The simplest way to bring up TMS is to name it directly and tie it to your history: "My depression has not lifted after the medications we've tried. Could I be a candidate for TMS, and if not, why not?" Your psychiatrist or therapist should welcome that question. It shows you are tracking your own care, and it opens a conversation about what has and has not worked.
This guide gives you wording you can borrow, the records worth gathering beforehand, how referrals usually work, and what to share if your clinician is unsure about the evidence. It is not a script for persuading anyone. A good outcome is a clear answer about whether TMS fits you now, later, or not at all.
Why the conversation is worth having
Professional bodies treat TMS as a mainstream option for depression that has not responded to medication. The Clinical TMS Society's consensus recommends that TMS "should be considered" for people with major depression when antidepressants have not given satisfactory benefit or cannot be tolerated. The American Psychiatric Association's 2024 position statement calls TMS "a safe and effective evidence-based medical treatment when administered by TMS-trained psychiatrists for appropriately selected patients." Canada's CANMAT 2023 guideline rates TMS a first-line option for treatment-resistant depression.
That does not make TMS the right next step for everyone. CANMAT also notes that TMS is typically recommended after first-line psychotherapy and medication have not worked, because of feasibility issues such as the visit schedule. The point of raising it is to get a reasoned answer, not a yes.
What to gather before the appointment
Clinicians decide about TMS largely on your treatment history, and insurers ask for the same details. Many people cannot remember doses and dates from years ago, so collecting them in advance makes the visit far more useful. One insurer request form, for example, asks for a table of medication names, doses and dates, plus any prior TMS or ECT in the past three years.
- Every antidepressant you have tried in this episode: name, highest dose, roughly how long you took it, and why you stopped (no effect, partial effect, side effects).
- Add-on medications such as a second drug used to boost an antidepressant. Some plans specifically ask about this "augmentation."
- Therapy history: type (for example CBT), how long, and whether it helped. Medicare in New York requires a documented trial of evidence-based psychotherapy before covering TMS.
- Any rating-scale scores you have, such as PHQ-9 results from past visits.
- Medical and safety items: seizures, head injury, metal or implants in or near the head, pacemakers or other implanted devices. These come up in screening for every TMS candidate.
Your pharmacy can print a fill history, and a patient portal often lists past prescriptions. If coverage is part of your decision, the guide to how many antidepressants insurers expect you to try explains why these details matter.
Questions you can ask, word for word
Pick the ones that fit. Writing two or three on your phone before the visit is usually enough.
- "Based on what we've tried, would you call my depression treatment-resistant? Why or why not?"
- "Is there anything we haven't tried yet that you'd do before TMS, such as a dose change, a different medication class, or a different therapy?"
- "Could anything else be keeping me from getting better, like sleep, thyroid, alcohol, or a diagnosis we should revisit?"
- "Are there reasons TMS would be unsafe or a poor fit for me?"
- "If I did TMS, would I keep my current medication and therapy?"
- "Can you refer me for a TMS consultation, or send my records to a TMS team?"
- "How would we measure whether it's working?"
For a longer list to take to the TMS team itself, see questions to ask before starting TMS therapy.
If you see a therapist but not a psychiatrist
Therapists cannot prescribe TMS, but they are often the first to notice that months of good work have not moved your mood. You can ask your therapist to write a short note describing your treatment course and current symptoms, or to talk directly with a psychiatrist about you, with your written permission. That coordination is routine; this piece on how psychiatrists and therapists coordinate care explains how it usually works. If you have no psychiatrist at all, a general psychiatric evaluation is the usual first step before any TMS consultation.
How referrals and consultations usually work
TMS is ordered by a physician, and under some plans by a psychiatric nurse practitioner. New York Medicare's policy, for example, describes an order written by a physician who has examined you and reviewed your record (a nurse practitioner may order where state scope of practice allows), with treatment given under direct physician supervision. In practice there are three common routes:
| Route | How it works | What to bring |
|---|---|---|
| Your own psychiatrist refers you | They send records and a referral to a TMS team, which schedules a consultation. | Medication list, recent notes, rating scores |
| You request a TMS consultation directly | The TMS psychiatrist evaluates you and, with your consent, contacts your current prescriber. | Everything on the list above, plus your prescriber's contact details |
| Your primary care doctor refers you | Common if your antidepressants came from primary care; expect a full psychiatric evaluation first. | Pharmacy fill history and any therapy records |
What happens at that visit is covered in what happens at a TMS consultation and what to bring, and a self-check is in am I a candidate for TMS?
If your clinician is skeptical
Skepticism is not always a bad sign. A careful psychiatrist may want to fix a dose problem, treat insomnia, or reconsider the diagnosis first, and those are fair reasons. Ask what specifically concerns them. If it is the evidence, a short, honest summary helps more than a brochure:
- In the NIMH-funded sham-controlled trial by George and colleagues (2010), remission was 14.1% with active TMS versus 5.1% with sham. Typical active-versus-sham remission gaps in randomized trials are about 9 to 18 percentage points.
- Guidelines differ in strength. CANMAT 2023 rates TMS first-line for treatment-resistant depression, while the 2022 VA/DoD guideline gives a "weak for" suggestion after two or more failed medication trials.
- A standard course means daily sessions, five days a week, for about six weeks, and consensus guidance says 20 to 30 sessions are "very likely" needed to match trial results.
Those numbers are modest, and saying so builds trust. If your clinician wants more detail, the physician-focused guide to referring a patient for TMS is written for them. If you still disagree after a real discussion, a second opinion from a psychiatrist who provides TMS is reasonable and common.
When TMS is not the right next step
Some situations call for a different or faster treatment first. Consensus guidance says people with psychotic symptoms or acute suicidal thoughts should be considered for other treatments with established efficacy, such as ECT. TMS also takes weeks, so it is not a crisis treatment. 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.
It may also make sense to wait if you have tried only one medication at a low dose, or have not yet had a solid trial of therapy. What treatment-resistant depression actually means and TMS or another antidepressant? walk through that decision.
After the conversation
Write down what your clinician said and what you agreed to try next, with a date to revisit it. If the answer was "not yet," ask what would change it. If the answer was "yes," the next steps are a consultation, a benefits check, and screening. The full TMS guide lays out each stage, and the TMS therapy page explains how to ask about a consultation.
Sources
- The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
- Position Statement on Transcranial Magnetic Stimulation (TMS). American Psychiatric Association, 2024. psychiatry.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
- VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder. U.S. Department of Veterans Affairs / Department of Defense, 2022. healthquality.va.gov
- Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Archives of General Psychiatry, 2010. pubmed.ncbi.nlm.nih.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
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. Food and Drug Administration, 2011. fda.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
- Carelon Behavioral Health Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, n.d.. carelonbehavioralhealth.com
- 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
FAQs
Do I need a referral to get a TMS consultation?
Not always. Some TMS teams accept self-referrals, but your insurer may still need records from your current prescriber, and the TMS psychiatrist will usually want to speak with them.
Will my psychiatrist be offended if I ask about TMS?
Most will not. Asking about an established treatment is a normal part of shared decision-making, and a clear question usually gets a clearer answer.
What if I can't remember my old medication doses?
Ask your pharmacy for a fill history and check your patient portal. Past prescribers can also send records. Approximate dates are better than none.
Can my therapist refer me for TMS?
A therapist cannot order TMS, but with your permission they can share notes and speak with a psychiatrist who evaluates you for it.
Should I stop my antidepressant before asking about TMS?
No. Do not change or stop any medication on your own. Whether to continue medication during TMS is a decision for you and your prescriber; see medications during TMS.
