Maintenance TMS means scheduled sessions after a successful course, given to keep depression from coming back. Booster sessions are a related idea: a short burst of extra treatment when early warning signs appear. Both are used, but the evidence is still unsettled. The 2025 international consensus calls maintenance TMS "promising" while noting that the right frequency "is unclear".
The practical picture in the US is shaped by insurance: most insurers do not cover maintenance TMS, so many people instead finish their course, get monitored closely, and come back for a repeat course if depression returns. Here is what the research shows, what schedules have been tried, and how to build a plan that keeps you well either way.
How long do TMS results last without maintenance?
For many people, benefit lasts months to more than a year, but relapse is common enough to plan for. A 2019 meta-analysis of 19 studies followed people who had responded to TMS:
| Time after the course | Still responding |
|---|---|
| 3 months | 66.5% |
| 6 months | 52.9% |
| 12 months | 46.3% |
A separate one-year US study, in which people stayed on antidepressants and could have TMS reintroduced as needed, found 62.5% of initial responders still met response criteria throughout follow-up. Put together, roughly half to about 6 in 10 people who respond are still doing well a year later in these studies. Dr. Lewis reviews the durability data in more depth in how long TMS results last.
One detail matters for this article: in the meta-analysis, receiving maintenance treatment was one of the factors linked with better long-term response. That is an association across studies, not proof that maintenance causes the difference.
What makes relapse more likely?
Research on this is limited, but a few patterns recur. In the medication-based STAR*D study, people who needed more treatment steps before getting well had higher relapse rates. In the TMS durability meta-analysis, studies with a higher proportion of women and studies that included maintenance treatment had better sustained response. Clinically, psychiatrists also watch for:
- a long history of recurrent episodes
- only partial improvement at the end of the course, rather than remission
- stopping medication or therapy soon after TMS ends
- major stressors, poor sleep or heavier drinking in the months afterward
None of these means relapse is inevitable. They are reasons to set up closer follow-up and a clear plan.
Maintenance schedules that have been studied
Researchers have tried two broad approaches: a single session at regular intervals, and "clustered" sessions, where several treatments are bunched into one or two days each month.
| Study | Schedule | What happened |
|---|---|---|
| Philip et al., 2016 (49 randomized) | One session a month vs observation | No significant difference between groups |
| Benadhira et al., 2017 (17 randomized) | Active vs sham, tapering over 11 months | Active better only between months 1 and 4 |
| Fitzgerald et al., 2013 (35, open-label) | Clustered: 5 sessions over 2 days, monthly | 25 of 35 relapsed, after an average of 10.5 months on maintenance, vs under 3 months well after their earlier course without it |
| Wang et al., 2017 (281) | Clustered: 5–10 sessions over 3–5 days, monthly | Relapse 15.9% with TMS plus antidepressant vs 44.4% with antidepressant alone |
Note that the Wang trial enrolled people who had recovered on medication, not after TMS, so it tests TMS as relapse prevention rather than as follow-up to a TMS course. Summing up these studies, the 2025 consensus says clustered schedules "have the potential for prolonging remission, but monthly single-session maintenance protocols may not be useful".
In everyday practice, members of the Clinical TMS Society report giving maintenance monthly, every two weeks or weekly, mainly for people with frequent relapses, meaning two or more in a year.
Why the evidence is still thin
Maintenance studies are hard to run. People have to stay in a study for a year while feeling well, and many drop out: in the monthly-session trial, only 32.7% completed all 53 weeks. Most trials are small, several are open-label, and they use different schedules, so results are hard to combine.
Guideline bodies reflect this. Canada's 2023 guidelines rate the evidence for TMS in an acute course at their highest level, but the evidence for maintenance only at Level 3, which covers small randomized trials, non-randomized prospective studies and high-quality retrospective studies. England's NICE guidance on TMS for depression specifically asks for more research on maintenance treatment and long-term outcomes. Claims that TMS results are "permanent" or that maintenance is "proven" to prevent relapse overstate what is known.
Taper, maintenance and retreatment are different things
- Taper: the step-down at the end of an acute course, such as three, two and then one session per week. The consensus says tapering "has little empirical support".
- Maintenance: scheduled sessions for months while you are well.
- Booster or retreatment: treatment restarted when symptoms return.
Retreatment has encouraging data. In a 2026 study across 20 US centers, 82.5% of people who had responded to a first course responded again to a second, and they responded sooner. In an older six-month study, 32 of 38 people whose symptoms worsened regained benefit when TMS was added back. The Clinical TMS Society recommends that if relapse occurs after a successful course, TMS should be reintroduced until remission is achieved again.
Does insurance cover maintenance TMS?
Usually not. Here is how several payers that cover New Yorkers word it:
| Payer | Maintenance | Repeat course after relapse |
|---|---|---|
| Medicare (New York LCD) | "Not reasonable and necessary" | Possible if the first course gave more than 50% improvement |
| Aetna | Experimental | Benefit must have lasted at least two months; not within 60 days of the last course |
| Cigna | Not medically necessary | Needs more than 50% improvement at the end of the last course, held for at least two months |
| Optum (behavioral health) | Unproven or not medically necessary | Relapse 6 months after the most recent treatment, with more than 50% improvement before |
Because retreatment is covered more often than maintenance, many clinics follow the pattern the consensus describes: treat, monitor, and retreat when needed. If you and your psychiatrist decide maintenance is worth it, expect to discuss self-pay. See does insurance cover TMS and TMS cost without insurance.
Who might consider maintenance?
There is no single recommended strategy after a good TMS course; the options include repeat TMS, medication, psychotherapy and others. Maintenance is more often discussed when:
- you have had several depressive episodes, especially two or more relapses within a year
- past episodes were severe or came on fast
- you cannot take antidepressants, or prefer not to
- you relapsed quickly after an earlier TMS course
It is less compelling if this was a first episode, you are on medication that is working, and you have a strong therapy and lifestyle plan.
What a maintenance visit involves
A maintenance session is usually the same treatment you had during the course, at the same target and dose, so it takes about as long as one of your regular sessions. A clustered schedule means several sessions in a day with breaks between them, which takes more planning around work. If months have passed, or your medications have changed, the team may recheck your motor threshold before treating.
Questions to settle with your psychiatrist before you start:
- What schedule do you suggest, and why that one?
- How will we decide whether it is helping, and when would we stop?
- What will it cost per session if insurance does not pay?
- If I relapse anyway, how quickly can a full repeat course begin?
Early warning signs of relapse
Relapse rarely arrives overnight. Learn your own early signs and agree in advance on who you will call. Common ones include:
- sleep changing for more than a few nights, especially early waking
- pulling back from people or activities you had returned to
- losing interest or pleasure again
- more irritability, guilt or self-criticism
- a PHQ-9 score creeping up across two or three checks
Retreatment policies often depend on documented scores, so periodic ratings after the course are worth doing; Medicare's retreatment rule, for example, refers to improvement measured on standard rating scales. Our guide to tracking your progress shows how. 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.
A relapse-prevention plan that does not depend on TMS alone
Whatever you decide about maintenance sessions, the strongest protection is usually layered:
- Medication decisions made with your prescriber. In the one-year study above, people stayed on antidepressants after TMS. In the Wang trial, TMS plus an antidepressant had the lowest relapse rate. Do not stop a medication because TMS worked without talking to your prescriber first; see getting off psychiatric medications safely.
- Therapy. Skills from CBT, behavioral activation or other approaches keep working after sessions end. See TMS and therapy together.
- Sleep, movement and routine. See supporting your TMS course with lifestyle.
- A written plan. List your warning signs, who to call, and what happens next, including how quickly you could restart TMS. Our template is in life after TMS: a relapse-prevention plan.
For more on the treatment itself, visit the TMS guide or the TMS therapy page.
Sources
- 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. doi.org
- Durability of antidepressant response to repetitive transcranial magnetic stimulation: Systematic review and meta-analysis. Brain Stimulation, 2019. 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
- 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 randomized, sham-controlled study of maintenance rTMS for treatment-resistant depression (TRD). Psychiatry Research, 2017. pubmed.ncbi.nlm.nih.gov
- An open label trial of clustered maintenance rTMS for patients with refractory depression. Brain Stimulation, 2013. pubmed.ncbi.nlm.nih.gov
- Clustered repetitive transcranial magnetic stimulation for the prevention of depressive relapse/recurrence: a randomized controlled trial. Translational Psychiatry, 2017. 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
- The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
- Transcranial Magnetic Stimulation Retreatment for Recurrent Depression: A Large Real-World Multisite Cohort Study. Acta Psychiatrica Scandinavica, 2026. pubmed.ncbi.nlm.nih.gov
- Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. American Journal of Psychiatry, 2006. pubmed.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
- Repetitive transcranial magnetic stimulation for depression (HTG396, formerly IPG542). NICE, 2015. nice.org.uk
- Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study. Brain Stimulation, 2010. pubmed.ncbi.nlm.nih.gov
- Transcranial Magnetic Stimulation LCD L33398 (version 40). CMS Medicare Coverage Database, 2026. cms.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- 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, 2025. providerexpress.com
FAQs
How often are TMS maintenance sessions given?
Schedules vary: single sessions weekly, every two weeks or monthly, or clustered sessions bunched into one or two days a month. Studies suggest clustered schedules may work better than a single monthly session, but no schedule is proven.
Is a booster session the same as maintenance?
Not quite. Maintenance is scheduled while you are well; a booster or retreatment is restarted when symptoms come back. Retreatment is more often covered by insurance.
If depression comes back, will TMS work again?
For people who responded the first time, the odds look good: in a large 2026 study, about 8 in 10 prior responders responded again. It is not guaranteed.
Can I stop my antidepressant after a good TMS course?
Only with your prescriber. Several durability studies kept people on medication after TMS, and any change should be planned and paced with your prescriber.
Does Medicare pay for maintenance TMS in New York?
No. The New York Medicare policy calls maintenance therapy not reasonable and necessary, though a repeat course after relapse can be covered if the first one worked.
