TMS for Treatment-Resistant Depression: What to Expect
Reviewed byWendy Delgado, P.A.
SiggyMD Clinical Team · Last updated June 30, 2026
Key Takeaways
- TMS (transcranial magnetic stimulation) is FDA-cleared for major depressive disorder and is indicated after prior antidepressant failures. About 50 to 60% of people with treatment-resistant depression respond to a standard TMS course, and roughly half of those achieve full remission.
- A typical TMS course involves 30 sessions over 4 to 6 weeks, five days per week. Theta-burst protocols can compress individual sessions to approximately 3 minutes with comparable efficacy to standard 20-to-40-minute sessions. No anesthesia is required; patients drive themselves to and from appointments.
- Most patients do not feel a therapeutic effect until week 3 or later. This is normal. The neuroplastic changes TMS produces accumulate over the course and continue for several weeks after the final session. Discontinuing early because nothing seems to be happening is the most common reason for missed response.
- TMS is not appropriate for patients with metal implants near the skull, certain cochlear implants, or a history of seizure disorders. It does not cause memory loss and does not require anesthesia, distinguishing it clearly from ECT.
- Continuing medication management alongside TMS produces better outcomes than TMS alone. Tracking mood, sleep, and side effects through ongoing check-ins lets a prescriber support the TMS course and plan what comes next.
The conversation about TMS usually happens at a specific point in the depression treatment journey: after two, three, or four medication trials that produced partial results or no results at all. You feel like you have tried the obvious things. You are wondering what the less obvious things are.
TMS is one of the most well-studied and widely available answers to that question. But the way it works, the timeline it requires, and what makes someone a good candidate are still poorly understood by most people considering it. This post answers those questions plainly.
What This Page Covers
- What TMS is and why it is used for treatment-resistant depression
- How it works: the neurobiological mechanism
- What a full TMS course looks like, week by week
- What patients actually experience during sessions
- Response and remission rates: what to realistically expect
- Who is a good candidate and who is not
- How to use TMS in combination with ongoing medication management
- How SiggyMD supports people going through TMS
What TMS Is and Why It Exists
Transcranial magnetic stimulation (TMS) uses a coil placed on the scalp to deliver focused magnetic pulses to a specific area of the brain. For depression, the target is the dorsolateral prefrontal cortex (DLPFC), a brain region that regulates mood, executive function, and the brain’s emotional circuitry.
TMS is a non-invasive, outpatient treatment for depression that uses magnetic pulses to stimulate targeted brain regions. It does not require anesthesia, does not cause seizures at therapeutic doses, and does not produce the memory loss associated with electroconvulsive therapy (ECT).
The FDA first cleared TMS for major depressive disorder in 2008. Its indicated use is for adults who have not achieved satisfactory improvement from prior antidepressant treatment. TMS is often used when standard antidepressants have failed or when patients cannot tolerate their side effects.
The clinical need it fills is real. Approximately 30% of people with major depressive disorder develop treatment-resistant depression. For that group, additional medication trials produce diminishing returns. TMS provides a non-pharmacological pathway that works through different mechanisms.
How TMS Works on the Brain
The depressed brain is characterized in part by underactivity in the left DLPFC, the region most directly involved in regulating the amygdala and the brain’s emotional response circuitry. TMS induces electric currents in the cortex that change patterns of neural activity and promote neuroplasticity, potentially improving mood and cognitive function.
High-frequency stimulation of the left DLPFC (typically 10 Hz) increases cortical excitability in that region. Over repeated sessions, this produces lasting changes in synaptic connectivity, increases BDNF (brain-derived neurotrophic factor) levels, and restores more normal communication between the prefrontal cortex and the limbic system.
This is why TMS effects are not immediate. The neuroplastic changes that produce antidepressant response accumulate over weeks of daily stimulation. A single session does not change your mood. A completed course of 30 sessions can change your brain.
What the Treatment Course Looks Like
The Standard Course
A typical TMS course for treatment-resistant depression involves five sessions per week for 4 to 6 weeks, totaling 20 to 36 sessions depending on the protocol and the patient’s response. Each session with standard high-frequency rTMS runs 20 to 40 minutes.
Newer theta-burst stimulation (iTBS) protocols compress each session to approximately 3 minutes. A large randomized controlled trial of 414 participants found that the 3-minute theta-burst protocol was non-inferior to 37.5 minutes of high-frequency rTMS. Many TMS centers now offer theta-burst as the primary protocol for this reason.
What Sessions Actually Feel Like
You sit in a chair, fully awake. A technician positions the TMS coil on your scalp at the location corresponding to the DLPFC. The coil delivers pulses, producing a rhythmic tapping or knocking sensation on your scalp and a clicking sound. Most patients find it manageable. Some experience mild scalp discomfort or a headache during the first few sessions, both of which typically diminish as the course continues.
No preparation is required. You are awake and alert throughout. After the session, you can drive yourself home and return to your day. There is no recovery period.
The Week-by-Week Experience
This is the part most pre-TMS information glosses over, and it is the part most relevant to what you will actually experience:
Weeks 1 to 2. Most patients feel nothing from a mood standpoint. The TMS is working at the neurological level, but the downstream changes in mood circuitry have not yet accumulated to the point of being felt. This is normal. Stopping because nothing is happening after week one is the most common reason for missed response.
Week 3. Many patients begin to notice subtle changes: slightly better energy, improved sleep, less emotional flatness. Some describe it as a barely perceptible shift that they notice mostly in retrospect. Others do not notice anything until later.
Weeks 4 to 6. The therapeutic effect, when it occurs, typically becomes apparent here. Patients often report that mood improvements feel more stable rather than dramatic. The flatness lifts. Motivation begins to return. The world starts feeling more present.
After the final session. Neuroplastic changes can continue to consolidate for several weeks after TMS ends. Some patients feel their best not at the end of the course but two to three weeks later. This is part of why response should be evaluated at follow-up, not at the final session.
Response and Remission Rates: What to Expect Realistically
In those undergoing treatment for depression, one in two patients who underwent TMS demonstrated a response, meaning a significant improvement in clinical symptoms, while one in three patients achieved remission. Stated differently: roughly 50 to 60% of patients with treatment-resistant depression see meaningful improvement, and about 30 to 35% reach full remission.
These numbers are better understood in context. For patients who are attempting a third or fourth medication trial, the expected response rate is substantially lower, dropping toward 10 to 20% per trial. TMS compares favorably to that baseline for the population it is intended for.
Not everyone responds. This is important to understand before starting. A completed TMS course that does not produce a response is not a failure of the patient or the treatment: it is information that directs the next clinical decision.
What Affects Your Likelihood of Responding
Several factors predict better TMS response:
Lower degree of treatment resistance. Response rates are generally higher in patients who have failed one or two antidepressants than in patients who have failed five or six.
Continued medication management alongside TMS. TMS combined with ongoing antidepressant treatment typically outperforms TMS alone.
Accurate DLPFC targeting. Not all TMS centers use the same targeting precision. Image-guided or connectivity-guided protocols, which personalize the stimulation target based on the patient’s own brain imaging, may produce better outcomes than standardized anatomical targeting.
Completing the full course. Patients who discontinue before week four are the most likely to report no response. Most response occurs in the second half of the course.
TMS is Not for Everyone: Candidacy Criteria
Contraindications to TMS include:
Metal implants in or near the skull (aneurysm clips, cochlear implants, surgical staples or hardware in the head and neck). Standard dental work is not a contraindication.
A history of seizure disorder. Seizure risk with TMS is approximately 0.1%, but pre-existing epilepsy substantially increases that risk.
Certain cardiac pacemakers and implanted stimulators. The TMS team screens for these before treatment begins.
Patients who are not appropriate TMS candidates may be eligible for other interventional approaches, including ECT for severe cases, or esketamine (Spravato) nasal spray, which is FDA-approved for treatment-resistant depression and produces effects through a different mechanism.
Managing the Transition: Before, During, and After TMS
Before TMS. Document your antidepressant trial history for your prescriber and the TMS program. Insurance prior authorization typically requires this. Continue current medications unless your prescriber advises otherwise.
During TMS. Maintain regular contact with your prescribing clinician. Medication adjustments during TMS can be made based on early response signals. Do not stop medication on your own during the TMS course.
After TMS. If you respond, your prescriber will discuss a maintenance plan. A 2024 study found that 86% of patients who achieved remission maintained it over 12 months with monitoring and retreatment triggered by early warning signs. Continuing to check in about mood patterns, even after feeling well, matters.
About SiggyMD
TMS is outside SiggyMD’s direct clinical services. What SiggyMD provides is the ongoing medication management and daily monitoring that supports and complements a TMS course.
For patients preparing for TMS, SiggyMD can help optimize the medication piece before the course begins and maintain medication continuity throughout. For patients who have completed TMS and achieved a response, the daily check-in model tracks early signs of recurrence that would trigger maintenance TMS before a full relapse develops.
For patients who have experienced TMS without adequate response, SiggyMD’s prescribers can review the full treatment history and work through what evidence-based options remain.
“TMS works best when it’s part of a clinical picture that someone is actively monitoring,” says Wendy Delgado, P.A. at SiggyMD. “The people I see who do best with TMS are the ones who stayed on their medications, checked in regularly, and came back for maintenance when things started slipping. The TMS does the heavy lifting during the course. What makes it stick is what happens around it.”
The anonymous intake at SiggyMD requires no name, email, or account to start. A licensed prescriber reviews every treatment plan.
For context on TMS in other settings, read our post on does TMS work for anxiety. For background on what makes depression resistant to treatment, read what causes treatment-resistant depression and our overview of treatment-resistant depression.
Start your anonymous intake with SiggyMD to talk with a licensed prescriber about where you are in your treatment journey and what the next step should be.
What Members Are Saying
AL
A.L., 52
Treatment-Resistant Depression
“I had tried four antidepressants over seven years. The TMS was the first thing that actually moved the needle. I did not feel anything for the first two weeks, which scared me. By week four I noticed I was getting out of bed without dreading it. That had not happened in a long time.”
KM
K.M., 36
Major Depressive Disorder
“Nobody told me that TMS keeps working after the course ends. I finished my 30 sessions feeling maybe 50% better. Two weeks later I was genuinely well, maybe 80%. My prescriber had warned me this could happen. Knowing to expect it meant I did not give up.”
Member stories reflect real experiences. Names and identifying details have been changed to protect privacy. Results vary.
If you are in crisis or experiencing thoughts of self-harm, call or text 988. If you are in immediate danger, call 911.
Sources
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American Psychiatric Association. What Is Transcranial Magnetic Stimulation (TMS)? APA. Accessed June 2026.
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Trevizol AP, et al. Use of Transcranial Magnetic Stimulation for Depression. Harvard Review of Psychiatry. 2019;27(4):216-232.
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Kiebs M, et al. Repetitive transcranial magnetic stimulation in non-treatment-resistant depression. British Journal of Psychiatry. 2019;215(2):445-446.
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Brunoni AR, et al. Mechanisms Underlying Treatment-Resistant Depression. PMC. 2024.
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Peng X, et al. Personalised transcranial magnetic stimulation for treatment-resistant depression: a narrative review. PMC. 2024.
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NAMI. ECT, TMS and Other Brain Stimulation Therapies. NAMI. Updated 2022.
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Cognitive FX. Treatment-Resistant Depression: Complete Guide to Evidence-Based Treatments. Accessed June 2026.
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National Center for PTSD. Complementary and Alternative Medicine. VA. Accessed June 2026.
Frequently Asked Questions
Who qualifies for TMS for depression?
TMS for major depressive disorder is indicated for adults who have not achieved satisfactory improvement from at least one adequate antidepressant trial. Insurance typically requires documentation of prior antidepressant failures for coverage approval. TMS is contraindicated in patients with metal implants in or near the skull (certain aneurysm clips, cochlear implants, surgical hardware in the head), history of seizure disorders, or certain cardiac pacemakers and deep brain stimulators. Standard dental work, fillings, and braces are not a contraindication.
What does a TMS session feel like?
During a session, a coil is placed on the scalp over the dorsolateral prefrontal cortex. The coil delivers rapid magnetic pulses, producing a tapping or knocking sensation at the scalp and a clicking sound. Most patients find it manageable. Some experience scalp discomfort or a mild headache during the first few sessions, both of which typically diminish as treatment continues. You are fully awake and can drive yourself to and from each session.
How long before TMS starts working?
Most patients do not experience a meaningful therapeutic effect until week 3 or 4 of a standard 6-week course. This is consistent with the neurobiological mechanism: TMS-induced changes in synaptic plasticity, BDNF expression, and prefrontal-limbic connectivity accumulate gradually. Some patients notice continued improvement in the weeks after completing the course as these changes consolidate. Do not assess whether TMS is working based on the first two weeks.
Does TMS work better than antidepressants?
TMS is most accurately described as an alternative pathway for patients who have not responded to antidepressants, not a superior option. In patients with treatment-resistant depression specifically, TMS response rates of 50 to 60% compare favorably to the response rates of additional medication trials in the same population. For first-episode depression, medication remains the first-line approach. TMS fills the gap for the substantial subset who do not achieve remission with medication alone.
Can TMS be used with medication?
Yes, and combining TMS with ongoing medication management typically produces better outcomes than TMS alone. Many patients continue their antidepressant regimen during TMS. Your treating prescriber determines whether medication adjustments are appropriate during or after the TMS course. The medication and TMS teams should communicate so that changes in one do not confound interpretation of the other.
What happens after a TMS course ends?
Patients typically continue to experience improvement for several weeks after their final TMS session as the neuroplastic changes consolidate. Maintenance strategies vary: some patients receive a tapering schedule of sessions, others are monitored and retreated when early signs of relapse appear. A 2024 study found that 86% of patients maintained remission over 12 months when retreatment was triggered by early warning signs, with most retreatment courses requiring only 1 to 2 days.
How much does TMS cost and is it covered by insurance?
A standard TMS course of 30 sessions typically costs $6,000 to $12,000 out-of-pocket. Most major insurance plans cover TMS for major depressive disorder with documented prior antidepressant failures. Medicare covers TMS for depression and expanded coverage to an accelerated protocol in 2025. The prior authorization process usually requires documentation of prior antidepressant trials. Your TMS provider's office typically handles authorization paperwork.
Mental healthcare should stay with you between appointments.
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