TMS Therapy in North Carolina

From The Doctors Desk: What to Expect During TMS Treatment

Written By R. Dewayne Book, MD — Chief Medical Officer, Advaita Integrated Medicine

If you’re reading this, there’s a good chance you’ve already been through a lot. Multiple medications. Years of appointments. Doing everything you were supposed to do — and still not feeling like yourself. By the time most of my patients sit down to talk about TMS, they don’t really believe it’s going to work.

I always tell them: of course you don’t. That’s the depression talking. If you walked in here convinced this was going to change your life, you probably wouldn’t need it. Persistent hopelessness and the expectation of a negative outcome are symptoms of depression. And they’re exactly what we’re going to treat.

I always tell them: of course you don’t. That’s the depression talking. If you walked in here convinced this was going to change your life, you probably wouldn’t need it. Persistent hopelessness and the expectation of a negative outcome are symptoms of depression. And they’re exactly what we’re going to treat.

What Happens at Your First TMS Appointment?

The first TMS appointment at AIM is a full psychiatric evaluation — not a brief screening. Before any treatment begins, the first appointment covers:

• Current severity of your depression
• How long symptoms have been present
• What treatments you’ve already tried and how you responded
• Whether any other conditions might be affecting treatment
• A baseline depression assessment using a clinician-administered scale

For the depression assessment, I use something called the Hamilton Depression Inventory Scale — a clinician-administered assessment that looks at the specific symptoms of depression and rates them objectively.

This isn’t a questionnaire you fill out in the waiting room. I administer it myself, and I use it throughout your entire treatment course to track what’s changing — not just what you feel like is changing, because those two things are often very different.

How Is Depression Measured Before TMS?

Tracking depression with clinician-administered assessments throughout TMS treatment matters because mood is typically the last symptom to improve — meaning how a patient feels often lags significantly behind what the clinical data is already showing. Without objective measurement at regular intervals, both patients and providers are likely to underestimate progress, or miss early warning signs that the treatment needs to be adjusted.

This is why I use the Hamilton Depression Inventory Scale for TMS treatment. We want to make sure you’re getting better and can see that objectively. This allows us to change course and adjust if scores aren’t improving.

What Happens on Day One of TMS Treatment?

The first day of TMS treatment involves mapping the brain to identify the precise treatment target before any stimulation begins. This is different from every session that follows — and it’s one of the most important steps in the entire process.

The way TMS works, I need to find a specific landmark first — the motor strip, the region of your brain that controls movement. Once I locate that, I can precisely identify the prefrontal cortex, which is where depression primarily lives. That’s the target. That’s where the treatment goes.

Day one is also when I set the dose. How strong does the magnetic impulse need to be for you specifically? That gets calibrated on the first visit, and it matters more than most people realize. An underdosed treatment doesn’t move the needle. An overdosed one causes unnecessary discomfort.

Most TMS programs have the physician come in on day one, set the parameters, and then not see the patient again until the very last session. That’s not how we run TMS at AIM. I’ll come back to why.

What Does TMS Feel Like During the First Two Weeks?

During the first two weeks of TMS treatment, most patients experience the physical sensation of treatment without noticing significant changes in mood — and that is completely normal. A full course of TMS is 36 sessions, five days a week over six to seven weeks. Each session runs between 20 and 40 minutes.

You sit in a reclined chair, a lightweight device rests against your head near the treatment area, and the stimulation begins. You’ll hear a clicking sound and feel a tapping sensation on your scalp — most patients adjust to this within the first few sessions. You’re completely awake, no sedation whatsoever, and when your session ends you can drive yourself to work and get on with your day.

In those early weeks, most patients don’t feel much differently yet. With depression, mood tends to be the last thing to improve. What typically returns first, in order:

• Energy
• Sleep
• Appetite
• Concentration and mental clarity
• Mood and overall emotional outlook

The subjective feeling that you’re actually getting better often lags far behind what the data is already showing — which is exactly why objective measurement throughout treatment matters as much as it does.

Why Does TMS Require Weekly Physician Visits?

Weekly physician visits during TMS treatment allow for real-time monitoring of the patient’s response and precise dose adjustment throughout the course — something that isn’t possible without consistent clinical contact.

This is exactly why I see every patient once a week throughout their entire treatment — not just on day one and day 36. Every weekly visit includes a Hamilton Depression Inventory Scale. I review the score, look at what’s changing and what isn’t, and make adjustments if the treatment needs them.

Some patients become more sensitive to the magnet over the course of treatment. Some become more resistant. If I’m only seeing you twice in six weeks, I’m going to miss that. And if the dose is wrong for where you are in treatment, the outcomes suffer. Weekly visits aren’t just about relationship — they’re clinical management.

Here’s something I’ve noticed over years of doing this: some of the clearest early signs that TMS is working show up in that weekly visit before the patient notices anything themselves. Posture changes. Eye contact improves. A handshake becomes firmer. I’ve had patients tell me they don’t feel any better while the family member standing behind them is nodding emphatically in the other direction. Patients are often the last to know.

How Does TMS Use Neuroplasticity to Treat Depression?

TMS treats depression by stimulating neurons in the prefrontal cortex to fire repeatedly, triggering neuroplasticity — the brain’s ability to reorganize and rewire its own circuitry. As those neurons fire, surrounding neurons begin to join in, essentially re-teaching the brain how to function the way it did before depression dampened it.

During active TMS treatment, that neuroplasticity is supercharged. The brain is in a heightened state of reorganization. And that window is an opportunity that extends well beyond what’s happening in the treatment chair.

Why Does Lifestyle Matter During TMS Treatment?

Lifestyle factors like exercise, sleep, and nutrition matter during TMS treatment because the brain’s heightened neuroplasticity during this period makes it significantly more receptive to lasting change than at any other time.

During our weekly visits in this phase, we’re going to talk about things that might surprise you — exercise, sleep, nutrition, relationships, and if it’s relevant, substance use. Not because I’m checking boxes, but because these things directly affect whether your results hold after treatment ends.

Most of my patients are well aware they should be exercising more or sleeping better. The problem is that depression has taken the energy and motivation required to actually do those things. As TMS begins to restore some of that, I want you to capitalize on it. The brain is already changing. We want to give those changes somewhere to go.

The ask in the early weeks is deliberately small. If you’ve been struggling to get out of bed, I’m not asking you to join a gym. I’m asking for one ten-minute walk in the next seven days. That’s a real commitment and we’re going to treat it like one. Because any small change is a real change, and real changes build on each other.

What Does TMS Remission Look Like? — Weeks Four Through Six

TMS remission typically becomes apparent in weeks four through six of treatment, as patients begin re-engaging with activities, relationships, and plans for the future that depression had made impossible. I don’t measure remission by a number on a scale alone — I measure it by what I see in the room.

A patient who mentions they’ve started cooking dinner for their family again. Someone who’s decided to take up yoga — something they used to love and had completely stopped. A person making plans for the future for the first time in years.

I had a patient several years ago who had struggled with severe depression for a long time. The smallest things would send her into a spiral of negativity — even something as ordinary as traffic. She’d sit in that traffic and feel it as a global confirmation that everything was going wrong, that the universe itself was conspiring against her. About five weeks into treatment, she got caught in traffic on the way to an appointment. She told me she could feel her brain starting to go to that familiar place. And then — for the first time — she had a different thought instead.

That’s what remission looks like. Not a life without hard moments. A different relationship to them. The lights in the room are back on — not just in the moment, but when you think about next month, next year, the future in general.

What Is a Good TMS Remission Rate?

A good TMS remission rate is considered to be significantly above the national average of 30 to 35%. At AIM, approximately 78% of patients complete treatment with Hamilton Depression Inventory scores in the range considered normal for the general population — nearly double the national benchmark.

I think two things drive that difference: the weekly physician engagement that allows for real-time dose adjustment and a genuine therapeutic relationship, and the Brainsway deep TMS machine we use, which has an H coil rather than a figure-8 coil and penetrates deeper into the prefrontal cortex than most other devices on the market.

What Happens After TMS Treatment Ends?

After completing a TMS treatment course, patients are referred back to their care team with a full account of their response, and follow-up appointments are scheduled to monitor progress over time. Completing TMS isn’t the end of the conversation — it’s a transition point.

Most patients continue therapy or medication management after TMS — and the combination is often more effective than either alone. The lifestyle changes we worked on during treatment need to continue. The skills your therapist has been building with you need to keep developing. TMS creates the neurological conditions for change. The rest of the work builds on that foundation.

If symptoms begin to return over time, a shorter follow-up course of TMS is sometimes appropriate. That’s not a failure — it’s how you manage a serious illness with the best tools available.

Can TMS Be Combined With Therapy and Medication?

Yes — TMS can be combined with therapy and medication, and for most patients the combination produces stronger and more lasting results than any single approach alone. TMS addresses the neurocircuitry. Therapy builds the behavioral and cognitive skills to sustain recovery. Medication, when appropriate, supports the neurochemistry. These aren’t competing approaches — they work best together, which is why an integrated practice like AIM coordinates all three under one roof.

Is TMS Right for You? How to Know If You’re a Candidate

TMS is appropriate for patients who have tried antidepressant medication without finding adequate relief — a condition clinicians call treatment-resistant depression. The FDA approved TMS after a single medication failure, making it a viable option earlier in the treatment process than most people realize.

Most insurance carriers require documentation of two or more failed medications before approving coverage. Our team can help navigate that process. But the more important question is whether you’ve been managing depression for years without the relief you deserve — because if the answer is yes, TMS may be the intervention that changes that.

How Many Antidepressants Do You Have to Try Before Qualifying for TMS?

The FDA approved TMS after one antidepressant failure, though most insurance carriers require documentation of two or more medication failures before approving coverage. In practice, by the time most patients come to me for a TMS consultation, they’ve been through five or six medications. That’s five or six attempts at a solution that wasn’t addressing the real problem — the circuitry, not just the chemistry.

I’ve watched patients come in resigned to the idea that this is just who they are now. That depression is their baseline and it always will be. I have patients in their 60s and 70s who reach remission after TMS and experience something close to grief — grief for the years they spent severely depressed when this was available to them. That’s not something I take lightly.

We have better tools now than we’ve ever had. There’s no reason to keep managing depression with an approach that isn’t working when something more effective exists.

If you’ve been managing depression for years and feel like you’ve run out of options, fill out the form below. There’s a good chance you haven’t.