Written by Dr. Anil Reddy K, Consultant Psychiatrist, Asha Hospitals Banjara Hills & Edge Clinics Hi Tec City, Hyderabad
As a consultant psychiatrist in Hyderabad, I increasingly see patients who want to treat their depression without starting medication first – either because they fear side effects, dislike pills, or have had bad experiences with antidepressants in the past.
At the same time, I also meet patients like Mr R, who have already tried multiple medications without adequate relief. His journey helped me see that rTMS and Deep TMS, when combined with structured psychotherapy, can be powerful tools both after medication failure and sometimes even before pills are started, especially in mild-to-moderate depression.
Patient Case Overview
Mr R, a 35-year-old software professional, had struggled with depression for over seven years. He had tried several antidepressants, sometimes in combination, yet his mood, energy, and concentration remained significantly impaired.
Medication side effects – nausea, sedation, and sexual dysfunction made long-term compliance difficult.
When I suggested repetitive Transcranial Magnetic Stimulation (rTMS) and later Deep TMS (dTMS), paired with structured psychotherapy, his treatment became a template for how brain-based neuromodulation can work alongside, or even instead of, medication in carefully selected cases.
From my perspective, this blog explains how I use rTMS and Deep TMS with therapy, both for patients who have exhausted medications and for those who would prefer to avoid starting pills altogether wherever clinically appropriate.
Clinical Diagnosis
By the time Mr R walked into my clinic, he met the clear clinical definition of treatment-resistant major depressive disorder (TRD):
- He had completed at least two adequate antidepressant trials
- Dose and duration were adjusted to guideline standards
- Persistent symptoms remained
Symptoms included:
- Chronic low mood
- Anhedonia
- Loss of interest in hobbies and relationships
- Significant fatigue
- “Brain fog”
- Difficulty concentrating
- Sleep disturbances
- Social withdrawal
- Sense of hopelessness
He had also experienced side effects from several antidepressants, which made long-term compliance difficult. Continuing with medication-only strategies would have meant cycling through more drugs with uncertain benefit and possible side-effect burden.
Why rTMS and Deep TMS Were Chosen?
In my clinical judgment, rTMS and later Deep TMS met the evidence-based indications for his case:
- TRD with partial or no response to multiple antidepressants
- Intolerable or limiting medication side effects
- Stable enough condition for outpatient treatment
Instead of saying “Let’s try another pill,” I framed TMS as a structured, guideline-supported neuromodulation option targeting his mood circuits directly, alongside psychotherapy.
Advantages of rTMS and Deep TMS
When I first mentioned rTMS to Mr R, his reaction was a mix of curiosity and caution. He asked, reasonably, “Why not just another antidepressant?”
Key advantages:
• Fewer systemic side effects
- Non-invasive, non-surgical, drug-free
- Mild scalp discomfort, headache, or muscle twitching
- Allowed him to continue full-time work
• Different mechanism of action
- Targets specific brain circuits
- Modulates prefrontal cortex activity
- Helps “reset” neural networks
• Faster functional improvement in some patients
- ~15–20% more effective than switching medications in TRD
- Improvements often seen within 2–3 weeks
This doesn’t mean TMS is a “quick fix,” but it can be a meaningful pivot away from repeated medication trials.
Integrated Treatment Approach
In my practice, I rarely use TMS as a standalone intervention.
Treatment Plan for Mr R:
- Daily rTMS sessions
- Weekly CBT-oriented psychotherapy
Benefits of combination:
- Higher response and remission rates
- Example: ~66% response and 56% remission (study data)
Clinical outcome:
- rTMS reduced negative mood circuits
- Therapy improved thinking patterns and coping
Insight: TMS opened the door; therapy helped him walk through it.
Transition to Deep TMS
Mr R began with standard rTMS:
- Daily sessions
- Target: dorsolateral prefrontal cortex
- Tool: figure-8 coil
Why shift to Deep TMS?
- Residual symptoms persisted
- Difficulty concentrating remained
Deep TMS advantages:
- Uses H-coil helmet
- Penetrates 3–4 cm into the brain
- Engages broader neural networks
- Sessions shorter (~20 minutes)
Patient improvements:
- Reduced emotional heaviness
- Better concentration
- Improved stress handling
Evidence and Research
- rTMS response rates: 50–60%
- Remission rates: 30–40%
- Deep TMS: higher remission and durability
Additional benefits:
- Helps OCD severity
- Improves anxiety symptoms
- FDA-cleared for multiple conditions
FDA Approval & Off-Label Use
Approved:
- Major depressive disorder (since 2008)
- Depression with anxiety
- OCD
Off-label (carefully monitored):
- PTSD
- Bipolar depression (selected cases)
- Chronic pain
- Migraine
- Tinnitus
- Parkinson-related symptoms
These are always part of a broader treatment plan—not standalone cures.
Early Use of rTMS
Newer data suggest rTMS can be used earlier:
- 2025 “Early-TMS” trial
- Expected response:
- rTMS: ~60%
- SSRI: ~40%
Ideal candidates:
- Mild-to-moderate depression
- Medication-averse patients
- Non-psychotic cases
Technical Approach
rTMS Protocols:
- High-frequency (10 Hz, left DLPFC) → excitatory (depression)
- Low-frequency (1 Hz, right DLPFC) → inhibitory (anxiety/OCD)
Deep TMS:
- Broader and deeper stimulation
- Used when rTMS gives partial results
Typical plan:
- 15–20 sessions
- 3–4 weeks
- Combined with psychotherapy
Final Outcome
After completing treatment:
- Mood improved from severe → near-normal
- Better sleep, energy, and concentration
- Improved work and social functioning
Maintenance includes:
- Follow-ups
- Lifestyle adjustments
- Periodic check-ins
Key takeaway:
TMS is not a magic cure, but a powerful tool in long-term recovery.
Who Should Consider This Approach?
If you or a loved one:
- Has mild-to-moderate depression or anxiety
- Has not responded well to medication
- Prefers to avoid pills
- Is not in a high-risk psychiatric state
Then rTMS or Deep TMS with psychotherapy may be a viable first-line option.
Clinical Offering
At Asha Hospitals, Banjara Hills, and Edge Clinics, HITEC City, I, Dr Anil Reddy K, offer:
- rTMS and Deep TMS
- Evidence-based psychiatric care
- Personalized treatment plans
I review each patient’s:
- Treatment history
- Symptom profile
- Neuromodulation needs
And discuss:
- Risks
- Benefits
- Realistic expectations
If you’ve ever felt “stuck” in the cycle of medication trials—or want to explore brain-based treatment without starting medication—this approach may be the next chapter in your journey toward recovery.
Book a consultation for liaison psychiatry at Asha Hospitals Banjara Hills or Edge Clinics HITEC City and begin your journey towards lasting wellness.
Dr. Anil Reddy K, MBBS, DPM, TMS ( AIIMS)
Consultant Neuropsychiatrist.
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