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What if TMS Doesn’t Work?

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What if TMS doesn't work? Alternatives to TMS
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TMS is an FDA-approved treatment option for depression, and studies have shown it to be particularly effective for people who have tried multiple antidepressants with no success.  In one study of treatment-resistant patients (patients for whom antidepressants did not work), 58% of patients saw improvement in their symptoms after one course of TMS, and 37.1% achieved full remission. (1) 

Depression patients who are resistant to the effects of antidepressants are the most difficult patients to treat, so for this patient population, these are extremely high rates of success. A well-known study shows that only 7-14% of patients who had tried and failed 2-3 antidepressants were able to achieve remission by trying yet another antidepressant. (2)  If you’ve tried several antidepressant medications, TMS is more likely to work than another antidepressant.

Although TMS has helped thousands of patients across the country, it’s true that it may not work for everyone. Many of my TMS patients have tried multiple antidepressants and fear that if TMS doesn’t work, there’s “no hope” for their depression.  But this is not true. If TMS doesn’t work, here’s what we do next.

Accept That Depression Treatment Is a Trial-and-Error Process 

Everyone responds to different treatments differently. If the first round of TMS doesn’t provide full symptom relief, this doesn’t mean that nothing will work. 

Many people with depression require a long-term treatment plan that involves trying multiple treatments. It’s common to combine antidepressants with talk therapy and/or lifestyle changes like an exercise regimen. It’s also common to combine TMS therapy with antidepressants. During and after TMS, you’ll have regular check-ins with your psychiatrist. Talk to them about how you’re feeling, keep an open mind, and be willing to try new things when it comes to tweaking your treatment approach.  Don’t lose hope.

Remember that depression is a medical condition just like any other. If someone with an infection doesn’t respond to the first antibiotic they’re prescribed, their doctor wouldn’t “give up” – they’d try different treatments until the infection clears. Some infections may require more aggressive treatment than others. Depression should be approached the same way. Keep an open dialogue with your psychiatrist and therapist, and work with them to find the right combination of treatments that work for you. 

Try New Combinations of TMS + Other Treatments

When I treat a patient with TMS and we do not see a reduction in depressive symptoms after the first round of treatment, we discuss the next possible options. We can repeat TMS alone, or we can combine it with an antidepressant or another treatment option like the ones mentioned below.

Try Tweaking Your Supplemental Treatments

If you’re already combining TMS with another treatment option, for example, drug-free treatment or natural treatment, we may look at whether any adjustments need to be made to the supplemental treatment. For example, should we adjust the dose of your medication?  Are your therapy sessions helpful? (Do you and your therapist “click?” Is their therapy style effectively giving you the tools you need to manage your symptoms from day to day?) If not, switching therapists can make a huge difference.

Consider Confirming Your Diagnosis

Though it’s not common, it’s possible for someone who actually has bipolar disorder to have been misdiagnosed with depression.  (TMS is not known to be an effective treatment for bipolar disorder.) If you’ve been diagnosed with depression and have ever experienced any symptoms of mania or hypomania, or have a family history of bipolar disorder, it may be advisable to get a second opinion.

Try Alternative Therapies to TMS

If you ultimately decide not to continue with TMS, there are other treatment options available.

Ketamine Treatment for Depression

Ketamine is a drug that has traditionally been used for anesthesia and pain control. Today, it’s being noticed for its fast-acting anti-depressive effects. (3)

Ketamine can be administered as an intravenous (IV) injection or as a prescription nose spray. A ketamine derivative nasal spray has been approved by the FDA for treating depression, but it must be administered by a healthcare professional in a doctor’s office. (4) Preliminary research shows that regular ketamine infusions reduce depressive symptoms for patients with treatment-resistant depression. (5,6)  

Ketamine treatments for depression are extremely safe, and are only administered at a doctor’s office or hospital.

Madison Avenue TMS & Psychiatry offers ketamine treatment at our practice. Contact us online or call us at (212) 731-2033 to learn more about it.

Electroconvulsive Therapy for Depression

Electroconvulsive therapy (ECT) is a 20-minute procedure performed under general anesthesia, in a hospital. During an ECT procedure, electrodes are placed on the patient’s head, and small, safe electrical pulses are passed through the electrodes. (7) ECT is thought to cause a change in the brain’s chemistry, increasing levels of certain neurotransmitters (serotonin and dopamine) known to be deficient in depressed individuals. (8)

ECT is typically only recommended when other treatment options have failed, due partly to the potential for serious side effects (including memory loss), and also because it requires a hospital stay. But ECT is proven to be effective in the treatment of depression, so it’s an option for patients who don’t see success with TMS.

Want To Know Whether TMS May Work for You?

Different people respond to different depression treatments for a variety of reasons. If you’re interested in learning whether you’re a candidate to try TMS, take our quiz or contact us online


1. Carpenter LL, Janicak PG, Aaronson ST, et al. Transcranial magnetic stimulation (TMS) for major depression: A multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety. 2012;29(7):587-96. Link. Accessed January 08, 2020.

2. Gaynes BM, Rush AJ, Madhukar HT, Wisniewski SR, Spencer D, Maurizio F. The STAR*D study: Treating depression in the real world. Cleveland Clinic Journal of Medicine. Jan 2008;75(1):57-66. Link. Accessed January 09, 2020.

3. Gao M, Rejaei D, Liu H. Ketamine use in current clinical practice. Acta Pharmacol Sin. 2016;37(7):865–872. Link. Accessed January 08, 2020. 

4. A New Ketamine Nasal Spray Has Been Approved for Depression (But It’s Not for Everyone). Cleveland Clinic. Published March 20, 2019. Link. Accessed January 08, 2020. 

5. Kevin Kunzmann. Weekly Ketamine infusions show initial, repeated depression benefits. Published April 08, 2019. Link. Accessed January 08, 2020. 

6. Phillips JL, Norris S, Talbot J, Birmingham M, Hatchard T, Ortiz A, Owoeye O, Batten LA, Blier P. Single, repeated, and maintenance ketamine infusions for treatment-resistant depression: A randomized controlled trial. The American Journal of Psychiatry. May 2019:1;176(5):401-409. Link. Accessed January 08, 2020. 

7. Frequently Asked Questions about ECT. Johns Hopkins Medicine. Publication Date Unavailable. Accessed January 08, 2020. 8. Singh A, Kar SK. How Electroconvulsive Therapy Works?: Understanding the Neurobiological Mechanisms. Clin Psychopharmacol Neurosci. 2017;15(3):210–221. Link. Accessed January 08, 2020.

Dr. David Woo

Dr. Woo has been seeing patients in private practice since 2002, always with the goals of combining evidence-based medicine with psychodynamic psychotherapy and collaborating with other mental health professionals to ensure the best possible outcomes for his patients. He has been certified to administer TMS at his practice since 2017. His greatest clinical interests include helping patients suffering from depression, anxiety, and obsessive compulsive disorder.

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