What Comes After Response? New Consensus on Maintenance TMS for Depression

As more clinicians and patients experience the rapid benefits of TMS for acute depression, conversations are naturally shifting beyond the initial treatment course. A recently published consensus paper from the Dutch-Flemish Brain Stimulation Foundation brings helpful clarity to post-acute strategies, drawing on 22 studies and real-world clinical experience from 11 Dutch institutions.

What Is TMS and Why Are Maintenance Sessions Needed?

TMS is an effective treatment typically delivered in daily sessions of around 20 minutes over a course of 20 to 30 treatments. For many patients, meaningful clinical improvement occurs within six to eight weeks. This rapid response raises practical questions about how best to sustain these gains over time. In everyday clinical practice, a range of approaches are already being used, but until recently these have been described inconsistently despite being well-established in routine care.

Three Approaches to Sustaining TMS Benefits

• Tapering: The gradual reduction of rTMS session frequency after successful acute treatment. Evidence suggests tapering may support maintenance of clinical improvement and reduce early relapse risk, particularly when guided by symptom monitoring rather than fixed time intervals.
• Maintenance TMS: Scheduled delivery of TMS sessions at fixed intervals to prevent recurrence. Clustered maintenance protocols—typically five sessions over two to five consecutive days on a monthly basis—demonstrate the most consistent signal of clinical benefit.
• Retreatment: Initiating a new course of TMS in response to symptom worsening or relapse after an initial response. Retreatment was effective in the majority of previously responding patients, often requiring fewer sessions to re-establish therapeutic benefit, and was the most frequently applied strategy in routine clinical practice.

Clinical Considerations and Patient Involvement

The consensus emphasizes that maintenance treatment with rTMS should be individualized rather than protocol-driven. Structured symptom monitoring using validated rating scales is considered essential to guide treatment decisions. Patient representatives highlighted the importance of shared decision-making, flexible scheduling, and transparent communication regarding treatment pathways as key factors supporting long-term engagement with rTMS.

Limitations and Future Research

Despite increasing clinical use, the evidence supporting maintenance rTMS remains limited and largely uncontrolled. The consensus statement underscores the need for adequately powered randomized controlled trials directly comparing tapering, maintenance, and retreatment strategies, as well as studies examining long-term outcomes and optimal dosing schedules.