If a TMS course ends without the improvement you hoped for, you still have real options. Depending on what happened, the next step may be extending the course, changing the TMS protocol or target, adjusting medication or therapy, trying esketamine (Spravato) or ketamine, considering ECT, or stepping back to recheck the diagnosis and look for medical factors that keep depression stuck.
Non-response is common enough that a good plan accounts for it from the start. In a secondary analysis of the THREE-D trial (388 adults), about 1 in 9 people (11%) followed a non-response trajectory across a 4-to-6-week course. This guide walks through how to tell what "did not work" means for you, and how psychiatrists usually think about what comes next.
First, define "did not work"
"It didn't work" can mean several different things, and each points to a different next step.
| Outcome | Usual definition | What it suggests |
|---|---|---|
| Remission | Score below a low cutoff, few symptoms left | Focus on staying well |
| Response | Score down by at least 50% | Clear benefit; plan for relapse prevention |
| Partial response | Meaningful improvement, but less than 50% | Extending or adjusting may help |
| Non-response | Little or no change | Reassess the diagnosis and the approach |
Look at your ratings across the whole course, not just the last one. Medicare's billing rules require the treating physician to track progress with a validated scale such as the PHQ-9, HAM-D or MADRS, so those numbers should exist. Ask to see them. Our guide to tracking progress during TMS explains what the scores mean.
Also give it a little time. After accelerated schedules in particular, some people improve in the weeks after the last session; in one small retrospective 2026 study of 40 people given a five-day accelerated course, the half of patients who had improved least by day 5 (8% on average) showed a 36% improvement at a follow-up two to four weeks later. A follow-up rating a few weeks out is a fairer test than the last treatment day.
Step 1: Was the course long enough?
Course length matters. In an observational registry analysis of 7,215 patients, courses of fewer than 30 sessions had worse outcomes, and people who kept going past 36 sessions continued to improve without a clear plateau. Those slower responders showed little change early and then improved gradually.
If you had a partial response, or stopped early because of scheduling or side effects, extending the course is often the simplest next step. The practical barrier is coverage: Aetna, for example, allows 30 sessions plus 6 tapering sessions and says treatment beyond 36 "may be reviewed for medical necessity". Your psychiatrist can document why more sessions are needed. See the week-by-week timeline for how a full course is structured.
It is also worth checking whether the dose was right. Aetna's policy, for instance, accepts additional re-mapping of the motor threshold when a patient is not responding or the threshold may have changed. A medication change during the course is one reason a threshold can shift.
Step 2: A different protocol or target
"TMS" is not one treatment. Canada's 2023 depression guidelines list several first-line protocols, including high-frequency stimulation of the left side, theta-burst to the left side, and low-frequency stimulation of the right side, with bilateral and accelerated protocols as second-line options. In one US clinical study, for example, patients who responded poorly to or could not tolerate left-sided treatment were switched to low-frequency stimulation on the right side.
Targeting is an active research area. One single-center 2026 trial found that brain-connectivity-guided targeting beat the standard scalp-measurement method at weeks 2 and 6, but the advantage was no longer significant by week 12. An earlier, larger trial found no difference between connectivity-guided theta-burst and MRI-navigated standard rTMS. So a new target is a reasonable thing to discuss, not a guaranteed fix.
What about a second course of the same protocol? Most retreatment data come from people who responded the first time: in a 2026 retrospective study across 20 US centers, 82.5% of 177 prior responders responded again. For people who did not respond, the evidence is thinner. A small chart review of 16 patients found that response to a first course correlated with response to a second. Repeating an identical course after a clear non-response is therefore less likely to help than changing something.
Step 3: Recheck the diagnosis and the body
When depression does not respond to two or three solid treatments, it is worth asking whether something else is driving it. New York Medicaid's TMS rules, for example, require providers to confirm the diagnosis and rule out other causes of depressive symptoms that can interfere with medication effectiveness. Questions a psychiatrist may revisit include:
- Is this bipolar depression? FDA's device guidance lists bipolar disorder among the groups lacking evidence for the effectiveness or safety of TMS. Bipolar depression is usually treated differently.
- Are there psychotic symptoms or severe suicidal thinking? Expert consensus says these patients should be considered for treatments with established efficacy, such as ECT.
- Medical contributors: thyroid problems, anemia, low vitamin B12, sleep apnea, hormone changes, chronic pain, medication side effects, alcohol or cannabis use.
- Ongoing stressors such as trauma, grief, burnout or an unsafe living situation, which TMS cannot fix.
An integrative or functional work-up can help here; see the functional psychiatry page and the physician guide treatment-resistant depression: every option compared.
Step 4: Medication and therapy changes
TMS is often combined with other treatment, and adjusting those can matter as much as the TMS itself. Options include switching or adding an antidepressant, an augmenting medication, or a structured therapy you have not yet tried. Our pages on TMS and talk therapy together and medications during TMS explain how they interact. In one study, people taking a benzodiazepine had lower response rates to TMS, though another found no difference.
Be realistic about medication sequences. In the large STAR*D study, remission rates on the third and fourth medication steps were 13.7% and 13.0%. A later reanalysis argued the overall figures were lower than first reported, and the original investigators disputed it. Either way, after several failed medications, the odds with yet another one are modest, which is why the options below are worth knowing.
Step 5: Esketamine and ketamine
Spravato (esketamine) nasal spray is FDA-approved for treatment-resistant depression; it was first approved in 2019 and approved for use on its own, without an oral antidepressant, in January 2025. It is given in a certified clinic, and you must be monitored for at least 2 hours after each dose. The label also says not to drive until the next day after a restful sleep. Learn more on the Spravato page.
IV ketamine is a different product. FDA states that ketamine is not approved for any psychiatric disorder, so its use for depression is off-label. In the ELEKT-D trial of people without psychotic features, IV ketamine was noninferior to ECT, with 55.4% responding on ketamine versus 41.2% on ECT. That trial excluded psychotic depression and used a self-rated outcome, so it does not prove ketamine beats ECT. See TMS vs ketamine therapy and the ketamine therapy page.
Step 6: ECT
For depression that has not responded to medication, the American Psychiatric Association's 2010 guideline says electroconvulsive therapy "remains the most effective form of therapy". In a 2014 meta-analysis of head-to-head trials, ECT beat TMS for response (64.4% vs 48.7%) and remission (52.9% vs 33.6%), mainly in psychotic depression. An acute ECT course usually takes 6 to 12 sessions under general anesthesia.
The trade-off is memory. A study of community ECT in the New York City area found cognitive effects still detectable six months later, more so with bilateral electrode placement. For many people with severe or psychotic depression the benefit clearly outweighs this risk. Dr. Lewis compares the two in TMS vs ECT.
Options side by side
| Option | Best fit | Main trade-offs |
|---|---|---|
| Extend the TMS course | Partial or late response | Time; coverage review |
| Change protocol or target | Non-response with no red flags | Evidence still developing |
| Medication or therapy change | Most people, alongside other steps | Slower; side effects |
| Spravato | Treatment-resistant depression | Clinic visits with 2-hour monitoring |
| IV ketamine | Treatment-resistant depression, off-label | Not FDA-approved for depression; ask about cost and coverage |
| ECT | Severe, psychotic or urgent depression | Anesthesia; memory effects |
Questions to bring to your end-of-course review
Ask for a dedicated appointment to review the course rather than a quick word at the last session. Useful questions:
- What did my scores do from start to finish, and was there any partial response?
- Did I complete the planned number of sessions, at the planned dose?
- Was my motor threshold rechecked after any medication change or long gap?
- Would a longer course, a different protocol or a different target make sense for me?
- Is there anything about my diagnosis, sleep, physical health or substance use we should look at again?
- Which of esketamine, ketamine or ECT would you consider for me, and why?
- Who will follow my mood while we decide, and how do I reach them between visits?
Writing the answers down makes it easier to compare options later, especially if more than one clinician is involved in your care.
When to act quickly
A disappointing TMS course can bring discouragement or hopelessness, especially after several earlier treatments. That is a reason to stay closely connected to your psychiatrist, not to step back. 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.
For the full range of TMS topics, return to the TMS guide or see the TMS therapy page.
Sources
- Trajectories of Response to Dorsolateral Prefrontal rTMS in Major Depression: A THREE-D Study. American Journal of Psychiatry, 2019. 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
- Billing and Coding: Transcranial Magnetic Stimulation (A57528). CMS Medicare Coverage Database, 2026. cms.gov
- Efficacy of 5 × 5 accelerated versus conventional repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression. Journal of Affective Disorders, 2026. pubmed.ncbi.nlm.nih.gov
- Dosing transcranial magnetic stimulation in major depressive disorder: Relations between number of treatment sessions and effectiveness in a large patient registry. Brain Stimulation, 2023. pubmed.ncbi.nlm.nih.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- 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
- Concomitant medication use and clinical outcome of repetitive Transcranial Magnetic Stimulation (rTMS) treatment of Major Depressive Disorder. Brain and Behavior, 2019. pubmed.ncbi.nlm.nih.gov
- Do benzodiazepines reduce the efficacy of transcranial magnetic stimulation?. Australasian Psychiatry, 2024. pubmed.ncbi.nlm.nih.gov
- Individualized Connectivity-Guided Versus Conventional Targeting of Accelerated Theta-Burst Stimulation in Depression: A Randomized, Double-Blind, Parallel-Design Trial. American Journal of Psychiatry, 2026. pubmed.ncbi.nlm.nih.gov
- Connectivity-guided intermittent theta burst versus repetitive transcranial magnetic stimulation for treatment-resistant depression: a randomized controlled trial. Nature Medicine, 2024. pubmed.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
- Initial Response to Transcranial Magnetic Stimulation Treatment for Depression Predicts Subsequent Response. Journal of Neuropsychiatry and Clinical Neurosciences, 2017. pmc.ncbi.nlm.nih.gov
- New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (NYS Medicaid Update, Vol. 41 No. 7). NYS Department of Health, 2025. healthweb-back.health.ny.gov
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 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
- 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
- A reanalysis of the STAR*D study's patient-level data with fidelity to the original research protocol. BMJ Open, 2023. pubmed.ncbi.nlm.nih.gov
- Drugs@FDA: NDA 211243 SPRAVATO. U.S. FDA, 2019. accessdata.fda.gov
- NDA 211243/S-016 Supplement Approval. U.S. FDA, 2025. accessdata.fda.gov
- SPRAVATO (esketamine) nasal spray, CIII - Prescribing Information. Janssen / DailyMed (NLM), 2026. dailymed.nlm.nih.gov
- SPRAVATO (esketamine) nasal spray, CIII - Prescribing Information, section 5.9 Impaired Ability to Drive and Operate Machinery. Janssen / DailyMed (NLM), 2026. dailymed.nlm.nih.gov
- FDA warns patients and health care providers about potential risks associated with compounded ketamine products, including oral formulations, for the treatment of psychiatric disorders. U.S. FDA, 2023. web.archive.org
- Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression. New England Journal of Medicine, 2023. pubmed.ncbi.nlm.nih.gov
- Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition. American Psychiatric Association, 2010. psychiatryonline.org
- Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: a systematic review and meta-analysis. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 2014. pubmed.ncbi.nlm.nih.gov
- The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology, 2007. pubmed.ncbi.nlm.nih.gov
FAQs
Does not responding to TMS mean my depression is untreatable?
No. TMS non-response tells your psychiatrist something useful, and other treatments, including ECT and esketamine, are different kinds of treatment that remain options after TMS.
Should I try a second TMS course if the first one failed?
Repeating the identical course after a clear non-response is less promising than changing something, such as course length, protocol or target. Most good retreatment data come from people who responded the first time.
Will insurance pay for more sessions?
Sometimes, with documentation. Some policies, such as Aetna's and Optum's, allow 30 sessions plus 6 tapering sessions, and Aetna says it may review anything beyond that for medical necessity. See does insurance cover TMS for New York details.
Can I go straight from TMS to Spravato or ECT?
Often, yes. The move should follow a fresh assessment of your diagnosis, safety and goals, and your psychiatrist will coordinate timing and any medication changes.
Could my medications have stopped TMS from working?
Possibly, though the evidence is mixed. Studies disagree on whether benzodiazepines blunt TMS response. Never stop a medication on your own; ask your prescriber.
