When you have already tried antidepressants and therapy and are still struggling with depression, being told to “try something else” usually raises an obvious question:
What else is there for depression besides antidepressants and therapy?
For people with treatment-resistant depression (TRD), trying yet another antidepressant is not the only option out there. Depending on your symptoms, treatment history, medical needs, and preferences, the next step could include a different kind of talk therapy, Transcranial Magnetic Stimulation (TMS), electroconvulsive therapy (ECT), or newer medication-based treatments that aren’t SSRIs, like as ketamine or esketamine.
These treatments are not interchangeable. Some involve medication and some do not. Some require anesthesia, while others allow you to return to your normal routine immediately afterward. Some may be particularly appropriate for severe or urgent depression, while others are designed to fit into the more flexible schedule outpatient treatment usually demands.
At Shanti TMS in Portland, Oregon, we specialize in TMS treatment for people with depression, including patients whose symptoms have not adequately improved with conventional treatment.
Our goal in this guide is not to suggest that everyone with treatment-resistant depression should choose TMS. It’s not the right choice for every patient, full stop.
Instead, our goal is to help you understand the treatment landscape, the important differences between your options, and why TMS may be worth discussing when antidepressants have not provided enough relief. Informed patients are empowered patients, and we hope this information helps you make the health care decisions that are right for you.
Beyond Another Antidepressant: What Are the Options?
There are several very different treatments that may come up in conversations about treatment-resistant depression.
Psychotherapy or “talk therapy” is a non-medication treatment that may remain part of care even when previous therapy has not provided enough relief. Sometimes the therapeutic approach changes, and sometimes therapy is combined with another treatment. It is important to find a “good fit” – clinicians and approaches vary widely in this field and patients often need to “shop around” to several providers before they’re able to find a provider they can make progress with.
TMS is a non-medication, noninvasive form of brain stimulation. TMS uses targeted magnetic fields to stimulate certain areas of the brain. It does not require anesthesia. It’s FDA approved and increasingly covered by many insurance plans as a depression treatment option, especially when antidepressants have not worked well enough or have been difficult to tolerate.
As the National Institute of Mental Health notes, treatment decisions involving brain stimulation depend on the individual needs and medical situation of patients.
ECT is also a non-medication brain stimulation treatment, but it is very, very different from TMS. ECT is more commonly known as “shock therapy” because it uses electricity to stimulate certain areas of the brain. While ECT has a negative reputation due to past abuses and a large number of side effects, today it is recognized as an evidence-based option with strict protocols that brings real relief to some patients. ECT requires general anesthesia and may be particularly important for patients with severe depression or situations in which a rapid response is necessary.
Ketamine and esketamine (Spravato) are medication-based treatments. Although they work differently from traditional antidepressants and may be options for some people with TRD, they are still medication-based treatments.
Why Another Antidepressant Isn’t the Only Next Step
Antidepressants help many people with depression, and trying another medication can still be a reasonable option, but treatment-resistant depression presents a particular challenge.
TRD is commonly used to describe major depressive disorder that has not adequately improved after multiple appropriate antidepressant trials. There is not one universally accepted definition, and clinicians consider more than a simple tally of “how many medications you’ve tried.”
Before calling depression “treatment-resistant,” our clinicians at Shanti TMS look at the whole picture and ask questions like: Were medications taken at appropriate doses? Were they taken for sufficient lengths of time? Could another medical or psychiatric condition be contributing to these symptoms? Are we certain this is even depression causing these persistent symptoms? Is the original diagnosis actually even correct?
Our guide to treatment-resistant depression and TMS in Portland explores this clinical trouble-shooting process in more depth.
Once a patient has gone through several well-managed treatment attempts without enough improvement, however, there comes a time when the question stops being, “Which medication should we try next?”
Eventually, patients and providers struggling with TRD start asking: “Should we consider a treatment that approaches depression differently?”
It’s at that moment in the TRD journey that TMS starts to become a particularly relevant option.
Psychotherapy Still Matters, Even When Depression Is Treatment-Resistant
Being depressed after months or years of therapy does not necessarily mean therapy has failed.
A different therapeutic approach, a different therapist, or psychotherapy combined with another depression treatment is usually still indicated.
Therapy addresses parts of recovery that biological treatments can’t fix on their own, including complex issues like relationship problems and patterns, personal coping patterns, isolation, trauma, and how to approach rebuilding routines and connections that support recovery as depression finally begins to improve.
For most people with TRD, the decision is not therapy or TMS because the two treatment modalities serve very different purposes and actually work together synergistically.
Lifestyle factors such as sleep, physical activity, substance use, physical health, and social connection can also support depression treatment. A 2024 BMJ systematic review and network meta-analysis involving more than 14,000 participants found that several forms of exercise were associated with improvements in depressive symptoms. However, it’s important to understand that these findings don’t mean that treatment-resistant depression is just a matter of needing to exercise more. Behavioral strategies can support treatment, but they are not a substitute for appropriate clinical care when depression remains severe or persistent.
TMS: Treating Depression Through Brain Stimulation Rather Than Medication
Transcranial Magnetic Stimulation or TMS takes a fundamentally different approach from antidepressant medication.
Instead of introducing a drug that circulates throughout the body, TMS uses repeated magnetic pulses to stimulate targeted neural circuits involved in depression.
An electromagnetic coil is positioned against the scalp while the patient remains awake. Treatment is noninvasive and does not require anesthesia.
The National Institute of Mental Health describes repetitive TMS as an FDA-cleared treatment for treatment-resistant depression and notes that it is used for moderate-to-severe depression when medications have been ineffective or difficult to tolerate.
At Shanti TMS, we’re committed to only offering our patients evidence-based treatments. We chose to focus on TMS at our clinic because TMS has a substantial clinical research base that demonstrates the potential of TMS treatment for TRD patients.
For patients, though, the practical differences can be just as important as the underlying science. TMS is noninvasive, performed while you are awake, and delivered without general anesthesia. It is performed in an outpatient treatment setting and patients can usually return to their normal daily activities directly after a treatment session. Although every patient is different and side effects are possible, TMS is unlikely to derail your day. Most of our patients are able to return to work, parenting, or other obligations after their session without issues.
The relatively mild side effect profile of TMS often comes as a welcome surprise to patients who have become accustomed to managing various chronic side effects associated with SSRIs.
TMS vs. ECT: Two Very Different Brain Stimulation Treatments
Patients sometimes hear the term “brain stimulation” and assume TMS and electroconvulsive therapy are similar procedures.
They are quite different.
ECT uses electrical stimulation to intentionally produce a controlled seizure while the patient is under general anesthesia. ECT is an important and highly effective treatment. According to the National Institute of Mental Health, ECT is particularly appropriate for patients dealing with catatonia, severe suicidality, or malnutrition associated with a psychiatric illness.
That said, ECT is notorious for cognitive side effects like temporary confusion and memory difficulties.
TMS uses magnetic pulses targeted to specific brain regions. You remain awake, anesthesia is not required, there’s no electricity involved, and providers don’t use electrical currents to induce seizures in TMS patients. Major negative side effects are rare during and after TMS treatments, especially when patients are properly screened for health conditions that make TMS a poor choice. Most patients report experiencing little to no discomfort associated with TMS treatment.
Still, TMS is not a replacement for ECT. They each play different roles. They’re two very different tools with two very different jobs in the TRD treatment toolbox.
Where Do Ketamine and Spravato Fit?
Ketamine and esketamine, sold under the brand name Spravato, frequently appear alongside TMS in discussions of treatment-resistant depression.
There is an important distinction: Ketamine and esketamine are medications. TMS is not.
Ketamine works differently from traditional antidepressants, and esketamine is administered as a nasal spray under medical supervision. These treatments may be appropriate for some patients with treatment-resistant depression.
Therefore, Ketamine and esketamine are legitimate alternatives to simply trying another conventional SSRI, but they are still medication-based treatments.
That difference may matter to patients who have experienced significant medication side effects. It may also matter to patients who want to move away from drugs that may impact systems throughout their whole body in unpredictable ways.
Have I Tried Enough Antidepressants to Consider TMS?
Great question. And this is one of the most practical questions someone with persistent depression can ask.
Unfortunately, it’s a complicated question that patients are generally not able to answer for themselves without the input and assistance of their care team. Medical necessity, insurance coverage, and quite a few other clinical considerations come into play when we tackle this question together as a team. At Shanti TMS, this question is at the center of every TMS evaluation we do with patients who are wondering about whether TMS might be a good next step in their TRD treatment.
During a TMS evaluation at Shanti TMS, your clinician will go over which antidepressants you have already tried, the doses and duration of those trials, whether they provided any improvement, and whether or not negative side effects may have impacted the dose and duration of those trials. Your unique psychotherapy history, current symptoms, other psychiatric diagnoses, medical history, current medications, and previous depression treatments also influence the assessment.
The FDA first cleared an rTMS device for depression in adults who had not responded to at least one antidepressant medication during the current depressive episode, but real-world treatment decisions and insurance coverage requirements may involve additional criteria. In many cases, rTMS is now used in moderate-to-severe depression when medications have been ineffective or intolerable.
Does Starting TMS Mean I Have to Stop My Antidepressant?
No.
TMS is a non-medication treatment but that does not mean that everyone receiving TMS must stop taking psychiatric medication.
Many of our patients receive TMS while also continuing to take antidepressants or other medications. Holistic TMS treatment plans often include psychotherapy, medication, or both.
Do not stop your existing treatment unless instructed to do so by your healthcare provider. Any decision to continue, change, or reduce medication should be made with the clinician responsible for prescribing it.
Why Some Patients With TRD Explore TMS
There is no single reason someone chooses to explore TMS, but a conversation about TMS starts to make sense when:
- Multiple antidepressant trials have not provided you sufficient relief
- Medication side effects have been difficult for you to tolerate
- Depression continues to interfere significantly with your daily life
- You want to explore a non-systemic treatment
- You want to explore a non-invasive option that does not require general anesthesia
- You want a flexible option that works around work, school, parenting, or other responsibilities
- Your clinician believes TMS may be appropriate based on your diagnosis and treatment history
Patients who want a more detailed discussion of the advantages and limitations can read our guide to the pros and cons of TMS therapy for treatment-resistant depression.
Skepticism About TMS is Healthy
Patients often arrive at Shanti TMS after a long, disappointing treatment journey.
At this point, you might feel skeptical about all depression treatments. TMS may sound like just another option that promises big results while just offering more of the same.
Skepticism about TMS is healthy and normal. When you’ve been disappointed repeatedly, hope can be difficult to access. Still, it’s important to remember that the data shows time and again that TMS really does have a good chance of relieving depression symptoms in patients who experience treatment-resistant depression. In TRD cases where nothing else seems to work, TMS is often the treatment that finally puts depression into remission.
That said, TMS does not work for every person, and not every patient with persistent depression should try it. There are situations in which another treatment or a different level of care may be a better choice. Some patients may get more benefit from medication changes, psychotherapy, ketamine or esketamine, or a combination of all of these approaches.
Good TMS care starts with clinical discernment, not simply access to a TMS machine.
What Does the Research Say About TMS for Treatment-Resistant Depression?
A growing body of evidence from randomized controlled trials and systematic reviews supports transcranial magnetic stimulation (TMS) as an effective treatment option for treatment-resistant depression.
A 2025 network meta-analysis published in Neuropsychopharmacology looked at 69 randomized trials and included a total of 10,285 patients who had not responded to at least two antidepressant treatments. The meta-analysis found that both repetitive TMS and theta-burst stimulation produced significantly higher treatment response rates in depression patients who found no relief in at least two antidepressant medications, as compared with patient response to sham or placebo treatments.
In other words, this study indicates that TMS isn’t a cure-all, but it does usually “work better” than a placebo for TRD patients who have not found relief with antidepressants.
A separate 2026 meta-analysis published in the Journal of Affective Disorders analyzed 30 randomized comparisons involving 1,850 participants with major depressive disorder, including treatment-resistant cases, and found significantly higher odds of both treatment response and remission with active TMS compared with sham stimulation.
Specifically, depression patients undergoing TMS in this meta-analysis had a 4.78 times better chance of experiencing a treatment response and a 3.55 times better chance of achieving full symptom remission when compared with depression patients who received placebo treatments.
Although outcomes vary and not all TMS patients achieve remission, the existing evidence demonstrates that TMS is worth trying for some patients, because it can produce clinically meaningful results up to and including total remission, even for patients who have not responded adequately to antidepressant medications.
Comparing TMS Treatment Options in Portland
If you are researching TMS in Portland, you may discover several clinics and treatment settings offering advanced depression care.
The machine itself should not be the only thing you compare.
When speaking with a prospective TMS provider, useful questions include:
- Who performs the initial clinical evaluation and provides medical oversight?
- How does the clinic review previous antidepressant trials and determine which TMS protocol is appropriate?
- How are depression symptoms measured during treatment?
- What happens if you are not improving as expected?
- How does the clinic coordinate with your existing psychiatrist, therapist, and/or primary care provider?
- What does your insurance require for coverage, and what does follow-up look like after the initial treatment course?
Shanti also provides additional information about major depressive disorder and TMS treatment for patients who want to understand how TMS fits into depression care more broadly.
Not Sure Whether TMS Is the Right Next Step?
Just trying one antidepressant after another is not the only path forward.
If antidepressants and therapy have not provided the relief you hoped for, you don’t need to figure out your next step by yourself.
At Shanti TMS in Portland, Oregon, a TMS consultation includes reviewing your depression symptoms, previous treatments, medication history, and other clinical factors to help you determine if TMS might be an appropriate next step for you.
Learn more about TMS for treatment-resistant depression in Portland or schedule a free consultation at our clinic to see if TMS might make sense for you.