If you stopped antidepressants because the side effects were too much, TMS may still be an option, and in some ways it was designed for you. Clinical consensus recommends considering TMS for major depression when medication has not helped enough or when intolerance to medication rules it out, and several insurers count documented intolerance as a failed trial. TMS has been studied on its own, without antidepressants, in its main trials.
Two cautions. TMS has its own side effects, though they are different in kind. And any change to your current medication, including stopping it, should be planned with your prescriber, not done on your own.
Intolerance is a recognized reason to consider TMS
The Clinical TMS Society's consensus recommendation (its strongest grade) is that TMS should be considered for people with major depression "for whom antidepressant medication has not provided a satisfactory clinical benefit, or for whom intolerance to medications precludes their use". The Canadian CANMAT 2023 guideline similarly says rTMS can be recommended as a first-choice treatment if there are tolerability concerns with medication options.
This matters because many people do not stay on antidepressants as prescribed. Using a definition of less than 80% adherence to the prescribed regimen, about 30% to 50% of people prescribed antidepressants are non-adherent in the acute phase of treatment. Stopping because you could not tolerate a drug is not a personal failing; it is clinical information.
How insurers count intolerance
Coverage rules are written plan by plan, and the details differ. The table summarizes how several policies that apply to New York patients treat intolerance; always check your own plan's current policy.
| Payer policy | How intolerance is treated |
|---|---|
| Medicare (LCD L33398, New York) | Intolerance shown in two trials from two different drug classes can meet the medication requirement; a psychotherapy trial is also required |
| Cigna / Evernorth | A failed trial can be lack of response after at least four weeks at an adequate dose, or documented intolerance or medical contraindication |
| UnitedHealthcare / Optum | Lack of response and/or inability to tolerate two medication regimens from at least two classes (adults) |
| Carelon request form (EmblemHealth behavioral health; undated) | Either two adequate trials of at least six weeks from two classes, or intolerance of four trials from two classes |
| Aetna | Framed around inadequate response to two antidepressants at the maximally tolerated labeled dose, plus an augmentation trial, each for at least 8 weeks |
The table summarizes the cited policies as of October 2026. Documentation is what turns a bad experience into a counted trial: the drug name, dose, dates, and what happened. Our guides to how many medications you need to try before TMS is covered and TMS prior authorization, step by step explain what to gather.
The side effects people stop for, and how TMS compares
Side-effect rates for antidepressants vary widely by drug and by how carefully people are asked. Three side effects that people often raise are well documented:
- Sexual side effects. A 2009 meta-analysis of studies that asked about sexual function directly found treatment-emergent sexual dysfunction in 25.8% to 80.3% of people on several commonly used antidepressants. Some others, including bupropion and mirtazapine, did not differ significantly from placebo.
- Emotional blunting. In a 2017 internet-based survey of 669 people with depression who were taking antidepressants, 46% reported feeling emotionally blunted, though the researchers found blunting also tracked with depression severity.
- Weight gain. In a UK cohort of nearly 300,000 adults followed over 10 years, antidepressant use was associated with a 21% higher rate of new episodes of at least 5% weight gain; the authors note the link may not be causal.
One nuance on blunting: the same survey found that blunting scores rose with depression scores, so feeling flat can partly be depression that has not fully lifted rather than the drug alone. That is worth sorting out with your prescriber, because the fix is different: a medication change for a side effect, or a stronger treatment for residual depression.
TMS is not a drug and does not circulate through the body, and sexual dysfunction, emotional blunting and weight gain are not among the common side effects reported in its main trials. Its common side effects are different, mostly felt at the treatment site, and usually short-lived.
| Typical antidepressant concerns | TMS | |
|---|---|---|
| Most common problems | Sexual dysfunction, emotional blunting, weight change, others depending on the drug | Scalp discomfort or pain at the coil site, headache |
| Timing | Can persist as long as the drug is taken | Usually during the course, easing after the first week |
| Serious but rare | Varies by drug | Seizure, estimated at fewer than 1 per 60,000 sessions within guidelines in people without risk factors |
| Thinking and memory | Varies by drug | No change in cognitive function in the NeuroStar development program |
| Time cost | A daily pill | Daily visits for several weeks |
The TMS column draws on the NeuroStar safety data and a large seizure survey. In the deep TMS pivotal trial, headache affected 26.7% of the active group vs 18.9% on sham. In the NeuroStar program, 4.5% stopped treatment because of side effects. So "TMS has no side effects" is not accurate; "its side effects are usually mild and temporary" is. TMS also requires earplugs, because the coil's click is loud. For the full picture, see TMS side effects: what is common, what is rare.
Evidence for TMS without antidepressants
Much of the core TMS evidence comes from people who were not taking antidepressants:
- The 2007 O'Reardon pivotal trial randomized 301 medication-free outpatients to active or sham TMS.
- The NIMH OPT-TMS trial (George, 2010) treated 199 antidepressant-free outpatients; remission was 14.1% with active TMS vs 5.1% with sham.
- The deep TMS pivotal trial (Levkovitz, 2015) used TMS as monotherapy and specifically included people who had not tolerated at least two antidepressants; in the intention-to-treat analysis, remission was 30.4% vs 15.8% with sham.
What happens afterward is less certain. In a small 12-month pilot study of medication-free people who had responded to TMS, scheduled monthly TMS sessions did no better than observation, and only about a third completed the full year. The one-year naturalistic follow-up study by Dunner and colleagues (2014) kept patients on antidepressants. If you plan to stay off medication after TMS, build a relapse plan with your psychiatrist; see life after TMS.
It is fair to add that not every study has favored TMS. The APA's 2010 depression guideline noted that one large sham-controlled trial of TMS added to medication showed no significant benefit, and that most meta-analyses then found small to moderate benefits. The evidence base has grown since; the APA's 2024 position statement calls TMS "a safe and effective evidence-based medical treatment" when given by TMS-trained psychiatrists to appropriately selected patients.
Note one exception: adolescent TMS labels (ages 15 to 21) are for use as an adjunct, meaning alongside an antidepressant, not in place of one.
Describing side effects so they count
Side effects are easy to wave away in a 15-minute appointment, especially the embarrassing ones. Being specific helps your prescriber judge whether the problem can be fixed with a dose change or switch, and it creates the record an insurer may later need. Before your next visit, write down:
- each medication, the highest dose you reached, and the dates you took it
- what the side effect was, when it started, and whether it eased
- how it affected your life: your relationship, your work, your sleep, your willingness to keep taking the pill
- whether the medication helped your mood at all before you stopped
- anything that was tried to manage the side effect, such as a lower dose or an add-on
Sexual side effects deserve a direct mention. People often leave them out, and the 2009 meta-analysis found they are reported far more often when patients are asked about them directly. Your prescriber has heard it before.
Tapering safely, and only with your prescriber
Having TMS does not automatically mean stopping an antidepressant; your psychiatrist will decide what makes sense for you. Our article on keeping your medications during TMS covers the common questions, and the drlewis.com review of combining TMS with medication looks at the research.
If you do want to come off an antidepressant, do it with a plan. A 2024 meta-analysis of 79 studies found that 31% of people stopping an antidepressant had at least one discontinuation symptom, compared with 17% stopping a placebo, and about 3% had severe symptoms. A gradual, supervised taper also lets your prescriber tell the difference between discontinuation effects and depression returning. The site's article on getting off psychiatric medications safely explains the process.
When TMS may not be the best next step
Side effects do not always mean medication as a whole is the problem. Sometimes a dose change or a switch solves it: in the 2009 meta-analysis, several antidepressants did not differ significantly from placebo on sexual dysfunction. Esketamine nasal spray (Spravato) is now FDA-approved for treatment-resistant depression as monotherapy too, with its own side-effect profile and monitoring requirements. And if depression is severe, with psychotic symptoms or acute suicidal thinking, expert consensus points toward treatments such as ECT before TMS. Our comparison of TMS vs another antidepressant walks through these trade-offs.
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.
When you are ready, read more in the TMS guide or about TMS treatment for depression.
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
- 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
- Transcranial Magnetic Stimulation (LCD L33398). CMS Medicare Coverage Database, 2026. cms.gov
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- Carelon Behavioral Health Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, 2026. carelonbehavioralhealth.com
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biological Psychiatry, 2007. pubmed.ncbi.nlm.nih.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
- 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
- Can Medication Free, Treatment-Resistant, Depressed Patients Who Initially Respond to TMS Be Maintained Off Medications? A Prospective, 12-Month Multisite Randomized Pilot Study. Brain Stimulation, 2016. pubmed.ncbi.nlm.nih.gov
- A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1-year follow-up period. Journal of Clinical Psychiatry, 2014. pubmed.ncbi.nlm.nih.gov
- K231926 510(k) Summary – NeuroStar Advanced Therapy System. U.S. FDA, 2024. accessdata.fda.gov
- Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. Journal of Clinical Psychiatry, 2008. europepmc.org
- Safety Information. NeuroStar (Neuronetics), 2026. neurostar.com
- Seizures from transcranial magnetic stimulation 2012-2016: Results of a survey of active laboratories and clinics. Clinical Neurophysiology, 2019. europepmc.org
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 2011. fda.gov
- NDA 211243/S-016 Supplement Approval. U.S. FDA, 2025. accessdata.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
- Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition. American Psychiatric Association, 2010. psychiatryonline.org
- Position Statement on Transcranial Magnetic Stimulation (TMS). American Psychiatric Association, 2024. psychiatry.org
- Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions. World Psychiatry, 2023. pmc.ncbi.nlm.nih.gov
- Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. Journal of Clinical Psychopharmacology, 2009. pubmed.ncbi.nlm.nih.gov
- Emotional blunting with antidepressant treatments: A survey among depressed patients. Journal of Affective Disorders, 2017. pubmed.ncbi.nlm.nih.gov
- Antidepressant utilisation and incidence of weight gain during 10 years' follow-up: population based cohort study. BMJ, 2018. pubmed.ncbi.nlm.nih.gov
- Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. The Lancet Psychiatry, 2024. pubmed.ncbi.nlm.nih.gov
FAQs
Can I have TMS without taking any antidepressant?
Yes, for adults. The main sham-controlled trials tested TMS in people who were not taking antidepressants. Adolescent TMS labels are different: they are for use alongside medication.
Does TMS cause sexual side effects or weight gain?
Sexual side effects and weight gain are not among the common TMS side effects reported in trials and device safety information. The common ones are scalp discomfort at the treatment site and headache, which usually ease after the first week.
Do I have to stop my antidepressant before starting TMS?
Not necessarily. Whether you stay on a medication during TMS is decided with your prescriber, and any change should be planned. See medications during TMS.
What records prove I could not tolerate a medication?
Prescriber notes or pharmacy records showing the drug, dose, dates and the side effects that led you to stop. Ask your current prescriber to summarize past trials if your records are scattered.
If I only took a medication for a week, does that count?
It depends on the plan and on why you stopped. A documented intolerance can count with some insurers even if the trial was short, but a trial stopped for other reasons usually does not.
