Pros and Cons of TMS Therapy

This page lays both sides out in the same place, without the enthusiasm of a brochure. Whether TMS is the right call depends on which of these pros and cons weigh most in your own situation, and we would rather you decide with the full picture.

Who it is for

The patients who get the most out of TMS are adults with major depressive disorder who have tried one or more antidepressants without reaching remission, or who could not tolerate the side effects, and who can commit to a daily schedule for six weeks. The pros weigh heaviest for people who are sensitive to medication side effects, who are older and on many other drugs, who are pregnant or planning to be, or whose depression comes with significant anxiety, since Deep TMS is cleared for anxious depression. The cons weigh heaviest for people with unpredictable work schedules, those who live far from a treatment center without reliable transportation, patients with psychotic features or a current manic episode, and anyone with a seizure disorder or metal in the head. If you are weighing TMS against Spravato, ECT or another medication trial, the comparison pages on this site go deeper on each.

How it works

Deep TMS uses a helmet-mounted magnetic coil to deliver brief pulses to the prefrontal cortex, the region that regulates mood and that is reliably underactive in depression. Each session lasts about 20 minutes. You are awake, seated and able to talk. The pulses feel like tapping on the scalp. Over weeks of daily sessions, the stimulation strengthens activity in that circuit, and in about two thirds of patients that translates into fewer depressive symptoms. Unlike medication, nothing enters your bloodstream, which is why TMS has no sexual, weight, gastrointestinal or sedating side effects. Unlike ECT, there is no anesthesia, no induced seizure and no memory loss. The trade is that the dose is delivered in person, one session at a time, which is where most of the cons come from.

What to expect

The process at Stedfast Psychiatry starts with an evaluation at any of our 13 offices or by video, where a psychiatrist confirms the diagnosis, reviews your medication history and screens for contraindications. Our TMS coordinator then verifies insurance and submits prior authorization. Treatment takes place at our TMS treatment centers, with Palm Beach Gardens as the primary center. The first visit includes motor threshold mapping, which takes about an hour; every visit after that is about 30 minutes door to door. Sessions run five days a week for six weeks, then taper over three weeks. We track your PHQ-9 weekly and discuss honestly whether to continue if you have not improved by the midpoint.

Benefits

• Response in roughly 60 to 75 percent of patients in real-world registries, after medication has already failed
• No systemic side effects: no weight gain, sexual dysfunction, nausea, sedation or drug interactions
• No anesthesia, no cognitive side effects and no memory loss, in contrast to ECT
• Covered by Medicare and most commercial insurers with prior authorization
• You can continue your current medication and therapy during the course
• Benefits last a year or more in about two thirds of responders, and repeat courses work for most who relapse

Risks and side effects

The common side effects are scalp discomfort at the coil site and mild headache, mostly during the first week, which respond to over-the-counter pain relievers and usually fade as you adjust. Jaw or facial muscle twitching during pulses is normal. Hearing protection is worn because the coil clicks loudly. The serious risk is seizure, which occurs in roughly one in 30,000 sessions, and we screen for factors that raise it, including seizure history, certain medications, sleep deprivation and heavy alcohol use. A small number of patients with bipolar disorder can switch into hypomania. There are no known long-term adverse effects after nearly two decades of use.

Cost and insurance

With insurance, your cost is typically your copay or coinsurance per session, which for Medicare is 20 percent of the allowed amount after the Part B deductible, often covered by a supplement plan. Commercial plans require documentation of two to four failed antidepressant trials and a psychotherapy trial before authorizing. Without insurance, a full 36-session course costs several thousand dollars, which is the single largest con for self-pay patients. Our TMS coordinator confirms your benefits before you begin so that there are no surprises, and can discuss appeals if your plan declines.

Pros and cons at a glance

The pros in detail

It works after medication has failed

The central advantage of TMS is that its success rate does not fall the way medication success rates do. In the STAR*D trial, about a third of patients remitted on the first antidepressant, and each subsequent medication step helped a smaller share, down to roughly 13 percent by the fourth step. TMS trials enroll patients who have already failed one to four medications and still produce response rates of 60 to 75 percent in real-world registries. For the patient who has tried three antidepressants, a fourth has a worse chance than TMS does.

No systemic side effects

The reasons people stop antidepressants are familiar: weight gain, sexual side effects, emotional flatness, nausea, sweating, sleep disruption. TMS produces none of these because nothing enters the body. For older adults on a long medication list, for people who have stopped multiple drugs because of side effects, and for pregnant patients weighing fetal exposure, this is often the deciding factor.

No cognitive cost

Compared with ECT, the other proven option for treatment-resistant depression, TMS has no anesthesia, no induced seizure and no memory loss. Several studies have found small improvements in attention and processing speed after a TMS course, which are probably a result of the depression lifting rather than a direct effect, but the point stands: you do not trade memory for mood.

Insurance covers it

Medicare covers TMS for major depressive disorder in Florida and South Carolina when the diagnosis and medication history are documented. Nearly every major commercial insurer has a TMS policy. Coverage is not automatic, and the documentation requirements are real, but a treatment that payers have reviewed and agreed to fund is a treatment with evidence behind it.

It lasts

In the largest durability study, 62.5 percent of responders maintained their response through 12 months. That compares reasonably with antidepressant continuation data, and the patients who relapsed mostly responded again to a repeat course.

The cons in detail

The schedule

This is the con that matters most in practice. A standard Deep TMS course is 36 sessions: five days a week for six weeks, then a taper of two sessions a week for three weeks. Missing an occasional session is fine, but missing a week in the middle weakens the effect. If you travel for work, have unpredictable childcare, or live an hour from the nearest treatment center without a reliable ride, the schedule can become the reason the treatment does not work.

One in three does not respond

A treatment that helps two thirds of people fails the other third, and if you are in that third you will have spent nine weeks and possibly a good deal of money. Predictors of non-response include a very long current episode, psychotic features, severe personality pathology, active substance use and high-dose benzodiazepine use. We screen for these at the evaluation and tell you if your odds look worse than average. We also track your PHQ-9 weekly and have an honest conversation at the midpoint if nothing is moving.

Early discomfort

Scalp pain, headache and facial twitching in the first week are the most common reasons patients consider quitting. They almost always ease by week two. The technician can reposition the coil and ramp intensity more gradually. Over-the-counter pain relievers before a session help.

Relapse

TMS treats the current episode. About a third of responders relapse within a year, which is roughly the same pattern seen with medication and with ECT. Continuing an antidepressant and therapy afterward lowers the risk, and repeat courses are covered for prior responders, but anyone expecting a permanent fix will be disappointed.

Cost without coverage

If your insurer declines, or if you are seeking TMS for an indication that is not covered, such as bipolar depression or PTSD, a course costs several thousand dollars. That is a legitimate reason to pursue authorization carefully, exhaust appeals, and consider whether another medication trial or Spravato makes more sense first.

Not for everyone

Ferromagnetic metal in the head, implanted electronic devices near the coil, active epilepsy and a current manic episode rule TMS out. Psychotic depression generally calls for ECT or antipsychotic augmentation instead.

Who benefits most

• Adults who have failed one to three antidepressants but have responded to medication at some point in the past
• Patients whose depression comes with prominent anxiety, since Deep TMS is cleared for anxious depression and the pooled data show both improve
• People who have stopped multiple medications because of side effects
• Older adults on complex medication regimens, for whom another drug adds interaction risk
• Pregnant or breastfeeding patients who want to limit medication exposure
• Patients with a stable daily routine who can attend the same time slot for six weeks

Who should look at other options first

• Anyone with psychotic depression, catatonia or acute danger, where ECT is the stronger treatment
• Patients who cannot attend daily for six weeks, for whom Spravato's twice-weekly schedule may be more realistic
• People with an active seizure disorder or metal in the head
• Patients in a current manic or mixed episode
• Those with active heavy alcohol or drug use, which both lowers response and raises seizure risk

How to decide

Write down the three things that matter most to you: effectiveness, side effects, time, cost, durability or safety. Then look at the table at the top of this page and see which column wins on those three. For many patients who have failed two medications and are tired of side effects, the pros win decisively. For a patient with a chaotic schedule and a first episode of moderate depression, another medication trial is the better first move. Neither answer is wrong, and a good psychiatrist will tell you which one fits.

Stedfast Psychiatry's TMS program begins with an evaluation at any of our 13 offices or by video, where a psychiatrist walks through these trade-offs against your own history. 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.

Where this treatment is offered

• Palm Beach Gardens, FL
  11641 Kew Gardens Ave, Suite 209(561) 437-2199

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.