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Key Takeaways

• Psychiatrists introduce TMS only after first-line treatments like therapy and medication have not produced sufficient improvement.
• Treatment-resistant depression must typically be documented before TMS becomes a clinical and insurance-approved option.
• Psychiatrists evaluate full treatment histories, symptom patterns, and prior therapy tolerance to determine TMS eligibility.
• Insurance requirements, including prior authorization and proof of failed treatments, often shape the timing of TMS access.
• TMS is usually added to – not substituted for – existing treatments, forming a layered approach monitored throughout the process.

Dr. Robert Harden is a highly experienced Texas psychiatrist with more than four decades of clinical practice, specializing in general, child, and adolescent psychiatry. After completing his residency and fellowship at Timberlawn Psychiatric Hospital, Robert Harden, MD, went on to lead inpatient youth programs at Texas Health Presbyterian Hospital of Plano and later provided care through the Texas Department of Health and Human Services. His expertise spans neurodevelopmental disorders, treatment-resistant depression, psychopharmacology, and neuromodulation therapies such as transcranial magnetic stimulation (TMS). Now a psychiatric consultant with Compassionate Psychiatric Services, Dr. Harden evaluates patients, supervises mental health clinicians, and helps guide treatment plans grounded in safety, evidence, and individualized care. With deep knowledge of when advanced interventions are appropriate, he offers insight into how psychiatrists decide when TMS is the right option for a patient.

How Psychiatrists Decide When to Use TMS

Patients frequently hear about transcranial magnetic stimulation, or TMS, early in their mental health journey and wonder why it is not recommended at the outset. Described as non-invasive and well-tolerated, it can seem counterintuitive that clinicians wait to introduce it. Understanding how treatment plans are structured requires examining how psychiatrists define first-line care, how TMS fits into broader clinical workflows, and why timing can depend on both patient response and insurance coverage.

TMS delivers focused magnetic pulses to brain regions linked to mood regulation. Clinics provide treatment in outpatient settings while patients remain awake and seated. Sessions usually last 20 to 40 minutes and take place five days a week for four to six weeks. Most patients report only mild side effects, such as scalp discomfort or fatigue. Because the procedure does not require anesthesia or hospitalization, many clinicians consider it an accessible option after earlier steps fail.

Psychiatrists begin with what are known as first-line treatments – typically therapy, medication, or both – because broad clinical evidence supports these options, providers can deliver them widely, and insurers often cover them without extensive pre-approval. Starting with them also lets clinicians observe how symptoms respond to standardized interventions before they consider specialized methods.

When symptoms do not improve after multiple attempts, clinicians may diagnose treatment-resistant depression. This usually requires documentation that at least two evidence-based treatments were tried at sufficient dosage and duration without success. At this stage, psychiatrists review side effects, dosing timelines, and symptom patterns to decide whether a change in strategy is justified.

If treatment resistance is confirmed, psychiatrists assess whether TMS fits the patient. They review the patient’s medication history, tolerance of prior therapies, and current symptom severity. Clinicians also look for patterns across the full treatment record, not just isolated failures, to evaluate whether the timing is right for adding a neuromodulation option.

In many systems, insurers influence how and when patients can receive TMS. Most insurers limit coverage to patients with documented treatment resistance and require prior authorization, proof of failed treatments, and intake evaluations. These steps can delay access even when the clinical case supports it. Psychiatrists often handle these requirements while continuing other treatments to preserve stability.

When introduced, TMS rarely replaces existing care. Psychiatrists typically continue therapy or medication alongside it, using a layered approach to reinforce progress. Clinicians monitor response closely, adjust coil placement or pulse settings as needed, and determine whether maintenance sessions are warranted after the initial cycle.

Public perception of TMS does not always align with clinical use. While some see it as a fast-track alternative to medication, psychiatric protocols follow step-based sequencing to ensure safety and consistency. Clinicians and payers do not intend delays to withhold care; they use documentation standards and risk evaluations that apply across mental health systems.

Families navigating this process are not being turned away; they are moving through a structured review that prioritizes eligibility and long-term planning. Tracking treatment history, asking questions during visits, and preparing for coverage requirements can help patients stay informed and engaged while they wait for the next step in care.

Some health systems are piloting referral pathways that flag likely TMS candidates earlier, pair documentation with prior authorization checklists, and reduce administrative waits. Clinics and payers are also developing measurement-based triggers and shared data handoffs so psychiatrists can route eligible patients without repeating prior steps. These operational shifts may accelerate access for appropriate patients while they preserve safety standards and insurance controls.

FAQs

Why isn’t TMS recommended at the start of treatment?

Psychiatrists begin with therapy and medication because these first-line options have broad evidence, accessibility, and insurance approval.

What qualifies as treatment-resistant depression?

It generally requires at least two evidence-supported treatments at appropriate dosage and duration without meaningful improvement.

How do psychiatrists decide if someone is eligible for TMS?

They review symptom patterns, past treatment responses, medication tolerance, and the overall trajectory of the patient’s clinical record.

Do insurance rules affect when TMS can begin?

Yes. Most insurers require documentation of failed treatments and prior authorization, which can delay access even when clinically appropriate.

Does TMS replace other treatments?

No. Psychiatrists typically add TMS to existing therapies, monitoring progress and adjusting settings throughout the treatment cycle.

About Robert Harden

Dr. Robert Harden is a Texas-based psychiatrist with more than 40 years of experience treating children, adolescents, and adults. A life fellow of the American Psychiatric Association, he has held leadership roles at major healthcare institutions and now serves as a psychiatric consultant with Compassionate Psychiatric Services. His expertise includes neurodevelopmental disorders, treatment-resistant depression, mindfulness, and neuromodulation techniques such as TMS. Outside of practice, he enjoys reading, meditation, and staying active.