You may be a good candidate for TMS if you are an adult with major depression that has not improved enough with antidepressant medication in the current episode, or you could not tolerate the medicines you tried, and you have no metal or implanted devices in or near your head that rule it out. You also need to be able to come in for sessions most weekdays for several weeks.
Insurance usually adds its own, stricter rules, and a few situations call for a different first step. The checklist below separates the three questions a TMS psychiatrist will ask: does TMS fit you medically, will your plan cover it, and can you realistically do it?
The quick checklist
Print this or copy it into your notes before a consultation. A "no" or "not sure" is not a disqualification; it is something to discuss.
- ☐ I have been diagnosed with major depressive disorder (not only low mood or stress).
- ☐ At least one antidepressant has not helped enough in this episode, or side effects made me stop.
- ☐ I know the names, doses and approximate dates of the medicines I have tried.
- ☐ I have tried talk therapy for this depression, or can explain why not.
- ☐ I have no metal implants, clips, shunts, stimulators or electronic devices in or near my head.
- ☐ I have no history of seizures or epilepsy, or my doctor knows about it.
- ☐ I have not had psychotic symptoms, mania or hypomania, or my psychiatrist has assessed them.
- ☐ I am not currently withdrawing from alcohol or other substances.
- ☐ I can attend sessions about five days a week for roughly six weeks.
- ☐ I know which insurance plan I have, or I am prepared to ask about self-pay.
Each item is explained below.
Clinical criteria and insurance criteria are not the same
A psychiatrist asks whether TMS is a sound medical choice for you. An insurer asks whether your history meets its written policy. The two overlap, but insurance rules are usually narrower.
| Question | What the clinical evidence and labels say | What insurers commonly require |
|---|---|---|
| Diagnosis | Major depressive disorder; the depression labels are for adults, with adjunct labels for ages 15 to 21 | Confirmed major depression, often with a severity score on a rating scale |
| Medication history | Not enough improvement from antidepressant medication in the current episode; the label no longer specifies a number of trials | Medicare in Brooklyn requires trials from at least two drug classes without a clinically significant response, or intolerance to two trials from two classes |
| Intolerance | Expert consensus supports TMS when intolerance to medication prevents its use | Usually counts if documented; rules differ by plan |
| Psychotherapy | Encouraged as part of care; not a label requirement | Medicare requires a trial of evidence-based psychotherapy without significant improvement |
| Maintenance after a course | Evidence is limited and the best schedule is unclear | Not covered by Medicare |
Commercial plans each set their own counts and definitions. Our guides on how many antidepressants you need to try and whether insurance covers TMS go plan by plan.
Guidelines also say where TMS sits in the sequence. The Canadian CANMAT guideline rates rTMS a first-line treatment for treatment-resistant depression, usually after first-line medication and psychotherapy, and says it can be a first choice when medications are not tolerated. The older APA guideline (2010) said evidence was insufficient to use TMS as the initial treatment.
Medical reasons TMS may not be safe
TMS works with a strong, rapidly changing magnetic field, so the main exclusions are about metal and electronics near the coil.
- Metal in or near the head. FDA guidance contraindicates TMS for people with conductive, ferromagnetic or other magnetic-sensitive metal implanted in the head or within 30 cm of the coil. Medicare's coverage policy gives aneurysm clips or coils and stents as examples.
- Implanted stimulators. Deep brain stimulators, cochlear implants and vagus nerve stimulators are listed contraindications.
- Pacemakers and defibrillators. These carry a labeled warning in FDA guidance, whatever their distance from the coil.
- Shunts. Pressure-programmable shunt valves have been considered safe, with the valve settings checked after a session.
- Dental work. Fillings, braces and implants are common questions, and the answer depends on the material and location, so list them all. Details are in implants, dental work and tattoos.
Removable items such as hearing aids, piercings, jewelry and glasses simply come off for sessions.
Some situations are precautions rather than outright exclusions. FDA guidance lists pregnancy and nursing, bipolar disorder and psychotic disorders among groups where evidence on efficacy or safety is lacking. Those need a specialist conversation, not an automatic yes or no.
Red flags that call for a different first step
Some situations do not rule TMS out forever, but mean something else should come first.
Psychosis or acute suicidal thoughts
Expert consensus says people with psychotic symptoms or acute suicidal thoughts should be considered for treatments with established efficacy in those situations, such as ECT. A standard TMS course runs for weeks of daily sessions, which is too slow when safety is at stake.
If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
Active alcohol or drug use
Alcohol withdrawal and stimulants such as cocaine or MDMA lower the seizure threshold. In the deep TMS depression trial, the one seizure followed heavy drinking the night before that the patient had not disclosed. Getting substance use under control usually comes first, and honesty about it protects you. See caffeine, alcohol and sleep during TMS.
A recent seizure or untreated neurologic problem
Seizure risk with TMS is very low overall, but it rises substantially with risk factors such as brain lesions and epilepsy. FDA guidance asks for close monitoring of people with a history of seizure, stroke, head injury or other neurologic disease. A recent or unexplained seizure needs a neurologic workup before anything else.
Possible bipolar disorder or a missed diagnosis
Some depression that looks "treatment-resistant" is really bipolar depression, a thyroid or sleep problem, or a medicine that was never given at a full dose for long enough. What treatment-resistant depression means explains how clinicians check.
Gray areas a psychiatrist weighs case by case
Some people fall between a clear yes and a clear no. These are the most common:
- Teens and young adults. Several systems are cleared as an add-on to medication for depression in people aged 15 to 21. Parents are part of the decision; see TMS for teens and young adults.
- Pregnancy. FDA guidance lists pregnancy as a precaution because evidence is limited, not as a contraindication. TMS during pregnancy and after birth covers what is known.
- Bipolar disorder. A meta-analysis of blinded trials found the risk of switching into hypomania or mania was not significantly different with active TMS than with sham, but bipolar depression is not a cleared indication and needs specialist oversight.
- A medication that was never given a fair trial. If the dose was low or it was stopped after a week or two, your psychiatrist may suggest adjusting it first.
In each case the answer depends on details only a full evaluation can give, which is why the checklist is a starting point and not a verdict.
Can you fit it into your life?
This is the question people underestimate. A standard course is daily on weekdays: one cleared schedule is 5 days a week for 6 weeks plus a 3-week taper, 36 sessions in all. A standard 10 Hz session can run from about 19 to 37.5 minutes, and a theta-burst session takes about 3 minutes of stimulation, plus check-in time either way. Accelerated schedules, with several sessions a day over fewer days, are also FDA-cleared on some systems.
Ask yourself honestly:
- Can I get there every weekday, in all weather, for six weeks?
- Can my job or school schedule bend for a daily appointment? See working, studying and driving during TMS.
- Who will notice if my mood changes, for better or worse, during the course?
- Can I keep my sleep and alcohol use steady for those weeks?
TMS does not require anesthesia and can be done in an office setting. Ask the TMS team about driving and returning to work after your sessions.
Who often turns out to be a strong candidate
In practice, people who fit well tend to share a profile: a clear diagnosis of major depression, two or more medication trials that did not work or caused side effects they could not tolerate, some therapy already tried, no implants near the head, and the time to attend. APA's 2024 position statement describes TMS as "a safe and effective evidence-based medical treatment when administered by TMS-trained psychiatrists for appropriately selected patients." "Appropriately selected" is the point of this checklist.
Results still vary. Even good candidates may not respond, and guidance from NICE says patients should understand that TMS may not give them benefit.
Next steps
If most boxes are ticked, bring the list to your psychiatrist or book a TMS evaluation. The guide to a TMS consultation explains what happens there and what records to bring, and how to bring up TMS with your psychiatrist helps if you are not sure how to start. The TMS guide has every related topic, and TMS therapy is where to begin a conversation about your own situation.
Sources
- 510(k) K160703 - NeuroStar TMS Therapy System. U.S. Food and Drug Administration, 2016. accessdata.fda.gov
- The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. Food and Drug Administration, 2011. fda.gov
- Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
- 510(k) Premarket Notification database (adolescent MDD clearances). U.S. Food and Drug Administration, 2026. accessdata.fda.gov
- Transcranial Magnetic Stimulation, LCD L33398 (version 40). Centers for Medicare & Medicaid Services, 2026. cms.gov
- Consensus review and considerations on TMS to treat depression: A comprehensive update endorsed by the National Network of Depression Centers, the Clinical TMS Society, and the International Federation of Clinical Neurophysiology. Clinical Neurophysiology, 2025. tmslab.org
- Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Canadian Journal of Psychiatry, 2024. pmc.ncbi.nlm.nih.gov
- Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition. American Psychiatric Association, 2010. psychiatryonline.org
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
- Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. pmc.ncbi.nlm.nih.gov
- Seizures from transcranial magnetic stimulation 2012-2016: Results of a survey of active laboratories and clinics. Clinical Neurophysiology, 2019. europepmc.org
- K231926 510(k) Summary - NeuroStar Advanced Therapy System. U.S. Food and Drug Administration, 2024. accessdata.fda.gov
- K173620 510(k) Summary - MagVita TMS Therapy System w/Theta Burst Stimulation. U.S. Food and Drug Administration, 2018. accessdata.fda.gov
- K260189 510(k) Summary - MagVenture Accelerated TMS (aTMS) Therapy System. U.S. Food and Drug Administration, 2026. accessdata.fda.gov
- Position Statement on Transcranial Magnetic Stimulation (TMS). American Psychiatric Association, 2024. psychiatry.org
- Repetitive transcranial magnetic stimulation for depression (HTG396, formerly IPG542). NICE, 2015. nice.org.uk
- Hypomanic/manic switch after transcranial magnetic stimulation in mood disorders: A systematic review and meta-analysis. World Journal of Psychiatry, 2021. europepmc.org
- Brain Stimulation Therapies. National Institute of Mental Health (NIMH), 2024. nimh.nih.gov
FAQs
Do I have to fail four antidepressants before TMS?
No. The current depression labels do not set a number of failed medicines. Insurers often do, and Medicare in Brooklyn looks for trials from at least two drug classes. See how many antidepressants before TMS is covered.
Can I have TMS if I am still taking antidepressants?
Often yes. Being on an antidepressant does not by itself rule TMS out. Your psychiatrist reviews each medicine as part of safety screening, because some drugs can lower the seizure threshold.
I have anxiety as well as depression. Does that rule me out?
No. Some systems are cleared for depression with anxiety symptoms. Anxiety on its own is a different question, covered in TMS for anxiety.
Is there an upper age limit?
The NeuroStar depression indication is written for "adult patients" and does not state an upper age; other devices' labels can differ, so ask which system a clinic uses. Older adults have extra things to review, covered in TMS for older adults.
What if I tick most boxes but not all?
Bring the list anyway. Many items are things to discuss, not automatic exclusions, and a psychiatrist can tell you which ones matter in your case.
