Antidepressants Not Working? Here’s How TMS Therapy Compares

Tried three different antidepressants and still dealing with side effects that feel almost as bad as the depression? You’re not alone. Here’s what your doctor might not have told you about TMS as an alternative.

I’ve been prescribing antidepressants for years. They work well for many people. But there’s a conversation I have at least once a week in my Mercer Island practice that goes something like this:

“The medication helps my mood, but I’ve gained 25 pounds and I have zero interest in sex. Is this just what I have to accept?”

The honest answer? No, you don’t have to accept it. But for a long time, the alternatives weren’t great either. Switch to a different medication and hope for fewer side effects. Add another medication to counteract the side effects of the first one. Try to find the “least bad” option.

TMS changed that equation for many of my patients. It’s not a miracle cure — nothing is — but it offers something medications fundamentally cannot: depression treatment without systemic side effects.

Let me explain what that actually means and help you figure out if it might be relevant for you.

The Side Effect Problem with Antidepressants

First, let’s be clear: antidepressants are effective medications that have helped millions of people. The problem isn’t that they don’t work — it’s that they work throughout your entire body, not just the parts of your brain involved in depression.

According to research published in the journal Psychiatry, about 40% of people taking antidepressants experience significant side effects. And the most common ones — weight gain and sexual dysfunction — are exactly the kind that make people want to stop treatment.

Why Antidepressants Cause These Side Effects

SSRIs and SNRIs (the most commonly prescribed antidepressants) work by increasing serotonin levels in your brain. The problem is that serotonin isn’t just in your brain — it’s throughout your entire body. Your gut has more serotonin receptors than your brain does. So do your sexual organs.

When you take an SSRI, you’re affecting serotonin everywhere, not just in the mood-regulating circuits. This is why:

• Sexual dysfunction affects 40-65% of SSRI users (some studies report even higher rates)
• Weight gain is common with most antidepressants, particularly paroxetine (Paxil) and mirtazapine
• Emotional blunting — feeling “flat” or unable to experience strong emotions — affects many patients
• GI issues like nausea and diarrhea are common, especially in the first few weeks
• Fatigue and drowsiness can persist throughout treatment

How TMS Works Differently

TMS stands for Transcranial Magnetic Stimulation. Instead of flooding your entire body with medication, TMS delivers magnetic pulses directly to the prefrontal cortex — the specific brain region involved in mood regulation.

Think of it this way: if your TV isn’t working, you can either rewire your entire house, or you can fix the specific circuit that’s malfunctioning. Antidepressants are more like rewiring the house. TMS is more like fixing the specific circuit.

The Science (Without Getting Too Technical)

In depression, certain areas of the brain — particularly the left dorsolateral prefrontal cortex — are underactive. PET scans actually show this visually: depressed brains have less activity in these regions compared to non-depressed brains.

TMS uses magnetic pulses (similar to what’s used in an MRI) to stimulate these underactive neurons. Over the course of treatment, this stimulation helps restore normal activity patterns. The brain essentially “relearns” how to regulate mood on its own.

This isn’t theoretical — it’s been confirmed in study after study. The FDA cleared TMS for depression in 2008, and since then, over 6.6 million treatments have been performed in more than 182,000 patients.

Side-by-Side Comparison: TMS vs. Medications

Here’s how the two treatments stack up across the factors that matter most to patients:

Which Treatment Actually Works Better?

This is where it gets interesting. You might assume medications would be more effective since they’ve been around longer and are more widely used. But the data tells a more nuanced story.

The STAR*D Reality Check

The largest antidepressant study ever conducted — called STAR*D — found that only about one-third of patients respond adequately to their first antidepressant. If that one doesn’t work, you try another. And another. With each failed medication trial, the odds of the next one working decrease.

By the time someone has tried 2-3 antidepressants without adequate response, they’re in “treatment-resistant” territory. And that’s exactly the population TMS was designed for.

TMS for Treatment-Resistant Depression

Here’s what the real-world data shows for patients who hadn’t responded to multiple medications:

• 83% of TMS patients showed meaningful improvement in depression symptoms
• 62% achieved remission — meaning their depression was essentially gone
• Effects lasted 12+ months in the majority of responders
• One year after treatment, 65.8% maintained their improvement

Compare that to medication statistics: response rates drop with each failed trial, and the medication only works while you’re taking it. Stop the pill, and for many patients, the depression returns.

Who Should Consider TMS Over Medications?

TMS isn’t right for everyone. Neither are medications. The question is which approach makes sense for your specific situation.

TMS Might Be Worth Considering If:

Medications Might Be Better If:

Can You Use Both Together?

Yes — and in fact, research suggests that combining TMS with medication may produce better outcomes than either treatment alone.

A 2019 study in the Journal of Psychiatric Research found that TMS plus antidepressant therapy achieved significantly higher remission rates than medication alone. This makes sense from a neurobiological perspective: you’re addressing the problem through two different mechanisms.

What This Looks Like in Practice

For many of my patients from Factoria, Eastgate, and across the Eastside, the treatment path looks something like this:

1. Initial medication trial(s): We start with first-line antidepressants, as guidelines recommend
2. Side effect management: If side effects are problematic, we may try different medications or adjust doses
3. TMS consideration: If medications aren’t working well enough, or side effects are unacceptable, we discuss TMS
4. Combined approach: Many patients continue a low-dose medication while doing TMS, then reassess afterward
5. Maintenance: After successful TMS, some patients can reduce or eliminate medications; others do better continuing both

There’s no one-size-fits-all answer. The goal is finding what actually works for you, with side effects you can live with.

Frequently Asked Questions

Written By

Cara J. Erkut, M.D.

Board-Certified Psychiatrist | Psychoanalyst | TMS Program Director

Dr. Erkut is a board-certified psychiatrist and psychoanalyst practicing on Mercer Island, WA. She earned her medical degree from Mayo Medical School and completed her psychiatry residency at the University of Washington, where she served as Chief Resident. She is an active member of the Clinical TMS Society and serves as a Clinical Instructor at UW Harborview Medical Center. Read full bio →