Curious about transcranial magnetic stimulation (TMS) therapy for depression? Guadalupe Gabba, PMHNP and Director of TMS at Evolve Health, breaks down how TMS works, what the experience is like, and why it might be more effective than people think. Whether you’re considering TMS or just want to understand it better, this expert perspective walks you through everything you need to know.
Guadalupe Gabba, Director of TMS at Evolve Health.
My name is Guadalupe Gabba, I am a psychiatric mental health nurse practitioner, and I am currently the Director of TMS for Evolve Health.
I’ve been a nurse for 33 years. I started out in geriatrics for the first two years, then moved into emergency room trauma and ICU, where I worked for about 13 to 15 years. After that, I decided to go back to school for nursing education but ended up switching into psychiatric nursing.
As an ER nurse 25 years ago, I saw so many patients who needed psychiatric care but weren’t getting it. Mental health is never well treated in the ER—it’s just not the right setting for it. Seeing that as a young nurse—watching patients suffer and not get the help they needed—it really stuck with me. I felt like, yeah, that’s something I want to do. And once I got into psych nursing, I absolutely loved it.
Basically, we’re using an electromagnetic field to generate a mild stimulus in specific parts of the brain to reactivate neural pathways and restart communication. Your brain kind of works like a relay system, so we’re just helping it get back online.
That’s a great question. One of the debates right now is whether we should be using TMS earlier in a patient’s illness progression.
Currently, the way insurance allows us to use it, TMS is considered a second-, third-, or even fourth-tier treatment—only after someone hasn’t responded to multiple other treatments. But if we could use it sooner, like when someone is just starting to feel more withdrawn or isolated, that would be ideal.
So, a “good candidate” is technically someone with depression who’s tried at least two medications and not had a good response or gone into remission. But by that time, they’ve already lost out on so many parts of their life. Ideally, we’d be using it earlier for anyone starting to show symptoms.
At Evolve Health, we offer TMS, SPRAVATO®, and IV ketamine. Of course, I’m the TMS person, so I love TMS. But it really depends on what the patient needs and can tolerate at the time.
If someone’s acutely sick, like experiencing intense suicidal ideation, we might choose a different option. But for someone feeling cognitively slow, foggy-headed, not functioning well, but without immediate safety concerns, I’d often recommend TMS. It’s short—just 18 and a half minutes per session. It doesn’t impair your ability to drive, so you can come and go from the clinic yourself. And it has long-lasting results. Some patients see improvements that last six months to a couple of years.
It also depends on practical things: Can the patient drive themselves to the clinic every day for six weeks? Can they afford the co-pays? The medical system complicates things. Otherwise, I’d say anyone with depression should be doing TMS.
It can be uncomfortable—but not intolerable. People describe it like a woodpecker tapping on the side of their head. So yeah, it’s not exactly comfortable. But over the first week, most people say they don’t notice it anymore.
Your brain naturally pays attention to things that are new or uncomfortable, and then it learns, like “Okay, this isn’t hurting me.” I’ve never had anyone stop treatment because it was too painful. Some have stopped for other reasons, but not because of the discomfort from the stimulation itself.
The biggest side effect is that local discomfort—and it’s temporary. The other most common one is a mild headache, which usually goes away within an hour or two with some Tylenol or Advil, and tends to fade within a week or two of starting treatment.
Beyond that, the side effects are mostly positive—improved function, improved cognition. Pretty quickly, people start saying they’re thinking more clearly and processing things faster. That’s probably my favorite side effect to hear about. Some people also report improved sleep, though for others it might cause decreased sleep or a bit of increased anxiety at first.
There’s a small risk of seizure, but it’s extremely rare. It’s something people hear about that sounds scary, but the risk is less than 0.01% for most people.
TMS isn’t a quick fix. The benefits are durable—they can last a long time—but the effects take time to show up. It usually takes two to four weeks to start noticing a difference, and for some people, not until the very end of treatment.
TMS is 36 sessions, five days a week. So, it could be six or seven weeks before someone really starts feeling better. But we’ve seen some amazing outcomes by the end.
We’ve had patients say, “I don’t feel anything,” and then a few weeks later they’re like, “I’m not suicidal anymore. My depression scores are way down. I feel great.” So yeah, it takes time, but it’s worth it.
Evolve Health TMS treatment chair.
I mentioned the cognitive piece. People start processing information more easily, making decisions, finding words without struggling. You can just see their brain waking up.
One of my favorite things is when someone says, “I woke up and noticed the sky was blue, and I could hear the birds singing.” Of course, the sky has always been blue, and the birds have always been singing, but now they can finally notice it again. Watching people reconnect with life like that is really beautiful.
TMS—transcranial magnetic stimulation—often gets confused with electroconvulsive therapy, which is a good treatment. I’ve seen it save lives. But it’s not the same thing. With ECT, you’re put to sleep, given medications to sedate you, and there can be memory issues.
TMS is not that. You’re awake the whole time, sitting in a chair. You can even chat with the technicians during your session.
Another thing people say is, “It’s such a huge time commitment.” It is and it isn’t—TMS is 18 and a half minutes a day, five days a week, for 36 sessions. But when you think about all the years you may have already lost to depression? Six weeks of treatment that you can drive yourself to, then go back to work after seems pretty doable.
Insurance kind of treats it that way. So, in a way, yes—it tends to come after someone has tried and not responded to at least two medications. Some insurance plans require even more than that.
We do offer out-of-pocket treatment, so if someone wants to start TMS earlier, we’re open to that. But unfortunately, the way the system is set up, it often becomes a “last resort.” Which is frustrating, because I think we’d get better results if we could start people on it sooner.
Come in and talk to us. We get a lot of people who are unsure. When you come in for an evaluation, I’ll show you the machine. Sometimes we even let people experience the stimulation on their hand. And usually, once they’ve seen it and felt it, they say, “Oh, that was no big deal at all.”
I think it’s just the fear of the unknown. TMS has been around since the early 1980s and used in all kinds of diagnostic procedures. It’s been FDA-approved for depression since 2009. So, it’s not new—it’s just not as widely known as it should be.
It comes down to different protocols. We’re targeting different areas of the brain, using different pulse patterns depending on whether we’re trying to slow something down or speed something up. Basically, we’re retraining the brain to work in healthier ways.
We’re trying to interrupt cognitive patterns and help people form new loops—new ways of thinking. Therapy helps reinforce that. But with TMS, we’re using electromagnetic pulses to stimulate those changes in brain activity.
I was just talking to a doctor from New York who’s doing research on using TMS for Alzheimer’s. We’re also seeing it used for stroke recovery, pain management (it’s now FDA-approved for that), OCD, and smoking cessation. PTSD is coming. It’s already used for depression in teens and older adults. It’s being used for head injury recovery and even for managing hallucinations in schizophrenia. It’s being explored for anxiety, too.
There are so many applications coming. It’s non-invasive, it doesn’t have significant side effects, and it works.
For depression alone, we’re seeing up to 75% remission rates. Honestly, I could stay up all night reading the literature and about all the indications and the ways that we can use this. It’s pretty exciting.
Live in Oregon and wondering if TMS, SPRAVATO®, or IV ketamine could help? Reach out to us for a consultation. Our team will connect with you directly to explore your options.
Evolve Health is an outpatient mental health clinic specializing in treating patients with major depressive disorder and treatment-resistant depression with Spravato (esketamine) nasal spray, and ketamine infusions. We are a team of medical providers who are excited to offer a refreshing, innovative approach to medicine. We work collaboratively with your existing treatment team. Our philosophy redefines the healing experience with cutting-edge science and wellness practices.
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