TMS Therapy · Hayward, CA

The conversation I have with most patients near the end of their TMS course is not the one they expected. They have responded. Their depression scores are down. They feel better — really, measurably better — for the first time in months or years. And the next question is almost always: now what.

The honest answer is that the acute course is the beginning, not the end. TMS opens a window where the brain is more able to shift out of depressive patterns, but staying out of those patterns is its own piece of work. For most patients that means some combination of medication continuation, therapy, behavioral routines, and — for many — a maintenance or relapse-prevention strategy with TMS itself.^[1]

What the data actually shows about durability

Without any maintenance treatment, the median rTMS responder retains response for about a year before relapse becomes more likely. A systematic review of TMS responders followed across multiple studies found 67% sustained response at 3 months, 53% at 6 months, and 46% at 12 months without further treatment.^[2] That number means a clear majority hold their gains across the medium term, but by 12 months more than half have lost some ground.

A 2023 meta-analysis of 24 maintenance studies in 911 patients sharpened the picture further. Maintenance rTMS performed monthly or more frequently kept mood symptoms relatively stable across the first 5 to 6 months post-course, with sustained benefits extending out to 12 months. Less frequent maintenance, or none at all, was associated with more drift back toward baseline.^[3]

And the most rigorous direct trial to date — the MAINT-R randomized clinical trial published in 2025 — randomized 75 patients with treatment-resistant depression who had responded to acute bilateral rTMS to either weekly low-frequency right-DLPFC rTMS (24 sessions over 24 weeks) or maintenance lithium pharmacotherapy. Across 24 weeks the two strategies were essentially equivalent for relapse prevention: 7 relapses in each group, no significant between-group difference in MADRS scores. But maintenance rTMS produced far fewer adverse events — 3 events versus 16 on lithium (odds ratio 7.10, p=.005) — and better overall tolerability.^[4]

That trial doesn’t make maintenance rTMS the only right answer. It does make it a credible alternative to long-term lithium for patients who responded well to acute TMS, particularly those who would prefer not to live with the side-effect profile, lab monitoring, and renal-thyroid considerations that come with chronic lithium.

The three post-acute strategies

Once you’ve finished an acute course of TMS and you’ve responded, your provider will usually discuss one of three paths. None is inherently right or wrong — the right one is the one that matches your relapse history, your TMS response strength, and your real life.^[5]

Stop and monitor

The simplest option. You finish the acute course, ramp back into normal life, and your provider tracks symptoms at regular follow-up visits — usually with a brief structured measure like PHQ-9 every 2 to 4 weeks for the first few months, then less frequently. If symptoms creep back, the plan shifts to retreatment or maintenance. This works well for patients who had a strong, complete response, no major recent stressors, stable medication, and a relatively short prior history of depressive episodes.

Taper

Instead of stopping at session 36, your provider extends treatment with progressively spaced sessions — for example, weeks 7–8 at three sessions a week, weeks 9–10 at twice weekly, weeks 11–14 at weekly, then a check-in at month 4. The taper extends the period of active brain stimulation while gradually disengaging the daily clinic routine.^[5]

Scheduled maintenance

Fixed-interval maintenance sessions — typically weekly or monthly — beyond the acute course. The MAINT-R trial used 24 weekly sessions of low-frequency right-DLPFC rTMS at 120% of resting motor threshold (900 pulses per session, 15-minute sessions).^[4] Other clinics use monthly sessions, or biweekly tapering to monthly. Insurance coverage for scheduled maintenance is more variable than coverage for acute treatment, so verify before you commit.

Retreatment if symptoms return

Many clinics combine “stop and monitor” with a pre-arranged path back to TMS if symptoms return. The trigger for retreatment is usually a PHQ-9 increase of ≥5 points sustained over 2 weeks, or any new suicidality. Retreatment courses are often shorter than the original acute course — sometimes 10 to 20 sessions — because the goal is recapture of response, not the full original calibration.^[5]

What relapse prevention looks like beyond TMS

The phrase “maintenance plan” can sound like it’s only about the TMS protocol. It is not. The most predictive variables for long-term outcomes after a depression course are not what protocol you used — they are what you do between sessions and after the course ends.

Medication. Most patients who respond to acute TMS continue on the antidepressant they were taking during treatment. Discontinuing antidepressants in the weeks following acute TMS response is associated with higher relapse rates. If you want to come off medication, plan it deliberately with your prescriber, not impulsively because you’re feeling better.

Therapy. CBT or behavioral activation during and after the acute course gives the brain a place to land its new neuroplastic flexibility. Skills practiced during the response window get encoded; skills not practiced fade.

Sleep. The single most common early-warning sign of relapse. A 30% increase in sleep onset latency, multiple nights of less than 6 hours, or a return of early-morning awakening all predict mood deterioration within 2 to 4 weeks. Track sleep.

Substance use. Alcohol and cannabis — even at “moderate” social levels — degrade response durability. Patients who maintained abstinence or near-abstinence during the post-acute window had measurably better 12-month outcomes than those who returned to baseline use.

Daily structure. Consistent wake time, regular meals, predictable movement, planned social contact. The patients who hold their TMS response best are not the ones with the most dramatic post-course lifestyle changes — they are the ones with the most boring weekly schedule.

The early-warning signals worth tracking

Relapse rarely arrives all at once. It accumulates across two to four weeks of small drift, and the earliest signals show up in behavior before they show up in mood scores. Track these. Tell your provider if any of them shift meaningfully.

Sleep onset, total sleep, early-morning awakening. Appetite, weight. Concentration — can you read for 20 minutes without re-reading the same paragraph. Motivation to do the things you enjoy. Irritability with people you usually tolerate. Avoidance of texts, calls, or appointments you would normally answer. Increased alcohol or cannabis use. A return of self-critical or hopeless thoughts. Any new suicidal thoughts, including passive ones.

Relapse caught at week two is dramatically easier to treat than relapse caught at week eight. The point of structured follow-up is to widen the early-detection window, not to test your willpower.

What to ask your TMS clinic before the acute course ends

The conversation about what happens after session 36 should not start at session 36. Most clinics will raise it around session 20 to 25, but if yours doesn’t, ask. Specifically:

What is your default recommendation — stop, taper, schedule maintenance, or pre-arranged retreatment? Why that one for me?

Which symptoms or measures will trigger a check-in or retreatment? Get a specific number (e.g., “PHQ-9 increase of 5 or more sustained over 2 weeks”).

How often will my depression be measured after the course ends? Monthly PHQ-9 is the minimum I would want.

Does my insurance cover maintenance TMS, or only retreatment after a relapse? This is the most common practical barrier. Plans vary widely. Some authorize maintenance after a single relapse; others require failure of medication maintenance first; some don’t cover maintenance at all.

What is the plan if I notice symptoms returning? Who do I call, how quickly will I be seen, what is the threshold for resuming sessions?

The bottom line

TMS doesn’t necessarily end when the acute course ends. About 46% of initial responders are still in response at 12 months without any further treatment, but for the rest, some form of maintenance — monthly sessions, scheduled taper, or pre-arranged retreatment — substantially extends the gains. Monthly or more frequent maintenance has the strongest evidence base for keeping mood stable through the first 5 to 12 months. The MAINT-R trial in 2025 found that maintenance rTMS matches lithium for relapse prevention in treatment-resistant depression, with fewer side effects.

The right maintenance plan depends on how strongly you responded, how recurrent your depression has been, what stressors are coming, and what your insurance covers. The wrong move is letting the acute course end without a plan and seeing what happens.

If you’re in Hayward or the East Bay and you want to think through what your post-acute strategy should look like — whether you’ve just finished a course or you’re planning ahead — that’s what a consultation is for.

Nefretiri Abat, JD, PMHNP-BC — Founder, Exxceed Wellness. Exxceed Wellness is a psychiatric practice based in Hayward, CA offering medication management, TMS therapy, SPRAVATO, and ketamine treatment for treatment-resistant depression, ADHD, anxiety, and related conditions. This article is for educational purposes and does not constitute medical advice. If you have just completed or are planning a TMS course and want to think through what comes next, schedule a consultation at exxceedwellness.com.