The TMS "Dip": What It Is, Why It Happens, and What to Do About It

Starting TMS therapy is a hopeful moment. After trying medications that didn't work or caused difficult side effects, many patients arrive at our Friendswood clinic ready for something different. That's why it can feel alarming (and often discouraging) when symptoms temporarily seem to get worse partway through treatment.



We call this experience the TMS dip. Here's what you need to know.

The TMS dip refers to a temporary worsening of symptoms, such as increased low mood, anxiety, irritability, fatigue, or disrupted sleep, that some patients experience during TMS therapy. It typically appears somewhere in the middle of a treatment course, though it can occur at any point.

At our clinic, as with TMS providers nationwide, a significant number of patients experience temporary symptom fluctuations during treatment. It can feel frustrating, especially when you were hoping to feel better quickly. But for most people, the dip is a short-lived phase, lasting anywhere from a few days to roughly two weeks, and it often precedes meaningful improvement.

Crucially, a dip does not mean TMS is harming you or that your brain is responding badly. In most cases, it reflects the opposite.

Why Does the TMS Dip Happen?

To understand the TMS dip, it helps to understand what TMS does in the brain.

TMS uses targeted magnetic pulses to stimulate underactive regions of the brain, particularly the dorsolateral prefrontal cortex, which plays a central role in mood regulation. This stimulation promotes neuroplasticity, the brain's ability to form new neural connections and reorganize existing ones. Research confirms that repetitive TMS induces synaptic changes, altering patterns of neural communication that, over time, lead to lasting symptom relief.

But rewiring the brain isn't instantaneous, and it isn't always smooth. In the early and middle stages of treatment, TMS disrupts established (but dysfunctional) neural pathways before the brain has fully built healthier alternatives. Think of it like renovating a house. There's a period where things look messier than when you started, even though meaningful improvements are underway.

Other factors can also contribute to or amplify a dip:

• Protocol or targeting factors. Small differences in coil placement or stimulation intensity can affect how a patient responds.
• Medication interactions. Recent medication changes, missed doses, or interactions between certain medications and TMS stimulation can contribute to symptom fluctuations.
• Undetected comorbidities. Conditions such as undiagnosed bipolar spectrum disorder, PTSD, or substance use can cause symptom volatility that resembles or amplifies a TMS dip.
  
• Psychological adjustment. For some patients, TMS can increase self-awareness or temporarily surface difficult emotions as the brain begins to shift, which can feel worse before it gets better.
  

Is a TMS Dip a Sign That Treatment Is Working?

Not always, but it can be. The dip often reflects the fact that your brain is actively changing and beginning to build healthier patterns of activity.

Research suggests that the brain has a built-in self-regulating system that helps keep these changes from going too far in either direction, which is part of why serious or long-lasting worsening is uncommon in patients who are properly screened and monitored.

What matters most is how the dip is managed, and that begins with telling your treatment team.

Just like our approach to all the mental health services we provide at Friendswood Psychiatry & TMS Clinic, our response to a dip is proactive and patient-centered.

1. Same-Day Assessment

 If you report worsening symptoms, we take it seriously immediately. We screen for safety, assess the nature and severity of the change, and review any physical symptoms such as headaches or dizziness. If safety is a concern at any point, we follow appropriate urgent care protocols without hesitation.

2. Medication and History Review

We review your current medications, look for any recent changes or missed doses, and flag any high-risk interactions. If adjustments are needed, we coordinate directly with your prescribing provider.

3. TMS Delivery Review

 Small mismatches in coil positioning or stimulation intensity can matter more than many patients realize. If recalibration is indicated, we do it. We may also adjust the protocol by modifying session frequency, dosing, or timing to better suit your individual response.

4. Continue, Pause, or Adjust Based on What's Best for You

Our treatment decisions are always individualized. There's no one-size-fits-all response.

• For a mild, brief dip, we typically continue treatment with closer monitoring and supportive measures.
• For a more persistent or moderate dip, we may pause and reassess within a few days before resuming.
• In the rare case of a severe or safety-related concern, we pause treatment and escalate to a full psychiatric evaluation.



5. Supportive Care

We address specific symptoms like headaches, sleep disruption, or acute anxiety. For patients whose dip involves increased rumination or emotional distress, we provide psychotherapeutic support.

6. Extended or Maintenance Sessions if Needed

If you're seeing some improvement but symptoms are still fluctuating, we may recommend additional or maintenance sessions to keep the progress going. A study of over 7,000 patients found that outcomes continued to improve when treatment was extended beyond the standard course. Sometimes, a little more time makes all the difference.

Prevention is always preferable to management. Our approach to minimizing the risk of a significant TMS dip includes:

• Thorough pre-treatment screening for bipolar spectrum conditions, seizure history, substance use, and other factors that can cause volatility during stimulation
  
• Precise motor-threshold mapping is individualized to each patient
• Careful coordination of any medication changes so we can avoid abrupt discontinuations and carefully make any needed changes
• Transparent expectation-setting so patients know what to watch for and feel confident reporting a dip if it occurs
  

 From your initial evaluation through every session and beyond, our team at Friendswood Psychiatry & TMS Clinic monitors your progress, adjusts your protocol when needed, and stays in close communication with you throughout the process.

If you're considering TMS for depression, anxiety, another mental health concern, or if you've had a discouraging experience with TMS elsewhere, we invite you to speak with our team.

We serve patients throughout Friendswood, League City, Pearland, and the greater Houston area. Contact us today to schedule your free consultation.