Can transcranial magnetic stimulation treat depression without medication?

Can TMS work as a standalone treatment, without any medication?

Yes, TMS can be effective on its own, but the evidence is strongest when it is used as an add-on to medication. A 2025 scoping review of 16 studies on late-life depression explicitly states that 'pharmacological co-treatment was common but not essential for clinical improvement, highlighting TMS's potential as a standalone therapy' [7]. This means that for elderly patients who cannot tolerate antidepressants due to side effects or interactions, TMS alone is a viable option. In a large community study of 1,351 patients receiving deep TMS, many were on no or minimal medication, and 30 sessions produced an 81.6% response rate and 65.3% remission rate [5]. These real-world results show that TMS can deliver meaningful improvement without drugs.

However, the most rigorous trials—those that compare TMS to a sham (fake) treatment—almost always keep patients on their existing medication. For example, a 2022 randomized controlled trial of 38 patients with treatment-resistant depression found that adding TMS to their current medication led to a 63% response rate and 42% remission rate, with TMS significantly outperforming sham [4]. Similarly, a 2024 study of 151 patients after aortic surgery found that combining TMS with medication was more effective than medication alone, with a 94.7% efficacy rate versus 80% [8]. These studies suggest that while TMS can work alone, the best results come from using it alongside medication, especially for severe or resistant depression.

How does TMS compare to medication alone?

TMS is at least as effective as medication for many patients, and it has a major advantage: it avoids the systemic side effects of drugs. A 2025 qualitative study of 20 patients who had tried both approaches found that participants 'perceived TMS as a safer and more tolerable alternative to medication, particularly due to its lack of systemic side effects' [10]. This is a key reason why patients seek out TMS—they want relief without the weight gain, sexual dysfunction, or nausea that often come with antidepressants. The same study noted that the most common motivation for seeking TMS was 'dissatisfaction with pharmacotherapy' [10].

In terms of raw numbers, TMS holds its own. The 2022 meta-analysis of 12 sham-controlled trials found a moderate-to-large effect size of 0.81, meaning TMS produced a significantly greater reduction in depression scores than placebo [1]. For comparison, many antidepressants show effect sizes of 0.3 to 0.5 in placebo-controlled trials. A 2022 study on deep TMS for anxious depression found that the pooled effect size across multiple trials was 0.55, which 'compares favorably to alternative treatments' like medication [2]. However, the same meta-analysis cautioned that the clinical significance of TMS is 'modest'—only 13.7% of patients responded to TMS versus 7.9% to sham in those early studies [1]. Newer protocols, like the FDA-cleared SAINT system, have improved on this dramatically, with a 2022 trial showing a 62% reduction in depression scores after just five days of accelerated TMS, compared to 14% with sham [9]. This suggests that TMS technology is improving rapidly, and its standalone efficacy may be better than older studies suggest.

Who benefits most from TMS without medication?

TMS without medication appears to be especially useful for specific groups: older adults, people with anxious depression, and those who cannot tolerate drug side effects. For older adults, a 2021 review of seven randomized controlled trials found that TMS produced clinical response rates ranging from 6.7% to 54.3%, with higher efficacy seen in bilateral or high-frequency protocols [3]. The same review emphasized that TMS is attractive for this group because it 'preserves cognitive functions and recognizes the prevalence of polypharmacy in elderly' [3]. A 2025 scoping review echoed this, noting that TMS is 'an effective alternative for elderly patients with depression, especially when side effects or comorbidities limit medication' [7].

For people with anxious depression—a common and hard-to-treat subtype—deep TMS with the H1 coil actually works better when anxiety is high. A 2022 study found that 'higher baseline anxiety was found to be predictive of successful outcome for the H1-Coil treatment,' which is the opposite of what happens with medication, where anxiety often predicts a poorer response [2]. This means that for patients whose depression is tangled with severe anxiety, TMS may be a better first-line option than drugs. Finally, a 2023 study on sex differences found that TMS may be more effective in women than men, with a large effect size (ηp² = 0.261) in reducing depression scores after a single session, though the sample was small [6]. While this needs more research, it hints that TMS could be a particularly good fit for women who struggle with medication side effects.

About These Sources

This answer is built on 10 peer-reviewed studies — published from 2021 to 2025, 4 from 2024 or later, 4 in Q1 journals, collectively cited 368 times — selected as the most relevant from 15 studies that passed quality screening, drawn from 77 papers retrieved from a database of over 500 million.

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