2014
A meta-analysis of durability studies found sustained response after TMS in about 66 percent of responders at three months, 53 percent at six months and 46 percent at 12 months without maintenance treatment.
Source: Senova et al., Brain Stimulation, 2019
In a randomized pilot study of medication-free TMS responders, scheduled monthly maintenance sessions did not significantly outperform observation with re-treatment on demand over 12 months, and both strategies kept most patients well.
Source: Philip et al., Brain Stimulation, 2016
In STAR*D, relapse within one year after remission ranged from about 33 percent for patients who remitted on the first treatment step to over 70 percent for those who required four steps.
Source: Rush et al., American Journal of Psychiatry, 2006
What to expect
After your final taper session, you move to a follow-up schedule with your Stedfast prescriber. We see you at two to four weeks, then monthly for the first six months, then every two to three months, with a PHQ-9 at each visit and by patient portal in between. We ask you to continue the antidepressant you were on during TMS for at least a year, and to continue or begin psychotherapy, because both reduce relapse. If your PHQ-9 rises by five points or more from your post-TMS low, or you notice the early signs we identified together, such as sleep disruption, withdrawal or loss of interest, we see you within a week. A small rise often settles with a medication adjustment or increased therapy; a sustained rise toward your pre-treatment score triggers a repeat course, which we aim to start before the episode is fully re-established, when the evidence suggests re-treatment works fastest.
Benefits
- Most responders remain well at one year without further TMS
- Re-treatment succeeds in the large majority of patients who responded to their first course
- Medicare and most commercial plans cover a repeat course for documented prior responders
- Structured monthly monitoring catches relapse early, when a shorter course may be enough
- Continued medication and therapy after TMS measurably improve durability
- No cumulative toxicity, so repeat courses over years carry no added long-term risk
Risks and side effects
The risk specific to this page is relapse itself, and the goal is to shorten the time between relapse and effective re-treatment. Repeat and maintenance TMS carry the same side-effect profile as the initial course: transient scalp discomfort and headache, a rare risk of seizure, and no cognitive effects. There is no evidence that repeated courses over years produce cumulative harm, and patients have received multiple courses over a decade without new safety concerns. The main practical risk is a gap in monitoring, which is why we structure follow-up rather than leaving it to the patient to call when things feel bad.
Cost and insurance
Medicare in Florida covers re-treatment with TMS for patients who responded to a previous course, defined as a documented 50 percent improvement on a standardized scale, and who have relapsed; our records from your first course provide that documentation. Most commercial plans follow similar logic and will authorize a repeat acute course after relapse for a prior responder, though many require a minimum interval and a current severity score in the moderate to severe range. Scheduled maintenance sessions in the absence of relapse are generally not covered by commercial insurance or Medicare, and we offer them on a self-pay basis for patients who want them; the coordinator can quote per-session rates. If you were treated elsewhere, we request those records to establish prior response for your insurer.
What the relapse data actually show
The most informative study followed 257 patients for a year after an acute course of TMS in routine clinical practice. Patients could continue medication and could receive a repeat course if they relapsed. Among those who had responded to the acute course, 62.5 percent met response criteria at every assessment across the 12 months. About 36 percent received re-treatment at some point, and most of them recovered their response. A 2019 meta-analysis pooling durability studies, most without maintenance treatment, found sustained response in about two thirds of responders at three months, about half at six months and just under half at one year. The relapses cluster early: patients who are still well at six months are likely to stay well at twelve. These rates compare favorably with medication at the same stage of treatment resistance, where STAR*D documented one-year relapse above 70 percent for patients who needed four treatment steps.
Three strategies after the acute course
Continuation with medication and therapy
This is the default and the one with the broadest support. Patients who continue an antidepressant during and after TMS have better durability, and evidence-based psychotherapy, particularly CBT and behavioral activation, reduces relapse after any depression treatment. We ask every patient to continue medication for at least a year after remission and to continue or begin therapy. The two are inexpensive, covered by insurance, and address the vulnerabilities that TMS does not.
Monitoring with re-treatment on demand
The patient is followed at structured intervals, and a repeat course is started when scores rise. This strategy matches the randomized evidence, which found it performed as well as scheduled maintenance, and it concentrates treatment on the patients and the periods that need it. It depends on reliable monitoring, which is why we schedule follow-up and PHQ-9 checks rather than waiting for a call. Early re-treatment, started when scores begin to climb rather than after a full episode has returned, often needs fewer sessions.
Scheduled maintenance sessions
Some patients receive booster sessions on a fixed schedule, for example weekly for a month after the taper, then every two weeks, then monthly, or clustered boosters of several sessions every few months. Observational reports suggest this holds response in patients prone to rapid relapse, but the one randomized trial did not show an advantage over monitoring with re-treatment on demand. Insurance rarely covers maintenance without relapse. We offer it on a self-pay basis and recommend it mainly for patients who have relapsed quickly after previous responses.
Re-treatment: what to expect the second time
A repeat course uses the same mapping and parameters as your first, which we keep on file, so day one is shorter. Prior response is the strongest predictor of response to a repeat course, and many patients respond faster the second time. Whether you need the full 36 sessions depends on how far symptoms have returned: an early, moderate relapse sometimes resolves within two to four weeks, while a fully re-established episode usually needs a full acute course and taper. We judge by the weekly PHQ-9 trend and stop when remission is reached and holds. Patients treated elsewhere can be re-treated here; we request prior records to document response for authorization.
How we monitor after TMS
| Timing | What happens |
|---|---|
| Final taper session | Post-treatment PHQ-9, relapse-signs plan, medication and therapy plan confirmed |
| 2 to 4 weeks after | Follow-up with prescriber; PHQ-9 |
| Months 1 to 6 | Monthly visit or portal PHQ-9; same-week visit if score rises 5 or more points |
| Months 6 to 12 | Visit every 2 to 3 months; portal PHQ-9 monthly |
| Any time | Call (561) 437-2199 if early signs appear; re-treatment authorized on documented relapse |
Reducing your own relapse risk
- Protect sleep: irregular or short sleep is the most common precursor to relapse we see, and it is modifiable.
- Keep the medication: do not stop or reduce an antidepressant without discussing it at a follow-up visit.
- Stay in therapy: skills learned while well are the ones available when mood starts to slip.
- Limit alcohol: it disrupts sleep, lowers mood and reduces the effect of medication.
- Plan for known stressors: anniversaries, seasonal changes, surgery and major life events are predictable; schedule an extra check-in around them.
- Act on the first signs: a week of early treatment is easier than six weeks after a full relapse.
Deep TMS at Stedfast Psychiatry, Palm Beach Gardens
Stedfast Psychiatry delivers initial and repeat Deep TMS courses at our Palm Beach Gardens office, 11641 Kew Gardens Ave, Suite 209, and follows every TMS patient with structured monitoring through our Florida and South Carolina offices and by telehealth. If you completed TMS with us or elsewhere and are noticing symptoms return, call (561) 437-2199; prior responders are prioritized for prompt evaluation, and our coordinator handles re-treatment authorization. If you are finishing a course now, your follow-up schedule and relapse plan are set before your last session.
Frequently asked questions
How likely is it that my depression comes back after TMS?
Roughly one third of patients who respond to TMS relapse within a year, and about two thirds remain well, based on the largest one-year follow-up study. Relapse, when it happens, is most common in the first three to six months. The comparison matters: patients at the same stage of treatment resistance who remit on medication relapse at higher rates. Continuing an antidepressant and therapy after TMS, keeping sleep regular and monitoring monthly all reduce the risk.
What are the signs of relapse I should watch for?
Usually the same early signs that preceded your previous episode, which we identify with you before you finish the course. Common ones are sleep disruption, loss of interest in things that had become enjoyable again, withdrawing from people, increased irritability or anxiety, and a creeping sense of effort in ordinary tasks. A PHQ-9 that rises five or more points from your post-TMS low is our threshold for a prompt visit. The point is to act on the early drift rather than wait until the full episode has returned.
What happens if I relapse?
We see you within a week, review medication, sleep, stressors and therapy, and repeat the PHQ-9. A modest rise often responds to a medication adjustment or more frequent therapy. A sustained rise toward your pre-treatment score leads to a repeat TMS course, which we start as soon as insurance authorizes it; prior responders are approved quickly because your records document response. Re-treatment works for the large majority of patients who responded the first time, and some respond faster the second time.
Does a repeat course mean the full 36 sessions again?
Not always. When relapse is caught early and symptoms are moderate, a shorter course of two to four weeks sometimes restores the previous response, and some clinics use brief clusters of five to ten sessions for early drift. When the episode has fully returned, a full acute course is usually needed. Insurers typically authorize a full course for a documented relapse, and we stop early if your scores reach remission sooner. The decision is made on your weekly PHQ-9 trend, not on a fixed number.
Should I keep taking my antidepressant after TMS?
Yes, for at least a year after remission, and we recommend it strongly. Patients who continue medication during and after TMS have better durability than those who stop, and stopping an antidepressant after any remission raises relapse risk. If side effects are a problem, we adjust the medication rather than discontinue it. Patients who have had several prior episodes often benefit from staying on medication indefinitely. The decision is made with your prescriber at follow-up, not at the end of the TMS course.
Is scheduled maintenance TMS worth it?
The evidence is mixed. The one randomized study comparing monthly maintenance sessions with observation and re-treatment on demand found no significant difference over a year, and both groups did well. Some patients with a history of rapid or severe relapse prefer scheduled boosters, and observational reports support them. Insurance generally does not cover maintenance without relapse, so it is a self-pay choice. Our usual recommendation is structured monitoring with prompt re-treatment, with scheduled maintenance reserved for patients who have relapsed quickly before.
Will insurance cover a second course?
In most cases, yes. Medicare in Florida covers re-treatment for patients who had a documented response, usually a 50 percent improvement on a standardized scale, and have relapsed. Most commercial plans cover a repeat acute course under similar criteria, sometimes with a minimum interval since the last course and a current PHQ-9 or HAM-D in the moderate to severe range. Our coordinator submits the authorization using your first-course records. Scheduled maintenance in the absence of relapse is typically not covered.
Can I have TMS again years later?
Yes. There is no limit on the number of courses over a lifetime and no evidence of cumulative harm; patients have received repeat courses over a decade or more without new safety concerns. Each course carries the same low risks as the first. Prior response is the best predictor of response to a later course, so a patient who did well before has good odds again, even after a long interval. We keep your mapping and treatment parameters on file to make a later course straightforward.
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.