## min read

What is a Silent Panic Attack

By

Sonia Garcia

|

November 3, 2026

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What is a Silent Panic Attack

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Last updated: November 2026.

A silent panic attack is a panic attack with strong internal symptoms, such as a racing heart, a wave of fear, and a fear of losing control, but few outward signs, so the people around you may not notice anything. Some people call it a silent anxiety attack or an internal panic attack. It isn't a formal diagnosis. The experience is real, though, and it deserves the same attention as a panic attack anyone can see.

What Are Silent Panic Attacks?

A panic attack is a sudden surge of intense fear that comes with physical symptoms. According to the National Institute of Mental Health (NIMH), an attack can last from a few minutes to an hour or sometimes longer.

"Silent" describes what other people see, not what you feel. During a quiet panic attack, your body and mind go through the full alarm, but on the outside you might look a little tense or distracted. Some people have learned to hide it at work or at home. Others go still instead of reacting visibly. People with high-functioning anxiety often know this pattern well.

One point often gets lost. Having a panic attack doesn't mean you have panic disorder. NIMH states plainly that an isolated panic attack is not a mental disorder. Panic disorder involves repeated, unexpected attacks and persistent worry about the next one.

Signs and Symptoms of a Silent Panic Attack

Silent panic attack symptoms are the same as those of any panic attack. What differs is how much of it shows. NIMH lists these common symptoms:

  • Racing or pounding heartbeat
  • Sweating
  • Chills
  • Trembling or shaking
  • Trouble breathing or a feeling of shortness of breath
  • Dizziness or feeling faint
  • Numbness or tingling
  • Chest pain
  • Nausea or stomach discomfort
  • A fear of dying or of losing control

Some people also describe feeling detached, as if things around them aren't quite real, which clinicians call derealization (StatPearls). Sweating and trembling can be visible, so "silent" rarely means no outward signs at all. It means the signs are small enough that others miss them.

What a silent panic attack feels like from the inside

Internal panic attack symptoms often start in the body. Your heart speeds up for no clear reason. Your chest tightens. Your thoughts narrow to one question: what is happening to me? You might keep talking or typing while a second track in your head runs through worst cases. And because nobody reacts, it's easy to feel alone in it, or to wonder if you're overreacting. You're not. The intensity of a panic attack has nothing to do with how visible it is.

What others might notice

If you're a friend or family member, you may see small changes rather than obvious distress. These are possible signs, not a checklist:

  • Going quiet in the middle of a conversation
  • Leaving the room suddenly, or asking to step outside
  • Gripping a chair, a phone, or the edge of a table
  • Sudden stillness, or a fixed stare
  • Short, clipped answers
  • Pale skin or light sweating

A safety note. Chest pain, shortness of breath, and dizziness can also be signs of a heart problem or another medical condition. If chest pain is new or severe, get emergency medical care right away. Don't try to decide on your own that it's "just panic." A clinician should rule out medical causes first.

Mini Panic Attacks

Maybe your episodes don't feel like the full-blown attacks you've read about. Under the DSM-5 definition, a panic attack is an abrupt surge of intense fear or discomfort with four or more of a set list of symptoms, as summarized in StatPearls: Panic Disorder. "Mini panic attack" is not a clinical term. People use it for episodes with fewer or milder symptoms: a brief rush of fear, a pounding heart, a tight throat, and then it fades.

Mini panic attack symptoms can still be unsettling. If they come back often, change how you live, or make you anxious about the next one, they're worth bringing to a clinician, whatever you call them.

Silent Panic Attack vs Anxiety Attack

"Panic attack" is a clinical term. It comes on suddenly and builds fast. "Anxiety attack" isn't a clinical term. People use it in different ways, often for anxiety that builds more gradually.

Panic attack (including silent)Anxiety attack (informal)
OnsetSudden, sometimes without a clear triggerNot defined; people use the term loosely
IntensityIntense surge of fear and body symptomsVaries
How longA few minutes to an hour or sometimes longer (NIMH)Varies

So a "silent anxiety attack" is usually a silent panic attack described in everyday words. The pattern matters more than the label.

Can You Have a Panic Attack Without Feeling Anxious?

Yes, in the sense that fear isn't always the first thing you notice. NIMH notes that panic attacks can happen unexpectedly, without a clear trigger.

Many people notice the body first: a jolt of heartbeat, a wave of heat, tingling in the hands. The fear arrives a moment later, often as a reaction to those sensations. Others never put the word "panic" to it at all. They think their heart is acting up and go to urgent care first, which is a reasonable step.

And you can have a panic attack without hyperventilating. A panic attack involves four or more of a list of symptoms, and shortness of breath is only one of them.

Causes and Risk Factors

There's no single cause of silent panic attacks. Several factors can raise the odds:

  • Genetics. Panic disorder sometimes runs in families (NIMH).
  • How the brain responds to threat. Researchers think several parts of the brain and certain biological processes play a role in fear and anxiety. Some describe panic attacks as "false alarms" from the body's survival system (NIMH).
  • Stress. Major life stress and long stretches of pressure can set off attacks.
  • Hard early experiences. Several studies link adverse childhood experiences to panic disorder later in life (StatPearls).
  • Substances. Alcohol, recreational drugs, and some medications can bring on panic-like symptoms or make them worse.
  • Medical conditions. Some health problems can mimic panic or trigger symptoms.

Having risk factors doesn't mean you'll have attacks. Some people have attacks with no obvious risk factor at all.

How Silent Panic Attacks Affect Daily Life

Unseen, silent panic attacks can still shape a life. People who have them may:

  • Avoid places or situations where an attack happened before
  • Find meetings, classes, or social plans harder to get through
  • Pull back from relationships when others don't understand sudden withdrawal
  • Have trouble concentrating or making decisions
  • Lean on alcohol or other substances to take the edge off

Panic rarely travels alone. NIMH notes that panic disorder often occurs alongside depression, other anxiety disorders, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and bipolar disorder. If low mood has crept in alongside the attacks, our guide to how anxiety and depression overlap explains why the two so often show up together.

When to Get Professional Help

A single attack, once, may never come back. Get an evaluation if:

  • Attacks keep coming back
  • You spend a lot of time worrying about the next one
  • You've started avoiding places, people, or activities
  • You're using alcohol or other substances to cope
  • Your mood has dropped, or you've had thoughts of suicide

Anxiety can become severe enough to take over most of your day. Our articles on crippling anxiety and on whether you can be hospitalized for anxiety explain what more intensive care looks like.

If your panic attacks come with depression, bipolar disorder, or another severe mental illness (SMI), our psychiatry-led team can help. You can request an intake appointment.

Treatment Options

Panic attacks respond to treatment, usually therapy, medication, or both.

Therapy

NIMH lists cognitive behavioral therapy (CBT) as a treatment for panic disorder. CBT helps you notice the thoughts that turn body sensations into alarm, and practice responding differently. A review of meta-analyses by Hofmann and colleagues (2012) found the strongest support for CBT in anxiety disorders.

Two related approaches named by NIMH:

  • Exposure therapy, which means facing feared situations gradually, with a therapist's guidance.
  • Interoceptive exposure, which means safely bringing on the body sensations of panic, like a fast heartbeat, so they lose their power to set off an attack.

Acceptance and commitment therapy (ACT) is another option some therapists use. It focuses on making room for anxious feelings instead of fighting them.

Medication

NIMH lists several medication classes used for panic disorder: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), beta-blockers, and benzodiazepines. Each has different benefits, side effects, and risks. Which one, if any, fits a person is a decision made with a prescriber who knows the full history.

How Amae Health approaches panic alongside other conditions

Amae Health provides psychiatry-led outpatient care for adults 18 and older living with complex mental health conditions, such as major depressive disorder and bipolar disorder. When panic attacks come with those conditions, they're part of one treatment plan, not a separate problem handled in a separate office. Our psychiatrists, therapists, primary care physicians, dietitians, and peer mentors work under one roof. You can read more about our care model.

Coping Strategies and Prevention

These tools don't replace treatment. Many people find them helpful in the moment, and over time:

  • Slow breathing. Some people use the 4-7-8 pattern: breathe in for 4 seconds, hold for 7, and breathe out for 8.
  • Grounding. The 5-4-3-2-1 method: name five things you see, four you can touch, three you hear, two you smell, and one you taste.
  • Questioning the thought. When panic rises, ask: what's the evidence for this fear, and against it?
  • Keeping a log. Note the time, place, and what came before each attack.
  • Cutting back on alcohol, and protecting sleep.
  • Self-compassion. Panic attacks are not a character flaw.
  • Telling someone. Letting a partner, friend, or coworker know what an attack looks like for you makes the next one less lonely.

How to help someone having a silent panic attack

  • Stay calm yourself. Your steadiness helps.
  • Ask quietly what helps, or whether they want space.
  • Don't tell them to calm down or that it's nothing.
  • Offer to step somewhere quieter together.

Conclusion

A silent panic attack can be just as intense as one anyone can see, even when no one around you notices. It isn't a separate diagnosis, but it is a real experience with real treatment. If attacks keep returning, or come with low mood, avoidance, or other symptoms, care can help, and you can reach our intake team to start.

Frequently Asked Questions

Are silent panic attacks a thing?

Yes, as an informal description. "Silent panic attack" isn't a separate diagnosis, but it describes a real experience: a panic attack with few outward signs. If they keep happening, a clinical evaluation can help.

Can you have a panic attack and not know it?

Yes. Many people mistake the symptoms for a physical problem, like a heart issue, or put them down to stress. A clinician can help sort out what's happening and rule out medical causes.

What does a mini panic attack feel like?

People usually describe a short burst of fear with fewer or milder symptoms than a full attack, such as a racing heart or a tight chest that passes quickly. "Mini panic attack" isn't a clinical term, but recurring episodes are still worth an evaluation.

How long does a silent panic attack last?

According to NIMH, a panic attack can last from a few minutes to an hour or sometimes longer. A silent one follows the same pattern.

What is the difference between a silent panic attack and a silent anxiety attack?

A panic attack comes on suddenly and peaks quickly. "Anxiety attack" isn't a clinical term. People use it loosely, often for anxiety that builds more gradually.

Can a panic attack feel like a heart attack?

Yes. Symptoms like chest pain and shortness of breath overlap. If chest pain is new or severe, get emergency medical care. Don't assume it's panic.

When should I get help for silent panic attacks?

When attacks recur, when you start avoiding things, or when your mood drops. If you have thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline. In life-threatening situations, call 911 (NIMH).

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# min read

What is Attention-Seeking Behavior?

By

Sonia Garcia

|

October 22, 2026

Someone calls a friend "such an attention seeker," and everyone nods. Maybe it's a coworker who turns every meeting into a story about themselves, a partner who escalates every disagreement, or a teenager whose posts get more dramatic by the week. Or maybe you've wondered whether the label fits you.

Attention-seeking behavior is any behavior aimed, consciously or not, at getting other people to notice, respond, or reassure. Everyone does it sometimes. Wanting to be seen is a basic human need. It becomes a problem when it's persistent, when it disrupts relationships or work, or when it's the visible edge of something harder underneath: loneliness, a mood episode, a personality disorder, or a crisis.

What counts as attention-seeking behavior?

Common examples include:

  • Exaggerating stories or symptoms to get a reaction
  • Steering conversations back to yourself
  • Dramatic emotional displays out of proportion to the situation
  • Fishing for compliments or reassurance
  • Provocative statements, posts, or clothing meant to stand out
  • Starting conflict to get engagement, even negative engagement

None of these, on its own, says anything about mental health. Context matters more than any single behavior: how often it happens, how much it costs the person, and what's driving it.

Why do people seek attention?

There's rarely a single reason. Common drivers include:

  • Loneliness and unmet needs for connection. When people feel unseen, any response can feel better than none.
  • Low self-worth. External validation can stand in for an internal sense of being okay.
  • Learned patterns. In some families, the only reliable way to get a response was to escalate. Habits learned early can carry into adulthood.
  • Stress or crisis. Even people who rarely seek attention may reach for it during a breakup, a loss, or a period of instability.
  • Social media. Likes and comments offer fast, measurable attention, which makes it easy to chase.

Sometimes, though, behavior that looks like attention-seeking is a symptom of a mental health condition, and treating it as a character flaw misses the point.

Is attention-seeking behavior a sign of a disorder?

Usually not. But persistent, intense attention-seeking can be part of several conditions.

"Attention-seeking disorder" isn't a real diagnosis

People often search for "attention seeking disorder." There's no condition by that name in the DSM-5. The diagnosis most closely tied to attention-seeking is histrionic personality disorder, and attention-seeking can also show up in borderline personality disorder, narcissistic personality disorder, and during manic episodes of bipolar disorder.

Histrionic personality disorder

Histrionic personality disorder (HPD) is defined by a long-standing pattern of excessive emotionality and attention-seeking. According to the MSD Manual, it affects about 2% of people in the U.S. Under DSM-5-TR criteria, a diagnosis requires at least five of the following, beginning by early adulthood:

  • Discomfort when not the center of attention
  • Inappropriately seductive or provocative interactions
  • Rapidly shifting, shallow-seeming emotions
  • Consistent use of physical appearance to draw attention
  • Speech that is vague and lacking in detail
  • Dramatic, theatrical, exaggerated emotional expression
  • Being easily influenced by others or situations
  • Seeing relationships as more intimate than they are

A StatPearls review on NCBI describes HPD as an enduring condition that typically begins in late adolescence or early adulthood. The key difference from ordinary attention-seeking is that the pattern is pervasive: it shows up across relationships and settings, for years, and causes real distress or impairment.

Borderline personality disorder

In borderline personality disorder (BPD), intense fear of abandonment, unstable relationships, and rapidly shifting moods can lead to behavior that others read as attention-seeking. Usually it's something closer to panic: an attempt to keep someone from leaving. BPD can also look the opposite way, turned inward. We've written about that in quiet BPD and about the outward-facing petulant type of BPD.

Bipolar disorder

During a manic episode, the NIMH describes symptoms such as feeling very up or elated, talking fast about many things, feeling unusually important, talented, or powerful, and an excessive appetite for pleasurable activities. To others, that can look like a bid for attention. It's actually a mood episode, and it needs treatment.

When "attention-seeking" is really a cry for help

Talk of suicide, self-harm, or hopelessness is sometimes dismissed as "just attention-seeking." That's dangerous. The NIMH's warning signs of suicide include talking about wanting to die, feeling like a burden, feeling hopeless or trapped, and withdrawing from friends. These are reasons to respond, not to roll your eyes.

Even if someone has said similar things before, take it seriously. Ask directly. Stay with them. If you or someone you know is in danger, call or text 988, the Suicide & Crisis Lifeline, or call 911.

How attention-seeking affects relationships

Persistent attention-seeking tends to wear people down. Friends and partners can feel exhausted, manipulated, or stuck in cycles of crisis and reconciliation. Over time, people pull back, which deepens the loneliness that often drove the behavior in the first place.

That cycle is why labeling someone an "attention seeker" rarely helps. It names the behavior without touching the need underneath.

What helps

When attention-seeking is a habit rather than a symptom, change usually starts with noticing the need before acting on it. Is it reassurance, connection, recognition? Saying that need directly often gets a better response than dramatizing it.

When it's part of a mental health condition, treatment targets the condition:

  • Personality disorders. Psychotherapy is the main treatment. The MSD Manual notes that for HPD, psychotherapy focusing on underlying conflicts may help. For BPD, a 2020 Cochrane review found that psychotherapy reduced symptom severity, with dialectical behavior therapy and mentalization-based treatment the most studied.
  • Bipolar disorder. According to the NIMH, bipolar disorder usually requires lifelong treatment, typically medication combined with psychotherapy.

If you're on the other side of it, as a partner, parent, or friend, it helps to respond to the underlying need calmly and consistently, while setting clear limits on behavior you can't sustain. For more, see how to help someone with mental health issues.

When to look for more support

Consider a professional evaluation when attention-seeking is constant, damages relationships or work, comes with intense mood swings or fear of abandonment, or comes with any talk of self-harm.

At Amae Health, our clinics specialize in conditions including Borderline Personality Disorder and bipolar disorder. Our care teams bring psychiatrists, therapists, peer mentors, and care coordinators under one roof, working from one treatment plan, so the pattern behind the behavior gets looked at, not just the behavior itself.

Frequently asked questions

What is an attention seeker?

"Attention seeker" is an informal label for someone who often behaves in ways meant to draw notice or reactions from others. It isn't a diagnosis, and it often oversimplifies what's going on.

Is attention-seeking a mental illness?

No. Attention-seeking is a behavior, not a diagnosis. Persistent, pervasive attention-seeking can be part of histrionic personality disorder, and it can also appear in borderline personality disorder and during manic episodes of bipolar disorder.

What causes attention-seeking behavior in adults?

Common drivers include loneliness, low self-worth, patterns learned in childhood, stress or crisis, and the pull of social media. In some cases, it's a symptom of a mental health condition.

How do you respond to someone who is attention-seeking?

Respond to the need behind the behavior, such as reassurance or connection, without rewarding escalation. Set calm, consistent limits. And never dismiss talk of suicide or self-harm as attention-seeking.

Key takeaways

  • Attention-seeking behavior is common and human. It becomes a concern when it's persistent and harmful.
  • "Attention-seeking disorder" isn't a diagnosis. Histrionic personality disorder is the condition most closely tied to it, and it can also appear in BPD and bipolar disorder.
  • Talk of suicide or self-harm should always be taken seriously, never written off as attention-seeking.
  • The most useful response is to address the need underneath the behavior.

If attention-seeking is part of a bigger pattern of mood swings, unstable relationships, or self-harm, for you or someone you love, request an intake appointment. Our team will explain how an evaluation works and what to expect from the first visit.

# min read

TMS vs Medication: Comparing Depression Treatments

By

Sonia Garcia

|

September 23, 2026

Most people comparing TMS vs medication for depression arrive at the question the same way: the antidepressants have not brought enough relief. If that is you, it helps to know that both are evidence-based, FDA-cleared treatments, and they work in completely different ways. Medication adjusts brain chemistry from the inside. TMS stimulates the brain directly with magnetic pulses. Neither is universally better. The right choice depends on your treatment history, the severity of your symptoms, how you tolerate side effects, and your own preferences, especially once you are dealing with treatment-resistant depression or trying to figure out what to do when antidepressants don't work. This article compares the two fairly, not to push one over the other.

How Antidepressants Work

Antidepressants change the availability of certain brain chemicals, mainly serotonin and norepinephrine, that influence mood. The most common are SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). Both are considered first-line treatment, meaning they are usually where a clinician starts.

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They are taken daily as a pill at home, and they work gradually. Most people need several weeks before the full effect shows, which is one of the harder parts of starting an antidepressant: you often have to wait to know whether it is working. Finding the right medication and dose regularly takes some trial and adjustment, and a first medication that does not help does not mean none will. There are many options within each class, so a clinician can switch or fine-tune based on how a person responds. Older tricyclic antidepressants (TCAs) also work but tend to cause harsher side effects, so they are usually reserved for later steps rather than first-line use. The main appeal of medication is convenience and evidence: it is taken at home, it is inexpensive, and it has decades of research behind it.

How TMS Works

Transcranial magnetic stimulation (TMS) is a non-invasive treatment that uses focused magnetic pulses, similar in strength to an MRI, to stimulate the mood-regulating areas of the brain that tend to be underactive in depression, mainly the left dorsolateral prefrontal cortex. It is FDA-cleared for major depressive disorder in adults, and also for OCD (NIMH, Brain Stimulation Therapies).

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TMS is not electroconvulsive therapy (ECT). There is no anesthesia and no sedation, and the patient stays fully awake through each session, then drives home and returns to normal activity. During a session, a coil rests against the scalp and delivers pulses in short cycles, which most people feel as a tapping sensation. A typical course runs about five days a week for several weeks, with each session lasting under an hour, and the benefit tends to build gradually across the course rather than after any single visit.

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As a non-drug option, TMS is one of the main alternatives to antidepressants for people whose medication has stopped short. It usually works best as part of a broader treatment plan, coordinated with therapy and, in many cases, ongoing medication, rather than as a replacement for all other care.

TMS vs Medication: Side-by-Side Comparison

The two treatments differ on almost every practical dimension, from how they are delivered to how quickly they work and what they ask of you day to day. The table below lays the key differences side by side, and the sections that follow unpack the two that matter most to people making this decision: side effects and success rates.

Factor Antidepressants TMS
How it works Adjusts brain chemistry (daily medication) Magnetic pulses stimulate mood-regulating brain areas
Schedule Daily pill, at home In-clinic sessions, about 5 days a week for several weeks
Onset Several weeks Often within a few weeks of the course
Common side effects Weight change, sexual dysfunction, fatigue, sleep changes Mild scalp discomfort or headache, usually fades after the first week
Effect on memory or cognition Varies by medication No known negative effect on memory or cognition
Best positioned for First-line, mild to moderate depression When medication has not worked or side effects are intolerable

Side Effects Compared

Antidepressant side effects vary by class. SSRIs commonly cause weight gain and sexual dysfunction, though some effects ease after the first few weeks. SNRIs have a similar profile that is often milder. TCAs tend to be harsher, which is why they are rarely a first choice. These are systemic effects, because the medication acts throughout the body.

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TMS side effects are usually mild and short-lived: scalp discomfort, headache, or lightheadedness that typically passes soon after a session and lessens over the first week. The most serious risk, seizure, is very rare. Because TMS is non-invasive and targeted rather than systemic, it avoids the weight, sexual, and sleep side effects associated with medication, and it does not affect memory or cognition the way some people fear based on older brain treatments like ECT.

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It is not side-effect-free, though, and its main practical downside is different in kind. Instead of a daily side effect, TMS asks for a time commitment: traveling to a clinic most weekdays for several weeks. For someone with a demanding schedule or limited transportation, that logistical cost is real and worth weighing against the appeal of avoiding medication side effects. Neither profile is automatically easier to live with; they are simply different, and which one fits depends on the person.

Success Rates: What the Research Shows

Both treatments help many people, and neither helps everyone. Reading the numbers honestly matters more than cheerleading for either one. Two terms come up often: response means a meaningful reduction in symptoms, usually cutting them roughly in half, while remission means symptoms largely resolve. Remission is the higher bar and the real goal.

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For medication, the landmark STAR*D study found that roughly a third of patients reached remission on their first SSRI (Trivedi et al., American Journal of Psychiatry, 2006). That is a genuinely useful result for many people. But it also means most did not remit on the first try, and STAR*D showed that with each additional medication tried after a failure, the odds of remission tend to drop while side-effect burden tends to rise. That diminishing return is exactly the situation that leads people to look at other options.

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For TMS, a large real-world registry of more than 5,000 patients found that most experienced measurable improvement, with response rates ranging from about 58% to 83% and remission from about 28% to 62%, depending on how outcomes were measured (Sackeim et al., Journal of Affective Disorders, 2020). The wide ranges are worth noting: they reflect different rating scales and patient groups, and many of those patients were also taking medication, so the numbers describe TMS in real-world use rather than in isolation.

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For treatment-resistant depression specifically, a 2024 randomized trial compared TMS with switching or augmenting medication in 89 people who had not responded to at least two antidepressants, with both groups also receiving psychotherapy. The TMS group had significantly higher response and remission rates than the medication group (Dalhuisen et al., American Journal of Psychiatry, 2024). It is one of the clearest head-to-head comparisons available, though individual results always vary, and these figures describe groups, not guarantees for any one person.

When Antidepressants Don't Work: Where TMS Fits

About a third of people with major depressive disorder do not respond adequately to first-line treatment, a pattern clinicians call treatment-resistant depression. It is not a sign of personal failure or a rare edge case; it is common, and it has its own growing set of treatment options. When two or more medications have failed, or when side effects are intolerable, TMS becomes a well-supported next step, and the 2024 trial above is part of why it is increasingly positioned early in the treatment-resistant pathway rather than as a last resort.

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TMS is not the only option at this stage. Spravato (esketamine), a nasal spray derived from ketamine, is FDA-approved for treatment-resistant depression when used together with an oral antidepressant. It is given in a certified clinic under medical supervision, with monitoring after each dose, because of its dissociative effects. Combining TMS with an antidepressant is another route, and research suggests the combination can improve outcomes over medication alone. The larger point is that once first-line medication falls short, the path forward branches into several evidence-based options, and those branches are not mutually exclusive. A person might use medication and TMS together, or move from one approach to another as their psychiatrist learns what their brain responds to.

Who Is Each Treatment For?

Medication is often the right starting point for someone who is:

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  • Early in treatment for depression
  • Managing mild to moderate symptoms
  • Looking to avoid in-clinic visits
  • Someone who has responded well to an antidepressant before

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TMS is generally considered for someone who:

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  • Has tried multiple antidepressants without adequate relief
  • Cannot tolerate medication side effects
  • Prefers a non-drug approach
  • Has treatment-resistant depression

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Many people use both at different points, and some use them together. Where a person lands is a clinical decision, not a solo consumer choice, and it belongs with a psychiatrist who knows the full history.

Making the Decision With a Psychiatrist

TMS, medication, Spravato, and therapy are not competing products. They are tools a psychiatrist combines and adjusts based on diagnosis, history, and how a person responds over time. Comparing TMS and medication on paper is useful, but the decision is rarely either-or, and it is rarely one-and-done. It usually looks more like a sequence: start somewhere reasonable, measure the response, and adjust. The most reliable way to navigate that sequence, and to change course when needed, is a thorough evaluation within an integrated care setting, where the clinician managing your medication is the same one weighing whether TMS or another option fits.

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That is how care works at Amae Health. Our psychiatry-led teams evaluate the whole picture and coordinate treatment across medication, therapy, and procedures like TMS, which we offer at our Los Angeles clinic. You can explore our full range of treatments or, for severe depression that needs more structure, our Partial Hospitalization Program. Our resources for patients and families explain how integrated care works, and you can contact our team to ask about an evaluation.

Frequently Asked Questions

Is TMS better than medication for depression? Neither is universally better. Medication is first-line and works well for many people. For treatment-resistant depression, where two or more medications have failed, TMS often outperforms a medication switch. The right choice depends on history, severity, and side-effect tolerance.

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Can you do TMS and take antidepressants at the same time? Yes. TMS can be combined with antidepressants, and research suggests the combination can improve outcomes compared with medication alone. This should be coordinated by a psychiatrist.

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What are the side effects of TMS vs medication? TMS side effects are usually mild and short-lived, mainly scalp discomfort or headache that fades after the first week. Medication side effects vary but can include weight change, sexual dysfunction, and fatigue. Because it is non-invasive, TMS avoids the systemic side effects of medication.

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Does TMS work when antidepressants don't? Often, yes. TMS is specifically supported for treatment-resistant depression. A 2024 randomized trial found higher response and remission rates with TMS than with switching medications after failed trials. Individual results vary.

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How long does TMS treatment take? A typical course is sessions about five days a week for several weeks, each lasting under an hour. Antidepressants, by contrast, are taken daily and may take several weeks to show their full effect.

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What if neither TMS nor medication works? Other options exist, including Spravato (esketamine) used with an oral antidepressant, combination approaches, and structured programs like IOP or PHP for severe depression. A psychiatrist can help identify next steps. Depression is hard, and support is available: if you are struggling, call or text the 988 Suicide and Crisis Lifeline at 988, anytime.

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Citations

  1. Trivedi MH, Rush AJ, Wisniewski SR, et al. "Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D." American Journal of Psychiatry, 2006. psychiatryonline.org. Tier 1 (peer-reviewed).
  2. Sackeim HA, Aaronson ST, Carpenter LL, et al. "Clinical outcomes in a large registry of patients with major depressive disorder treated with transcranial magnetic stimulation." Journal of Affective Disorders, 2020. sciencedirect.com. Tier 1 (peer-reviewed).
  3. Dalhuisen I, van Oostrom I, Spijker J, et al. "rTMS as a Next Step in Antidepressant Nonresponders: A Randomized Comparison With Current Antidepressant Treatment Approaches." American Journal of Psychiatry, 2024. PubMed 39108161. Tier 1 (peer-reviewed RCT).
  4. National Institute of Mental Health, "Brain Stimulation Therapies." nimh.nih.gov. Tier 2 (U.S. government).

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Further reading (external resources): NIMH, Depression; Mayo Clinic, Transcranial Magnetic Stimulation.

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# min read

How Long Do TMS Results Last? Maintenance and Relapse

By

Sonia Garcia

|

October 10, 2026

Finishing a course of TMS and feeling like yourself again brings a new worry: will it hold? How long do TMS results last, and what happens if the depression comes back? The research is more encouraging than many people expect. Among people who respond to a course, roughly half to nearly two-thirds are still responding a year later, and when symptoms do return, restarting TMS brought back the improvement for most people in the research.

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None of that predicts any one person's course. It does show what tends to help results last, and why the months after treatment deserve a plan of their own.

What "Lasting" Means: Response vs. Remission

Two terms do most of the work in durability research. A person has responded when their depression scores fall by at least half on a standard rating scale. They're in remission when scores drop low enough that the depression is largely gone.

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Durability studies then ask a narrower question than the original trials did: of the people who responded or reached remission by the end of a course, how many were still doing well months later? That framing matters when you read the numbers. A result such as 62.5% of people keeping their response for a year describes people who had already responded, not everyone who started TMS. Those follow-up checks happen at set points, typically three, six, and 12 months after a course, so durability is reported as the share of people still responding at each checkpoint.

What the Research Shows About Durability

The most direct data come from a 2014 study in The Journal of Clinical Psychiatry that followed people with medication-resistant major depression for a year after they finished TMS at 42 U.S. clinical practices. Of the 257 people who completed a course and agreed to follow-up, 120 had responded or reached remission by the end of treatment. Of those 120, 75 (62.5%) kept meeting response criteria through the full 12 months.

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Two details shape that result. The study used a practical approach after the course: continued antidepressant medication, plus access to more TMS if symptoms returned. And over the year, 93 participants (36.2%) had TMS reintroduced at some point, averaging about 16 treatment days. So the 62.5% reflects TMS inside ongoing care, not a single course left to stand on its own.

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A 2019 meta-analysis in Brain Stimulation pooled 19 studies of people who had responded to a TMS course. About two-thirds were still responding at three months, about 53% at six months, and about 46% at one year. The authors' summary: roughly half of responders keep their response for up to a year after a successful course.

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Read together, the two studies give a realistic range of around half to nearly two-thirds of responders still doing well a year out. The other side of those numbers matters just as much. A meaningful share of people see symptoms return within the first year, and planning for that possibility is part of good care, not a sign that treatment failed.

Factors That Influence How Long Results Last

The research has identified a few patterns, mostly at the level of groups rather than individuals:

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  • Maintenance treatment. In the 2019 meta-analysis, studies that included maintenance treatment showed higher sustained response at some time points.
  • The mix of people studied. Studies with a higher proportion of women also showed higher sustained response, a group-level pattern that says nothing reliable about any one person.
  • Continued medication. The best-known durability results come from people who stayed on antidepressants after TMS, so those numbers describe that combination.
  • A completed course. Durability figures come from people who finished a full acute course. They don't describe what happens after a partial one.

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Clinicians also weigh a person's history when planning follow-up, such as how many depressive episodes they've had and how many treatments failed before TMS. The findings above don't establish how much those factors change the odds, so they inform a clinician's judgment rather than supply a number.

Maintenance TMS: What It Is and Who May Need It

TMS maintenance treatment means periodic sessions after the main course, scheduled to protect a response rather than to answer a relapse. Schedules vary between providers and between people, and no single schedule has become standard.

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The evidence supports the idea without settling the details. The 2019 meta-analysis found maintenance associated with more durable response, and its authors suggested maintenance be considered in practice and tested in future trials. That's a promising signal, not a proven protocol. Maintenance TMS is also separate from staying on medication: in both the year-long and six-month studies, people continued antidepressants whether or not they received more TMS.

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Not everyone needs it. Some people stay well for long stretches without it. Whether maintenance makes sense for a particular person is a judgment a psychiatrist makes from their history and how they're doing in the months after the course.

Can TMS Be Repeated If Symptoms Return?

Yes, and the research on restarting TMS is among the most reassuring parts of this topic. In a six-month study in Brain Stimulation, people whose depression had improved by at least a quarter with TMS stopped treatment gradually over three weeks while starting maintenance antidepressant medication. In that study, worsening had a specific meaning: a clinician-rated decline that held for two consecutive weeks, which triggered restarting TMS. Over the next 24 weeks, 38% had symptoms worsen enough to restart TMS, and 32 of those 38 people (84%) regained their improvement. Only 10% of the 99 people whose results were reported met the study's definition of relapse.

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A repeat course is different from maintenance. Maintenance is planned in advance to hold a response; a repeat course starts because symptoms have come back. In the year-long study described above, about a third of participants had TMS reintroduced at some point. Whether and when to restart is a decision made with a psychiatrist, based on how symptoms are changing.

What Helps Results Last Longer

Beyond maintenance and continued medication, two more things help, though neither promises that results will last for a particular person:

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  • Catching changes early. In the six-month study, regular assessments flagged worsening symptoms, and most people who restarted TMS at that point regained their improvement.
  • Staying connected to care. Therapy and regular psychiatric visits mean someone is watching for early changes between treatments.

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Knowing what returning depression tends to look like makes early changes easier to catch: shifts in sleep or appetite, lower energy, less interest in usual activities, and a low mood that lingers instead of lifting after a few days. When those signs show up, reaching out sooner gives a care team more options, and our guide on how to ask for help when depressed covers how to start that conversation.

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These describe what research associates with better long-term results in groups of patients. They aren't instructions for any one person's treatment plan; that's a psychiatrist's call, made with the whole history in view.

Talking to a Psychiatrist About a Long-Term Plan

A TMS course is the start of a plan, not the end of one. The months afterward are when follow-up, medication decisions, and a clear plan for what happens if symptoms return matter most.

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At Amae, TMS sits inside our integrated care model, where psychiatric care, therapy, primary care, and peer support stay linked after the course ends. We provide TMS therapy for major depressive disorder at our Los Angeles clinic and at our Bay Area clinics in Los Altos and San Mateo. Commercial insurance plans and cash pay are both accepted, and our intake team handles prior authorization. To map out what comes after a course, talk with an Amae psychiatrist about a long-term plan. Anyone in crisis can reach the 988 Suicide and Crisis Lifeline by call or text.

Frequently Asked Questions

How long do TMS results typically last?

For many people, months to a year or longer, though it varies. In a year-long study of people who responded to TMS, 62.5% kept meeting response criteria for the full 12 months. A 2019 meta-analysis found that about half of responders were still responding at one year.

What percentage of people relapse after TMS?

Some return of symptoms within a year is common. In the 2019 meta-analysis, roughly half of responders were no longer responding at one year. That isn't always a full relapse: in a six-month study, 38% had symptoms worsen enough to restart TMS, while 10% met the study's definition of relapse.

Can TMS be repeated if depression comes back?

Yes. In a six-month study, 84% of people whose symptoms worsened regained their improvement when TMS was restarted. A repeat course is different from ongoing maintenance sessions, and the decision is made with a psychiatrist based on individual history.

Do I need maintenance TMS sessions after my initial course?

Not necessarily. Some people stay well without them, and there is no standard maintenance schedule across providers. Research links maintenance with longer-lasting response, so whether it fits is a decision a psychiatrist makes based on your response and how closely symptoms are being monitored.

What can help TMS results last longer?

The research points to planned follow-up, continued medication when it's part of the plan, and catching symptom changes early. These are general findings from groups of patients, not instructions for any one person's treatment.

Is maintenance TMS covered by insurance?

It depends on the insurer and on whether sessions are billed as maintenance or as a new course for returning symptoms, since coverage can differ between the two. Ask the provider to verify benefits with your insurer before sessions begin.

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Citations

  1. Dunner DL, Aaronson ST, Sackeim HA, et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1-year follow-up period. Journal of Clinical Psychiatry. 2014;75(12):1394-1401. https://pubmed.ncbi.nlm.nih.gov/25271871/
  2. Senova S, Cotovio G, Pascual-Leone A, Oliveira-Maia AJ. Durability of antidepressant response to repetitive transcranial magnetic stimulation: systematic review and meta-analysis. Brain Stimulation. 2019;12(1):119-128. https://pubmed.ncbi.nlm.nih.gov/30344109/
  3. Janicak PG, Nahas Z, Lisanby SH, et al. Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study. Brain Stimulation. 2010;3(4):187-199. https://pubmed.ncbi.nlm.nih.gov/20965447/
  4. 988 Suicide and Crisis Lifeline. https://988lifeline.org

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