What If TMS Doesn't Work? Your Clinical Options, Explained

While transcranial magnetic stimulation, or TMS, is an effective option for many people, some don't experience enough improvement over a full course of treatment. While not getting the results you hoped for can be frustrating, a limited response doesn't mean you've run out of treatment options — or even that TMS has delivered all of its potential benefits. The next step is to evaluate the possible reasons for a limited response and consider other evidence-based treatment options, says Ava Meyer, PMHNP-BC, MSN, APRN, a Psychiatric Nurse Practitioner at Radial.

Quick answers:

• TMS non-response generally means that symptoms did not improve sufficiently after a complete course of treatment.
• Approximately 50% to 60% of patients respond to standard TMS treatment, while remission rates are typically around 30% to 40%. Meanwhile, some accelerated TMS protocols boast a response rate of 86% and a remission rate of 78%.
• Non-response doesn't mean you're out of treatment options; potential next steps after TMS include Spravato, a protocol adjustment, a diagnostic re-evaluation, or electroconvulsive therapy (ECT).

Why TMS doesn't work for everyone

TMS therapy is an effective option for many people with depression, but every person responds a little differently. Some people achieve full remission, but it's also possible to see partial improvement, a delayed response, or even minimal change.

When measuring the effectiveness of mental health treatments, it's important to consider both the response rate and the remission rate. Response means that a person experiences a meaningful reduction in symptoms (usually about 50%), while remission means symptoms have largely resolved.

After standard TMS treatment, clinical studies suggest a response rate of 50%-60% and a remission rate of 30%-40%, according to a review published in Current Opinion in Psychiatry. Those numbers are even higher with some accelerated protocols: SAINT TMS treatment has a 78% remission rate after just 5 days of treatment. 

A limited response can happen for reasons outside a person's control, such as symptom severity, co-occurring conditions, and treatment protocols, explains a review published in Clinical Psychopharmacology and Neuroscience. This doesn't reflect how hard someone is trying or how committed they are to getting better. Some patients achieve remission, some experience meaningful symptom relief, and some require additional treatment approaches.

It's also important to remember that treatment outcomes aren't always all-or-nothing. A partial response still counts as a meaningful improvement, and it can help guide additional treatment decisions. A response might seem delay because it may take time for TMS to start working.

"If a patient completes a full course of TMS and still hasn't seen much benefit, I remind them that symptom relief may still take several weeks to emerge following the acute treatment period," Meyer says. That's because the brain continues to strengthen and consolidate the neural changes that are started by TMS.

What are your options if TMS isn't effective?

A partial improvement from TMS doesn't rule out other options. These approaches also aren't mutually exclusive, and a combination of treatment strategies is common.

• Spravato (esketamine): "If TMS has not been successful in alleviating depressive symptoms, with or without suicidal ideation, Spravato may be an appropriate treatment option," Meyer says. Spravato is an FDA-approved treatment that acts through a different mechanism than TMS, so it may help some people who had a limited response to TMS. 
• Diagnosis re-evaluation: A limited response can also prompt a closer look at what's happening, because conditions like PTSD, OCD, and ADHD can overlap with depression. Not responding can prompt a clinician to reassess whether depression is the only condition contributing to the symptoms a person is experiencing.
• Protocol adjustment: When a patient improves but doesn't get enough symptom relief, adjusting coil placement, stimulation intensity, or treatment protocol can sometimes help.
• ECT: Electroconvulsive therapy, or ECT, is one of the most effective treatments available for severe, treatment-resistant depression, says Focus. One difference between TMS and ECT is that ECT requires anesthesia, while TMS is a noninvasive outpatient treatment.

Even when results don't lead to full remission, meaningful symptom reduction still matters. Rather than automatically moving on to another treatment, Meyer says providers look at the whole picture — including co-occurring medical conditions, situational stressors, symptom ratings, and medication changes — and then work with the patient to determine what comes next.