Why Psychiatric Follow-Up Matters During and After TMS

TMS should be part of a broader treatment plan

Transcranial magnetic stimulation (TMS) is a non-invasive treatment that uses focused magnetic pulses to influence brain networks involved in mood regulation. For depression, it is typically delivered repeatedly over several weeks rather than as a single procedure.

The technical delivery of each session is only one part of good TMS care. Comprehensive treatment also includes psychiatric assessment, appropriate protocol selection, medication review, structured symptom monitoring and a plan for care after the acute course. These elements help clinicians respond when symptoms change, progress is slower than expected or new clinical concerns emerge.

This does not mean a psychiatrist must personally administer every magnetic pulse. Trained TMS technicians have an important role in positioning the treatment coil, following prescribed parameters, documenting sessions and recognizing concerns that should be escalated. Medical assessment and treatment decisions, however, require qualified clinical judgment.

Why assessment before TMS matters

Depressive symptoms can arise in different clinical contexts, and not every person with depression is an appropriate candidate for every TMS protocol. Before treatment, a psychiatric assessment should clarify the diagnosis, symptom pattern, severity, functional impact and previous treatment history.

The assessment should also examine factors relevant to safety and treatment planning. These can include a history of seizures, neurological conditions, implanted or metallic devices, substance use, pregnancy, current medications and symptoms that could suggest bipolar-spectrum illness, psychosis or another condition requiring a modified approach.

Reviewing previous medication and psychotherapy trials helps establish whether depression is treatment resistant and whether reasonable options have been adequately attempted. It also creates a baseline against which the effect of TMS can be judged. An assessment is not simply an administrative gateway; it determines what is being treated and how treatment should be monitored.

• Confirm the working diagnosis and current treatment target
• Review previous treatments, benefits and adverse effects
• Screen for contraindications and relevant risk factors
• Select an evidence-supported TMS protocol for the clinical situation
• Document baseline symptoms, functioning and treatment goals

Monitoring progress during a TMS course

Improvement during TMS is not always immediate or linear. Some people notice changes in sleep, energy, concentration or daily functioning before a clear shift in mood. Others improve later in the course, respond only partially or do not obtain a meaningful benefit.

Measurement-based care uses standardized symptom scales at baseline and at planned intervals. These scores do not replace conversation or clinical judgment, but they provide a consistent way to track change. Monitoring should also include functioning, tolerability, attendance, medication changes and the patient’s own treatment priorities.

If response is limited, clinical reassessment can explore several possibilities: the diagnosis or main treatment target may need review; treatment delivery and adherence may need confirmation; medications or substance use may have changed; or the prescribed protocol, dose or course length may warrant reconsideration. Not all TMS protocols have identical evidence, and any adjustment should be based on the clinical indication, safety considerations and available evidence.

Medication review and safety during TMS

TMS is generally well tolerated. Common adverse effects include temporary scalp discomfort or headache, particularly early in treatment. Serious adverse events such as seizures are uncommon, but risk assessment and appropriate procedures remain necessary.

Medication review is relevant because some drugs—and abrupt medication changes—can affect cortical excitability, alertness, mood or seizure threshold. Patients should provide an accurate medication list and inform the treating team about new prescriptions, dose changes, non-prescription substances and significant changes in alcohol or recreational drug use.

The relationship between benzodiazepines and antidepressant response to TMS remains uncertain. Some observational findings have raised the possibility that benzodiazepines could influence response in certain settings, but the evidence is not sufficient to support a universal rule. Benzodiazepines can also cause dependence and withdrawal; stopping them abruptly can be dangerous. Any change should be individualized and supervised by the prescribing clinician.

Similarly, taking a medication associated with a lower seizure threshold does not automatically exclude someone from TMS. The relevant questions include dose, combinations, individual risk factors and whether medication use is stable. These decisions require a clinical risk–benefit assessment rather than a simple prohibited-drug list.

When mood changes require reassessment

Follow-up provides a route for addressing clinically important changes rather than waiting until the course ends. Worsening depression, new suicidal thoughts, marked agitation, unusual activation, reduced need for sleep or other possible manic symptoms should be reported promptly.

These developments do not all have the same meaning, and they cannot be interpreted from a questionnaire score alone. A clinician may need to reassess diagnosis, medication, immediate safety and whether TMS should continue unchanged, be modified or be paused. Anyone at immediate risk should seek urgent or emergency help rather than wait for a routine appointment.

What happens after the acute TMS course?

Finishing the scheduled sessions should lead to a transition plan, not an abrupt end to care. Depression is often recurrent, and improvement following TMS does not guarantee that symptoms will remain controlled indefinitely. A post-treatment review should document the degree of response, residual symptoms, functional recovery and the patient’s relapse risk.

Ongoing treatment may include pharmacotherapy, psychotherapy, sleep and substance-use interventions, and management of relevant medical or psychiatric conditions. The right combination varies. Medications should not automatically be stopped because TMS helped, and psychotherapy can remain useful for residual symptoms, coping, relationships and relapse-prevention skills.

Maintenance TMS refers to planned sessions after an acute course, while repeat or rescue treatment is generally considered when symptoms begin to return. Maintenance schedules vary, and the evidence does not establish one universal approach for every patient. Decisions may consider the initial response, previous relapses, treatment burden, patient preference and access to care.

A practical relapse plan identifies early warning signs and specifies whom to contact. If symptoms return, reassessment should determine whether to optimize current treatment, restart psychotherapy, adjust medication, consider repeat TMS or discuss another evidence-based option. Ketamine-based treatment is distinct from TMS and requires its own candidacy and safety assessment; it is not automatically the next step for every person.

• Record end-of-course symptom and functioning measures
• Identify residual symptoms and personal warning signs
• Clarify medication and psychotherapy follow-up
• Discuss whether maintenance monitoring or TMS is appropriate
• Set out how and when to seek reassessment if symptoms recur

Questions to ask when comparing TMS care models

When choosing a clinic, it is reasonable to ask how technical treatment and clinical care are connected. The goal is not to diminish the role of technicians, but to understand who is responsible for diagnosis, prescribing, safety decisions and treatment changes.

• Who completes the psychiatric and medical assessment before treatment?
• How is the TMS protocol selected and prescribed?
• How often are symptoms and functioning measured?
• Who reviews adverse effects, medication changes or worsening mood?
• What happens if improvement is limited or symptoms become activated?
• Who provides follow-up and relapse-prevention planning after the course?

Integrated TMS care at NeuroLinks

NeuroLinks is a psychiatrist-led clinic in Nanaimo serving Vancouver Island and appropriate patients elsewhere in British Columbia. TMS is integrated into psychiatric assessment, monitoring and longer-term planning rather than treated solely as a sequence of device appointments.

Whether TMS is suitable—and what follow-up should involve—depends on an individualized clinical assessment. Adults considering treatment can contact NeuroLinks or speak with their current clinician about referral options. Please do not send patient-identifying or confidential clinical details through general website forms.