Able Psychiatry

Glossary

What Is Maintenance TMS?

Written by the Able Psychiatry clinical team

Updated September 27, 2026

Maintenance TMS is a course of occasional rTMS sessions continued after a person finishes their initial (“acute”) course of treatment, given to help sustain the antidepressant response and lower the chance of relapse. Protocols vary widely between studies and clinics.

Key takeaways

  • A 2023 systematic review of maintenance TMS protocols for major depression found that “most studies highlighted significant efficacy of maintenance protocols in decreasing relapse risk,” but that “administering two or fewer stimulations per month is ineffective in sustaining an antidepressant effect.”
  • The same review found “the risk of relapse was most pronounced after five months from the acute treatment.”
  • In one study included in that review, responders who received 20 weeks of maintenance TMS relapsed less often than those who received no additional TMS (37.8% vs. 81.8%).
  • Researchers group maintenance protocols into four general types — tapering, cluster, continuous, and rescue — and the review found no clear evidence yet that any single schedule works best.

How maintenance TMS works

After a person completes a standard course of TMS and responds, maintenance TMS continues treatment at a reduced frequency rather than stopping altogether. A 2023 systematic review of 14 studies found high variation in how this is done: some protocols begin “within the first week after acute protocol,” while others start “from one week to one month after acute treatment,” and the review “did not identify any significant difference in outcomes depending on the amount of time between acute and maintenance protocols.”

The same review’s key practical finding was about frequency, not timing: protocols that gave two or fewer sessions per month were not enough to sustain the treatment effect or reduce relapse risk, and relapse risk climbed most sharply around the five-month mark after the acute course ended — which is the window the review suggests maintenance sessions need to cover.

Types of maintenance TMS protocols

  • Tapering rTMS: defined in the review as “a progressive and gradual reduction of session[s] and stimulation across several weeks.” One included study (Richieri et al., 2013) gave three sessions in week 1, two in weeks 2-3, one per week for two weeks, one every two weeks for two months, then one per month for two months.
  • Cluster rTMS: “5 intensive sessions delivered over 2.5-5 days, separated by monthly or greater non-treatment periods.”
  • Continuous rTMS: in this review’s terminology, maintenance sessions “delivered within the first week after acute protocol,” continuing without a gap.
  • Rescue rTMS: “multiple protocols delivered during a relapse of a depressive episode,” rather than on a fixed preventive schedule.

Example of maintenance TMS

In a study included in the 2023 review (Richieri et al., 2013), 59 patients with pharmacoresistant depression who had responded to an acute TMS course were followed for 20 weeks; 37 received a tapering maintenance schedule (three sessions in week 1, gradually spacing out to monthly sessions) and 22 received no additional TMS. The review reports this maintenance schedule “was associated with a significantly lower relapse rate (37.8% vs. 81.8%)” among responders in routine clinical practice.

What people get wrong

People sometimes assume “maintenance TMS” means going back to the full course all over again. In the studies reviewed, it almost never does — maintenance sessions are far less frequent than an acute course, whether that means a handful of sessions spaced weeks apart or one session a month. The bigger misconception is that any small amount of follow-up treatment counts as “maintenance”: the review found that two or fewer sessions a month was not enough to protect against relapse.

Maintenance TMS vs. an acute TMS course

Acute TMS course Maintenance TMS
Goal Produce an initial response or remission Sustain that response and reduce relapse
Typical frequency Daily sessions, several days a week Weekly to monthly, or tapering down over months
When it happens The first course of treatment After the acute course, once a response is established
Evidence on minimum frequency Not applicable Two or fewer sessions per month was found ineffective in the 2023 review

An acute course establishes whether TMS works for a given patient. Maintenance TMS is a separate, lower-frequency phase that follows a response, aimed at keeping depressive symptoms from returning.

Frequently asked questions

Does everyone who responds to TMS need maintenance treatment?
This is a clinical decision for you and your treating clinician. The available research shows maintenance protocols can reduce relapse risk for responders, but studies vary widely in who was included and how maintenance was scheduled.

How often are maintenance TMS sessions given?
There is no single standard. A 2023 systematic review found schedules ranging from a single session every month to tapering schedules that start weekly and gradually space out, and found that two or fewer sessions per month did not sustain the treatment effect.

When does relapse risk after TMS peak?
A 2023 systematic review of maintenance TMS protocols found relapse risk “was most pronounced after five months from the acute treatment,” which is part of why many maintenance schedules are designed to extend past that point.

The bottom line

Maintenance TMS is a lower-frequency continuation of treatment for people who have already responded to an acute TMS course, aimed at protecting that gain rather than producing a new one. The evidence is still thin and protocols vary a great deal, but the clearest finding so far is that very infrequent sessions (two or fewer a month) are not enough, and relapse risk is highest around five months after the acute course ends.

Sources

Considering TMS? Read what to expect at a TMS appointment, or learn about TMS treatment at Able Psychiatry in Chicago.

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