What Happens If TMS Doesn’t Work? Next Steps

You’ve heard the success stories. The impressive response rates. The life-changing results. But what nobody talks about is what happens when you’re in that other group, the one where TMS doesn’t deliver the relief you were hoping for. If that’s you, or if you’re worried it might be, this honest guide is for you.

Let me be direct with you about something most TMS providers won’t say out loud: not everyone responds to TMS therapy. The marketing materials focus on success stories, and for good reason. TMS genuinely changes lives. But if you’re reading this, you’re probably looking for the honest version.

Maybe you’re considering TMS and want to know the real odds. Maybe you’re partway through treatment and not feeling better yet. Or maybe you’ve finished a full course and the results weren’t what you hoped for.

Whatever brought you here, this guide gives you the complete picture. The real statistics, the reasons some people don’t respond, and most importantly, what you can actually do about it.

The Real Numbers: TMS Response Rates Explained

Before we get into why TMS doesn’t work for everyone, let’s establish what the research actually shows. Not the marketing brochures, but the peer-reviewed data from real clinical settings.

The Largest Real-World TMS Study

The NeuroStar Outcomes Registry, published in the Journal of Affective Disorders in 2020, represents the most comprehensive real-world TMS data available. Among patients who completed their full treatment course:

Those are encouraging numbers. But here’s what doesn’t get talked about as much: that still leaves roughly 17% who don’t see significant improvement, and about 38% who improve but don’t reach full remission.

Dr. Cara Erkut’s Response Board-Certified Psychiatrist, TMS Program Director

This is a really important question, and I appreciate the honesty. Here’s what the data shows: patients who show some improvement by session 10 are much more likely to be responders by session 36. But some patients don’t feel changes until the final week or even after treatment ends. At session 25 with no change, I’d want to have a conversation about several things: Are there medications that might be interfering? Is the diagnosis accurate? Should we consider protocol adjustments? “Trust the process” isn’t wrong, but it should come with specific benchmarks and a backup plan. You deserve more than vague reassurance.

How Treatment Resistance Affects Response Rates

The numbers shift significantly based on how treatment-resistant someone’s depression is. The landmark STAR*D study showed that after failing three medications, the chance of remission from any subsequent medication drops to less than 7%.

This context matters because it shows why TMS exists in the first place. Even conservative estimates showing 30-40% remission rates for treatment-resistant patients are remarkable compared to continuing to try more medications after multiple failures.

What “Response” and “Remission” Actually Mean

When researchers talk about TMS outcomes, they use specific definitions: Response means at least 50% symptom reduction on standardized scales. Remission means symptoms reduced to where you wouldn’t meet criteria for depression. Partial response is noticeable improvement but less than 50%. Non-response is no significant change after completing treatment.

Some people respond but don’t remit, meaning they feel noticeably better but still have some symptoms. Others don’t respond at all. Both scenarios deserve honest discussion and a clear plan forward.

Why TMS Doesn’t Work for Everyone

If TMS is targeting the brain directly, why doesn’t everyone respond? The honest answer is that depression is complicated, and so is the brain.

The Biology of Individual Variation

TMS works by delivering magnetic pulses to the left dorsolateral prefrontal cortex (DLPFC), a brain region involved in mood regulation. The goal is to “wake up” underactive neural circuits and restore healthy communication patterns.

But here’s the thing: not everyone’s brain anatomy is exactly the same. The standard targeting approach uses a measurement from the motor cortex, but individual variation in brain structure means that placement might not hit the optimal spot for everyone.

Some people have depression that involves different brain circuits than the ones TMS typically targets. Others have co-occurring conditions like anxiety disorders, PTSD, or personality disorders that can complicate the picture and require different or additional approaches.

Diagnostic Considerations

Sometimes what looks like treatment-resistant depression is actually something else. Bipolar disorder, for instance, can present with depressive episodes that look identical to major depressive disorder, but TMS protocols designed for unipolar depression may not be appropriate and could potentially worsen symptoms.

Dr. Cara Erkut’s Response Board-Certified Psychiatrist, TMS Program Director

The pattern you’re describing, feeling great briefly then crashing, raises some important questions. First, that initial response tells us TMS did affect your brain, which is valuable information. Second, a pattern of mood improvement followed by a significant crash can sometimes indicate underlying bipolar features that weren’t fully captured in the initial evaluation. I’d recommend a thorough re-evaluation with particular attention to any history of elevated mood periods, even brief ones. You didn’t waste your money because you now have important data about how your brain responds, but you need a clinician who will take this pattern seriously and adjust the treatment approach accordingly.

Medication Interactions

Some medications may interfere with TMS response, though the research here is still evolving. Several studies have examined the relationship between benzodiazepine use and TMS outcomes:

The research on benzodiazepines and TMS is mixed. One study in the American Journal of Psychiatry found benzodiazepine use was associated with more than double the odds of being in a “non-response” trajectory, possibly because these medications affect GABA systems that TMS is trying to modulate. However, a 2020 pooled analysis found no significant relationship. The relationship may be correlative rather than causative, since patients on benzodiazepines often have higher baseline anxiety, which itself predicts poorer response.

The takeaway: medication optimization should be part of the conversation, but don’t assume benzodiazepines are definitely the problem.

Factors That Predict TMS Response

Researchers have identified several factors that tend to predict how well someone will respond to TMS. Understanding these can help set realistic expectations and identify areas for optimization.

Factors Associated with Better Response

Factors associated with better TMS response include: fewer prior medication failures (patients who’ve tried 1-2 medications respond better than those who’ve tried 4+), shorter current depressive episode (under 24 months), mild to moderate symptom severity, early improvement by session 10, younger age (modest effect, likely due to brain plasticity), and higher persistence as a personality trait.

Factors Associated with Lower Response

A June 2025 study published in Translational Psychiatry used machine learning to identify predictors of TMS non-response. The factors associated with lower probability of success included:

What to Do If TMS Isn’t Working

If you’re partway through TMS treatment and not seeing results, or if you’ve completed a full course without adequate response, here’s a practical framework for next steps.

Step 1: Reassess the Diagnosis. Is the primary diagnosis accurate? Are there co-occurring conditions that haven’t been fully addressed? Could this be bipolar depression rather than unipolar? A fresh diagnostic evaluation, ideally with a different clinician for a second perspective, can reveal important information.

Step 2: Review Medication Optimization. Are you on any medications that might interfere with TMS? Is there room to optimize your current medication regimen? Sometimes adjusting or tapering certain medications can improve TMS response. This should be done carefully with medical supervision.

Step 3: Consider Protocol Adjustments. Different TMS protocols may work better for different people. Options include extended treatment courses, theta burst stimulation (iTBS), deep TMS, bilateral stimulation, or adjustments to treatment intensity and targeting.

Step 4: Add Psychotherapy. If you’re not already in therapy, adding psychotherapy during or after TMS can significantly boost response rates. Research shows combined treatment achieved 66% response rates versus 30-40% for TMS alone.

Step 5: Explore Alternative Interventions. If TMS hasn’t worked, other interventional treatments like Spravato (esketamine) or ECT may be appropriate next steps. These work through different mechanisms and may succeed where TMS didn’t.

Alternative Treatments After TMS

If TMS hasn’t delivered the results you need, several other evidence-based options are available. Each has its own profile of benefits, risks, and practical considerations.

Spravato (Esketamine)

Spravato is a nasal spray form of ketamine that received FDA approval for treatment-resistant depression in 2019, with an expanded monotherapy indication in January 2025. It works through a completely different mechanism than TMS, targeting the glutamate system rather than directly stimulating neural circuits.

Spravato (esketamine) offers several advantages for TMS non-responders: rapid onset (effects often felt within 24 hours), a completely different mechanism targeting glutamate/NMDA pathways, and strong insurance coverage after 2+ failed antidepressant trials. It’s administered as a nasal spray in certified clinics with a 2-hour observation period, initially twice weekly for 4 weeks, then weekly maintenance. Common side effects include dissociation, dizziness, and sedation, all monitored during treatment.

For some patients who haven’t responded to TMS, Spravato offers a different pathway that may be more effective for their particular brain chemistry.

Extended or Modified TMS Protocols

For partial responders, extending TMS beyond the standard 36 sessions can sometimes push people over the threshold into full response. Research on crossover trials has shown that about 26% of initial non-responders will respond to an additional course of treatment.

Advanced TMS protocol options include: extended courses (30+ additional sessions for partial responders), theta burst stimulation (iTBS) with shorter sessions, deep TMS with different coil designs that reach deeper brain structures, bilateral stimulation targeting both sides of the brain, and accelerated protocols like SAINT (multiple daily sessions over 5 days with 70-90% remission rates in research, though ~$30,000 and not insurance-covered).

Electroconvulsive Therapy (ECT)

ECT remains the most effective treatment for severe, treatment-resistant depression, with response rates higher than any other intervention. It requires general anesthesia and typically 6-12 sessions over several weeks.

Modern ECT is much different from its historical portrayal. Memory side effects, while still a consideration, have been significantly reduced with newer protocols. For patients with severe depression who haven’t responded to TMS or Spravato, ECT is an important option to discuss.

Cost Comparison of Alternative Treatments

Combination Approaches That Boost Success

One of the most promising developments in TMS treatment is the evidence for combining it with other interventions to boost response rates.

TMS Plus Psychotherapy

Research has consistently shown that combining TMS with psychotherapy produces better outcomes than either treatment alone. One study found that combined treatment achieved a 66% response rate and 56% remission rate, compared to 30-40% for TMS alone.

Psychotherapy approaches that complement TMS include Cognitive Behavioral Therapy (CBT, the most studied combination), Dialectical Behavior Therapy (especially for emotion regulation challenges), Acceptance and Commitment Therapy (emerging evidence), psychodynamic therapy (for underlying patterns), and trauma-informed approaches (essential if PTSD or significant trauma history is present).

TMS Plus Spravato

For patients with severe treatment-resistant depression, combining TMS and Spravato is an emerging approach. The rapid-acting effects of Spravato combined with the circuit-level changes from TMS may provide both quick relief and lasting improvement.

The Honest Truth About Finding Relief

Here’s what I tell patients who are worried about TMS not working, or who have already been through a course without the results they wanted:

Non-response to one treatment is not a verdict on your ability to get better. It’s information.

Depression treatment is increasingly understood as a process of finding the right match between your particular brain, your particular symptoms, and the available treatments. TMS works for many people. For those it doesn’t work for, the fact that they tried it and gathered that data helps narrow down what might work better.

The patients who struggle most are often those who give up after one or two treatments don’t work. The ones who find relief are typically those who stay engaged, keep working with their providers, and remain open to trying different approaches.

What to remember if TMS didn’t work: Non-response is data, not failure. There are more options now than ever before. Combination approaches may work when single treatments don’t. Many non-responders respond to modified protocols. Your experience with TMS helps inform what to try next. And giving up is the only thing that guarantees you won’t find relief.

If you’re considering TMS and worried about what happens if it doesn’t work, the answer is: you keep going. You try something else. You don’t give up.

And if you’ve already tried TMS without success, the same message applies. There are more options now than there have ever been. The path forward exists. Finding it requires persistence and the right clinical partnership.

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 →