The "TMS Dip": What It Is, When It Happens, and What to Do
The "TMS dip" is the name patients and clinicians use for a temporary worsening of mood, energy, or anxiety that some people report partway through a course of TMS, most often around the second or third week. It is not universal, it is not a sign the treatment has failed, and it is not something to manage alone — it is a reason to tell your psychiatrist so the course can be reviewed and, if needed, adjusted.
Where the term comes from
Clinicians who run TMS programs noticed that a share of patients describe a rough patch somewhere between the first and third week — a few days of feeling flatter, more irritable, or more anxious — before their symptom scores begin to improve. The pattern was common enough to get a nickname. It is worth being precise about what that nickname is and is not: a description of what some patients report, not a stage of treatment that everyone passes through.
What the evidence does and does not say
TMS has been FDA-cleared for major depressive disorder since 2008, and the clinical trials that supported clearance measured outcomes at the end of a full course. Those trials were not designed to track week-by-week mood swings, so there is no large, controlled study that defines a dip, measures how often it occurs, or proves what causes it. What exists is clinical observation and patient report. That is a real and useful kind of knowledge, but it means any explanation — that the brain is "reorganizing," that it reflects early neuroplastic change — is a hypothesis, not an established mechanism. We say that plainly because patients deserve the honest version.
What a dip can look like
- Mood that was lifting slightly seems to slide back for several days.
- More fatigue than usual after sessions, or trouble sleeping.
- A spike in anxiety or irritability without an obvious trigger.
- A feeling that the treatment "stopped working" after an early improvement.
Several things can produce the same picture and have nothing to do with TMS: a medication change made at the same time, a stressful week, poor sleep, or the ordinary variability of depression itself. Sorting that out is the psychiatrist's job, and it is why we track symptom scores at every stage rather than relying on how a single day felt.
What to do if it happens
- Tell the clinic the same day. Do not wait for your next scheduled check-in or assume it will pass.
- Keep your sessions unless your psychiatrist tells you otherwise. Stopping mid-course on a bad week is the most common way a treatable dip becomes an incomplete course.
- Expect a review, not a reflex. Your psychiatrist will look at your scores, your medications, your sleep, and what else is going on, and may adjust the plan or simply watch closely for a few sessions.
- If you have thoughts of harming yourself at any point, that is not a dip to wait out: call or text 988 or go to the nearest emergency room, and tell the clinic.
How we approach it at Denver TMS Therapy
Every course here is prescribed and overseen by a psychiatrist, and symptom scores are recorded throughout rather than only at the start and end. That is the practical safeguard: a dip shows up in the data, gets discussed, and gets a decision — continue, adjust, or add something — instead of being left to the patient to interpret alone. Patients who ask about the dip before starting are told exactly what is in this article: it may happen, it may not, and either way you will not be navigating it by yourself.
FAQ
How common is the TMS dip?
No controlled study has measured it, so there is no reliable percentage. Clinics report that a minority of patients describe a temporary rough patch, most often in the second or third week, and that many patients never experience one.
Does a dip mean TMS isn't working for me?
No. A temporary worsening early in the course is not, by itself, evidence that the treatment has failed. Response is judged on symptom scores across the full course, which is why those scores are tracked throughout.
Should I stop TMS if I feel worse?
Not without talking to your psychiatrist. Tell the clinic the same day; the usual response is a review of your scores and medications and, often, continuing treatment with closer monitoring.
Can the dip happen with accelerated TMS?
Patients on compressed iTBS schedules sometimes describe similar rough patches on a shorter timeline. The same rule applies: report it the same day, and your psychiatrist decides whether anything changes.
Considering TMS and want to talk through what the course looks like week by week? Request a consultation.