Why Some Patients Need Multiple TMS Courses

Ashley Keays • March 30, 2026

Transcranial magnetic stimulation (TMS) is a proven, FDA-approved treatment for conditions like treatment-resistant depression and OCD - and for many patients, a single course of TMS delivers meaningful, lasting relief. But for others, the journey looks a little different. Some patients benefit from a second course of TMS, periodic booster sessions, or an ongoing maintenance plan to sustain their results over time.


If you've completed TMS and are wondering what comes next - or if your clinician has mentioned the possibility of additional treatment - this guide will help you understand why repeat courses happen, how decisions about further treatment are made, and what maintenance TMS can look like in practice.



What Is a TMS Course, and How Does It Typically Work?


A standard course of TMS at Creative Wellness typically involves daily sessions, five days a week, over four to six weeks. Each session lasts approximately 20 minutes. During treatment, magnetic pulses are precisely delivered to areas of the brain associated with mood regulation, gradually encouraging healthier neural activity.


Many patients begin noticing improvements within the first few weeks, and results often continue to develop after the course concludes. For a significant proportion of patients, this initial course produces sustained symptom relief - sometimes for a year or more.


However, TMS is not a one-size-fits-all treatment. The brain is complex, mental health conditions vary enormously between individuals, and factors like the severity of symptoms, prior treatment history, and the presence of other conditions all influence how someone responds to TMS.




Why Some Patients Benefit From More Than One Course



The need for additional TMS treatment doesn't mean the first course failed - in most cases, it means the opposite. Here are the most common reasons a patient might return for further TMS:


1. Symptom Recurrence Over Time


Conditions like treatment-resistant depression are chronic for many people. Even when TMS produces an excellent initial response, symptoms can return over time - particularly during periods of heightened stress, major life changes, or seasonal shifts. This is not unique to TMS; it reflects the nature of the underlying condition.


In these cases, a repeat course of TMS can effectively re-establish the neural changes that reduced symptoms in the first place. Research suggests that patients who have responded well to TMS previously are likely to respond well again.


2. Partial Response to the Initial Course


Some patients experience meaningful improvement during their first TMS course but don't achieve full remission. This partial response is still clinically significant - and it often means the brain is showing signs of neuroplasticity that a second course can build upon.


In these situations, a clinician may recommend adjusting the treatment protocol — including targeting different brain regions, modifying the frequency or intensity of pulses, or extending the overall course length — to optimize outcomes.


3. Complex or Comorbid Conditions


Patients managing multiple mental health conditions - such as depression alongside PTSD, OCD, or anxiety - often have more complex treatment needs. TMS may need to be applied across different brain regions or protocols to address overlapping symptoms, which can mean a longer or more phased treatment journey.


4. Medication Changes or Life Stressors


Significant changes to a medication regimen, a major health event, or a sustained period of stress can sometimes destabilize progress. TMS can play a stabilizing role during these periods, either through a short booster series or a more structured maintenance plan.

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How Clinicians Decide Whether Additional TMS Is Appropriate


The decision to recommend further TMS is never made arbitrarily. At Creative Wellness, our clinicians take a thorough, individualized approach to evaluating whether additional treatment is in your best interest.


Key factors considered include:


  • Degree of symptom response: How much did your symptoms improve, and how well have those improvements held over time?


  • Duration of remission: How long did your improvement last before symptoms began to return?


  • Current symptom severity: Are symptoms mildly creeping back, or is there a significant relapse requiring prompt intervention?



  • Patient goals and preferences: What are you hoping to achieve, and what level of commitment is realistic for your schedule and lifestyle?


This evaluation is a collaborative process. Your clinician will never push additional treatment for its own sake - the goal is always to ensure that any recommended course of action is grounded in your clinical picture and personal circumstances.




Understanding Maintenance TMS


Maintenance TMS refers to a less intensive, ongoing schedule of TMS sessions designed to preserve the gains made during a full treatment course. Rather than five sessions per week, maintenance might look like one session per week, fortnightly, or monthly - tailored to what keeps your symptoms at bay.


Think of it similarly to how some patients with chronic depression continue low-dose medication even when feeling well - not because they're unwell, but because sustained support helps prevent a return of symptoms.


Maintenance TMS is particularly worth considering for patients who:


  • Have a history of recurrent depressive episodes
  • Responded very well to TMS but have experienced symptom recurrence after previous courses
  • Prefer to reduce or avoid long-term medication reliance
  • Have a lifestyle or occupational profile that makes sustained well-being particularly important


Your clinician will work with you to design a maintenance schedule that fits your life - and will reassess regularly to make sure it's still the right approach.

Interested in learning more?


Schedule a consultation to see if TMS could be right for you.

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What the Research Says About Repeat TMS


The evidence base for repeat and maintenance TMS is growing. Studies consistently show that patients who respond to an initial TMS course and then receive a repeat course following relapse show similar - and in some cases better - outcomes than their first course. This aligns with what we understand about neuroplasticity: the brain's capacity for change doesn't simply 'switch off' after the first round of treatment.


Maintenance protocols are also increasingly well-supported, with evidence suggesting that patients on structured maintenance programs experience fewer relapses and longer periods of wellness compared to those who stop TMS entirely after a single course.



TMS as Part of a Broader Care Plan


At Creative Wellness, we believe in a whole-person approach to mental health. TMS - whether it's a first course, a repeat course, or maintenance sessions - is rarely the only tool in play. Our clinicians regularly coordinate TMS care alongside:


  • Medication management: Carefully monitored psychiatric medication can complement TMS and help stabilize outcomes between courses.


  • Counseling and therapy: Evidence-based therapies like CBT build coping skills and emotional resilience that support and sustain TMS outcomes.



This integrated approach means that your TMS clinician isn't working in isolation - they're part of a team that considers the full picture of your mental health.




What to Expect If You're Considering a Second Course


If you've completed TMS and are noticing symptoms returning, or if you feel like you gained some benefit but not quite enough, the first step is to speak with your clinician. There's no pressure to commit to anything immediately - the conversation itself is informative and valuable.


A follow-up evaluation will typically involve:


  • Reviewing your symptom history since completing TMS
  • Assessing your current symptom severity using validated clinical tools
  • Reviewing any changes to your medication or other treatments
  • Discussing your schedule, insurance, and practical considerations
  • Talking through what a new course or maintenance plan would look like specifically for you


For patients who have completed a TMS course, the process is often quicker to navigate - your clinician already has a strong understanding of how your brain responds to treatment.

  • Does needing a second course of TMS mean the first one didn’t work?

    Not at all. In most cases, the need for a repeat course actually reflects a strong previous response — the brain responded well to TMS, and a second course is simply reinforcing those changes. Conditions like treatment-resistant depression are often chronic, and returning for additional treatment is a normal, evidence-based part of long-term care for many patients.


  • How often would I need to come in for maintenance TMS sessions?

    Maintenance schedules vary from patient to patient and are built around what works for you. Some patients come in once a week, others fortnightly or monthly. Your clinician will assess your symptom history and response over time and adjust the schedule accordingly - the goal is the lightest touch that keeps you well.

  • Will my insurance cover a second course of TMS?

    Coverage for repeat TMS courses depends on your individual insurance plan and the clinical documentation supporting the need for further treatment. Many insurers do cover additional courses where there is clear clinical justification. Our team at Creative Wellness has extensive experience navigating insurance approvals and will work with you to understand your options and prepare the necessary documentation.


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CBT for Adult ADHD: How Therapy Helps Where Medication Falls Short

By Ashley Keays • June 26, 2026
Quick Answer : CBT (cognitive behavioral therapy) for adult ADHD is structured, skills-based talk therapy that targets the daily problems ADHD actually creates - time management, organization, follow-through, and the self-critical thinking that piles up over years. Medication can turn up focus and dial down impulsivity, but it doesn't teach those skills. For many adults, the two work best together. If you've started medication for ADHD and found that you can focus better but still can't seem to get the laundry folded, answer that email, or stop calling yourself lazy, you're not doing it wrong. Medication and therapy solve different parts of the problem. This post covers what CBT for adult ADHD targets, why a pill alone often isn't the whole answer, and how the two fit together. What medication does well - and what it doesn't For a lot of adults, ADHD medication is genuinely useful. It can reduce the core symptoms: the wandering attention, the restlessness, the impulsive decisions. When it works, the volume on those symptoms comes down. But medication doesn't teach skills. It won't build you a system for tracking deadlines, break the habit of starting five things and finishing none, or undo years of believing you're the problem. Those are learned patterns, and learned patterns respond to practice, not chemistry. That gap - between "I can focus now" and "I still don't know how to run my life" - is exactly where CBT comes in. This isn't an argument against medication. Many people do best with both. It's just that they're built to do different jobs. What CBT for adult ADHD actually targets Regular talk therapy often explores feelings and history. CBT for ADHD is more practical and present-focused. It works on the specific ways ADHD shows up in your week. Executive function and the daily logistics This is the heart of it. ADHD makes the "managing yourself" tasks harder: planning, prioritizing, starting boring-but-important things, keeping track of time, and following through. CBT for ADHD builds concrete tools for these - external systems for memory and deadlines, ways to break overwhelming tasks into startable pieces, and routines that don't rely on willpower you can't summon on demand. The goal is structure that works with an ADHD brain instead of fighting it. The thought patterns ADHD leaves behind Most adults with ADHD have spent years missing deadlines, losing things, and being told to "just try harder." That leaves a mark. A lot of people arrive with a running internal monologue - I'm lazy, I'm careless, something's wrong with me — that isn't accurate but feels like fact. The "cognitive" part of CBT is about catching those thoughts, testing them against reality, and replacing them with something truer and more useful. This matters because the shame and the symptoms feed each other. Emotional regulation and sensitivity to criticism ADHD isn't only about attention. Many adults also struggle with intense, fast-moving emotions and a strong reaction to perceived criticism or rejection. CBT can help you notice the spike sooner and respond instead of react, which tends to ease the friction in relationships and at work.
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Therapy in Olympia: Finding the Right Counselor for What You're Going Through

By Ashley Keays • June 26, 2026
Quick Answer: Finding the right therapist in Olympia comes down to matching three things: the kind of help you need (individual, couples, or family work), a therapist whose style and experience fit your situation, and the practical details - location, availability, cost, and whether they take your insurance. This guide walks through how to weigh each of those so you book with someone who's actually a good fit, not just the first name that comes up. Choosing a counselor can feel like one more hard decision at a time when you're already low on energy. The good news is that "the right therapist" isn't a single perfect person you have to hunt down. It's about a reasonable fit on a few specific things, and most of those you can sort out in a phone call or a first session. Here's how to narrow it down. Start with what you're actually looking for Before you compare therapists, get clear on the problem you want help with. "I've been anxious and can't sleep" points somewhere different than "my partner and I keep having the same fight." That clarity makes every later step easier. A few useful distinctions: Individual therapy - for things you're carrying yourself: depression, anxiety, grief, trauma, life transitions, self-esteem, or feeling stuck. Couples therapy - for the relationship itself: communication, recurring conflict, trust, or rebuilding connection. Family therapy - for patterns involving parents, kids, or the household as a whole. You don't need a diagnosis or a perfect description to start. But knowing roughly which category you're in helps you filter quickly, since not every therapist does all three. Types of therapy - and why fit usually matters more You'll see a lot of acronyms when you search: CBT, DBT, EFT, solution-focused, and more. They're real, and they matter, but for most people, the therapist matters more than the method. A quick orientation: Cognitive Behavioral Therapy (CBT) focuses on the link between thoughts, feelings, and behavior, and on changing unhelpful patterns. It's practical and often shorter-term. Solution-focused work zeroes in on the specific change you want and the steps to get there, rather than spending months on backstory. Couples and family approaches look at the patterns between people - how a conversation goes sideways, who shuts down, what each person actually needs. At Creative Wellness, our therapists draw on evidence-based approaches like these and tailor them to your goals rather than forcing you into one method. If you're curious how a session is actually structured, our counseling and therapy page covers what to expect. Questions worth asking before you book A short phone consultation tells you a lot. Most reputable practices offer one. Things worth asking: Do you have experience with what I'm dealing with? Depression, trauma, and relationship conflict each call for different experience. Do you work with individuals, couples, or both? Make sure they cover your situation. What does a typical session look like with you? You're listening for an approach that sounds like something you could actually do. In person, virtual, or both? Decide what's realistic for your schedule. What's the cost, and do you take my insurance or offer self-pay? Get the real number before you commit. If a therapist can't or won't answer these clearly, that's useful information too. Contact us here
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Creative Wellness vs Other TMS Clinics in Washington

By Ashley Keays • June 4, 2026
Quick Answer: Many TMS clinics in Washington offer TMS and very little else. Creative Wellness offers TMS , Spravato, counseling, medication management, and genetic testing under one roof, across our three Washington locations. For most patients, that means fewer providers to coordinate, faster adjustments when something isn't working, and a treatment plan that can flex as their needs change. When you start researching TMS in Washington, you'll find a lot of clinics offering it. On the surface, they look similar - same FDA-approved technology, same general process, similar pitch. The differences are harder to spot from the outside. One of the biggest differences is also one of the easiest to miss: what happens if TMS alone isn't enough. The TMS-only model: what most clinics look like The standard model in Washington is a clinic that does TMS and not much else. Maybe a consultation, maybe Spravato, but the core offering is the TMS course. For patients who respond well to TMS alone, this model works fine. You come in, you do your sessions, you finish your course, you feel better. The problems start when one of these is true: TMS doesn't work as well as hoped. Roughly half of TMS patients respond strongly. Others see partial improvement. Some need a different combination of treatments to get all the way there. You need medication adjustments during or after TMS. Many patients are on antidepressants when they start. The right next step is sometimes a tweak - but who handles that? Therapy would help alongside TMS. Research consistently shows therapy and TMS work better together for many conditions. But your TMS clinic doesn't offer therapy. A different treatment turns out to be a better fit. Sometimes the original plan needs to change — to Spravato, to medication management, to therapy, or to a combination. At a TMS-only clinic, the answer is the same in every scenario: "you'll need to see someone else for that." That means new referrals, new wait times, new intake paperwork, new providers who don't know your history. The Creative Wellness model: services that work together Creative Wellness offers TMS, but we also offer: Counseling and therapy - individual, couples, and family Spravato (esketamine) - for treatment-resistant depression Medication management - full psychiatric prescribing and monitoring Genetic testing- to guide medication choices through Tempus NeuroPsych TMS for teens (15 and up- the only FDA-approved use of TMS in adolescents, available through our NeuroStar device All of these are available through the same clinic, the same team, and the same patient file. That changes what happens when a treatment plan needs to shift.
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Couples Counseling in Olympia, WA: What to Expect and How to Get Started

By Ashley Keays • June 4, 2026
Quick Answer: Couples counseling at Creative Wellness in Olympia is led by Dr. David Simonsen, who has over 25 years of experience working with couples. Sessions are $180 for 60 minutes, available in person or by secure video, and focus on practical work - communication, conflict, trust, and shared goals - without fluff or judgment. Most couples don't come to counseling because everything is fine. They come because something has shifted - communication has gotten harder, the same arguments keep coming back, trust has been damaged, or they've drifted somewhere they didn't plan to be. Some couples are in crisis. Some just want to get back to feeling like a team. When couples counseling makes sense There isn't a single right moment to start. Some common reasons people get in touch: Communication has broken down. Conversations turn into arguments, or stop happening at all. One or both partners feel unheard. The same fight keeps coming back. You've talked about it. You've agreed to change. Nothing actually changes, and you're back in the same place a few weeks later. Trust has been damaged. Infidelity, dishonesty, broken commitments - and you're trying to decide if and how to rebuild. You feel like roommates, not partners. Physical and emotional connection has faded. You're going through the motions. A major life change is straining things. A new baby, a career change, an illness, a move, kids leaving home, retirement. Big transitions tend to expose cracks. You disagree on something fundamental. Money, parenting, intimacy, where to live, whether to stay together at all. You don't need to wait for things to be bad. Couples come for tune-ups too - to strengthen what's working and address small things before they become big ones.
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TMS Therapy Cost in Washington: A Real Breakdown With and Without Insurance

By Ashley Keays • June 4, 2026
Quick Answer: A full course of TMS at Creative Wellness is $5,000 for 36 sessions ($150 per session). With in-network insurance and a successful prior authorization, most patients pay a few hundred to around $1,000 out of pocket. Patients with high deductibles or partial coverage usually land somewhere between $1,000 and $3,000. Without insurance, expect roughly $4,000–$7,000 depending on extras. We do free benefits checks before you commit to anything. Money is one of the first questions people ask about TMS - and it's one of the hardest to get a straight answer on. List prices and out-of-pocket costs are different numbers. What insurance pays varies wildly between plans. And the "average cost" figures you'll find online don't tell you what you, specifically, are going to pay. What you're actually paying for A TMS bill isn't one line item. It bundles several things, and knowing what goes into it makes the final number make more sense. The treatment course itself - daily sessions, usually 30 to 36 in total, over four to six weeks. This is the biggest part of the bill. An initial psychiatric evaluation - your first appointment, $250, to confirm TMS is appropriate and safe for you. Motor-threshold mapping - a one-time clinical step at your first session that personalizes the treatment to your brain. It sets the dose and target. Medication management follow-ups during treatment - $150 per session, covering follow-ups, medication adjustments, and monitoring. Facility and technician time - the chair, the device, the staff running each session. Optional extras - Tempus NeuroPsych genetic testing consultation ($250, with the test itself billed separately by Tempus and generally covered by insurance), Spravato consults if you're combining treatments. Maintenance or booster sessions later on - sometimes recommended after a course wraps up, and sometimes billed separately. A full course at Creative Wellness is $5,000 for 36 sessions - $150 per session . Each session is valued the same whether it's a mapping session to create your personalized protocol or a full treatment session. Learn More: What to Expect How insurance changes the math in Washington Most major commercial insurers in Washington cover TMS for treatment-resistant depression. They generally also require a prior authorization, which is a formal request your clinic submits proving you meet their coverage criteria = usually a documented history of trying multiple antidepressants without enough relief. Each plan handles TMS differently - same insurer, different policies — so the only way to know your specific number is a benefits check. We see Regence often in our patient base, and TriWest covers TMS for military families and dependents (including teens 15+ since the October 2025 expansion). We do these for free, before you commit to anything. You'll get a clear estimate of what your plan covers, what your deductible looks like, and what you'd realistically owe. Any Questions? Contact Us

TMS for Bipolar Depression: What Patients in Washington Need to Know

By Ashley Keays • April 29, 2026
Bipolar disorder has two sides - the highs (mania) and the lows (depression). For most people, the lows are where they spend most of their time, and the lows are usually what does the most damage to work, relationships, and day-to-day life. They're also the harder side to treat. Most bipolar medications are aimed at the highs, and many people try one after another for years without finding something that holds. TMS - a treatment that uses gentle magnetic pulses to the brain - is giving some of these patients a real option. But bipolar depression is trickier than regular depression, so we want to be straight with you about what TMS can and can't do, what the research actually shows, and how treatment works if you decide to try it. Is TMS approved for bipolar depression? Not yet. Right now, TMS is officially approved by the FDA for regular (non-bipolar) depression, for OCD, and for teens aged 15 and up with regular depression. For bipolar depression, doctors use it "off-label" - meaning it's allowed and widely used, but it doesn't yet carry a formal FDA approval for that specific condition. There has been a big step forward, though. In 2020, the FDA gave the NeuroStar TMS device - the one we use at Creative Wellness - something called a Breakthrough Device Designation for bipolar depression. That's the FDA saying, in effect: "This looks promising enough that we want to help it move through the approval pipeline faster." It's not full approval yet. But it's nothing either. Does it actually work? There's growing evidence that TMS can ease symptoms of bipolar depression - enough that the FDA granted NeuroStar (the device we use) Breakthrough Device Designation in 2020 to formally evaluate it for this use. Results vary from person to person. Some people respond well, some don't. We don't promise outcomes. What we can say confidently is that TMS is well-tolerated and safe for people with bipolar depression, without the systemic side effects that come with most bipolar medications.  One important note: there's some evidence that TMS can occasionally trigger a manic episode in a small number of bipolar patients. It's rare, but real - which is why we monitor closely throughout treatment. Before starting, an accurate diagnosis matters. Some patients have been labelled bipolar when the diagnosis isn't entirely clear, and a careful review sometimes identifies regular (unipolar) depression as the better fit, which changes the treatment plan and what insurance will cover.
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TMS for First Responders in Washington State

By Ashley Keays • April 29, 2026
First responders carry something most people don't: the cumulative weight of traumatic events, repeated over years, absorbed as part of the job. The hypervigilance that keeps you sharp on a shift doesn't switch off when you go home. The images don't fade on schedule. Sleep gets harder. Reactions get bigger. Relationships get harder to hold onto. For many first responders, the symptoms build quietly for years before anyone names them. Some people call it burnout. Some call it stress. Clinically, it often meets the criteria for PTSD, treatment-resistant depression, or both. This post is about one treatment option that's increasingly being used for people in this situation: transcranial magnetic stimulation (TMS). This non-drug treatment works directly on the brain circuits driving these symptoms. Why first responders are at higher risk Working in emergency services is a recognised risk factor for PTSD . It sits alongside combat exposure, childhood trauma, and other situations where the brain gets pushed into survival mode repeatedly and struggles to come back down. Roughly 7 to 9% of people will experience PTSD at some point in their lifetime. For people in emergency services roles, the exposure is repeated and cumulative - it's not one big event but the tenth, the fiftieth, the hundredth. The math changes. One more thing to know: PTSD rarely travels alone. Roughly half of the people with PTSD also have depression. Anxiety, sleep problems, and substance use often come into the picture too. What might look like "just depression" or "just not sleeping well" is often something more layered. What's actually happening When you go through something life-threatening, your brain drops into a survival mode - hypervigilant, on edge, ready to react. Normally, once the danger passes, your brain returns to its usual state. With repeated or severe trauma, that reset doesn't fully happen. Certain pathways get stuck on high alert. The practical result is a brain that keeps sounding the alarm when there's no fire. That's the hypervigilance, the startle response, the inability to fully relax. It's not a character flaw or weakness. It's a biological pattern - and that means it's something that can be changed with the right treatment. What PTSD actually looks like The symptoms tend to fall into four groups: Intrusive thoughts - flashbacks, nightmares, distressing memories that show up without warning Negative mood and thinking - persistent fear, anger, guilt, or shame; feeling detached from people you used to feel close to; loss of interest in things you used to enjoy. Being constantly on edge - easily startled, struggling to sleep, trouble concentrating, irritability or aggression Avoidance - steering clear of anything that brings it back Any of these can make normal life harder - holding down a job, keeping relationships intact, making decisions, and getting proper rest. Left untreated, PTSD also raises the risk of depression, suicidal thoughts, and substance misuse. Will insurance cover it? It depends on the diagnosis and the insurer. For treatment-resistant depression, TMS is FDA-approved and covered by most plans when the paperwork supports it . For PTSD specifically, coverage is less consistent - some insurers approve it, others don't. When both are present, there's often a clear path to coverage through the depression diagnosis, with PTSD adjustments added during the same course. We check your coverage upfront and are straight with you about costs either way. No surprises.
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The Insurance Approval Process for TMS: What Happens Behind the Scenes

By Ashley Keays • March 31, 2026
For most patients, the insurance approval process for TMS is a black box. You submit information, wait, and eventually hear yes or no - often without a clear understanding of what happened in between or why the decision went the way it did. That lack of visibility is a problem because what happens behind the scenes matters. A well-prepared prior authorization submission significantly improves the likelihood of approval. A poorly documented one - or one that misses a specific insurer’s criteria - can result in a denial that takes weeks to appeal, delaying treatment the patient genuinely needs. Why TMS Requires Prior Authorization TMS is an FDA-approved treatment, but FDA approval and insurance coverage are entirely separate things. Insurers make their own coverage determinations based on their own clinical policies, which vary by provider and are updated periodically as the evidence base evolves. Most major insurers in Washington now cover TMS for treatment-resistant major depressive disorder, but they require prior authorization - a formal request from the treating clinic that demonstrates the patient meets their specific eligibility criteria before treatment begins. This is standard for any high-cost or specialist treatment, not unique to TMS. The keyword is “before.” Starting treatment without authorization in place is a significant financial risk. If coverage is denied after treatment has begun, the patient may be liable for the full cost. A clinic that allows this to happen is not doing its job. What Insurers Typically Require Each insurer has its own coverage policy, but most share a common set of core requirements. Understanding these in advance helps you arrive at your evaluation with the right history documented. Diagnosis T MS is covered fo r major depressive dis order (MDD) and, with some insurers, OCD . The diagnosis must be formally documented by a qualified clinician. Off-label uses - anxiety, PTSD, and others - are generally not covered, though this varies and is worth checking with your specific insurer. Prior medication trials Most insurers require documented evidence that the patient has tried and failed to respond to a minimum number of antidepressants - typically two to four, from different drug classes, at adequate doses and durations. “Failed to respond” means either no meaningful improvement or side effects that made the medication intolerable. This documentation needs to be specific: drug names, doses, duration, and outcome. Symptom severity Insurers typically require evidence of moderate to severe depression, usually demonstrated through a validated rating scale score. This is part of why the clinical evaluation matters - it generates the baseline data that supports the authorization request. Prior psychotherapy Some insurers also require documented evidence of prior psychotherapy, typically a course of CBT or equivalent. This requirement is not universal, but it appears in enough coverage policies that it is worth checking early. Medical necessity statement The treating clinician must provide a written statement explaining why TMS is medically necessary for this specific patient, given their history and current presentation. Vague or generic statements are a common reason for denials. The documentation needs to tell a clear, specific clinical story.
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Combining TMS With Therapy: Why CBT and ERP Improve Results

By Ashley Keays • March 31, 2026
TMS is often described as a standalone treatment - and it can be. But the research, and clinical experience, point consistently in the same direction: patients who combine TMS with evidence-based therapy tend to do better. Not marginally better. Meaningfully better, with stronger outcomes and longer-lasting results. This article explains why that is, how CBT and ERP specifically complement what TMS does neurologically, and how care coordination works in practice when you’re receiving both treatments - whether from Creative Wellness directly or from an external therapy provider. Why TMS and Therapy Target Different Things TMS works by delivering magnetic pulses to specific areas of the brain involved in mood regulation. For depression, the primary target is the left dorsolateral prefrontal cortex - a region that is typically underactive in people with major depressive disorder. Repeated stimulation over a course of treatment helps restore more normal activity patterns in these neural circuits. What TMS does not do is change how you think. It does not teach coping skills, restructure unhelpful thought patterns, or help you process experiences that may be contributing to your symptoms. That is what therapy does. This is not a limitation of TMS - it is simply a different mechanism. The two approaches address different dimensions of the same condition. TMS creates the neurological conditions for improvement; therapy builds the cognitive and behavioural skills to sustain it. Used together, each makes the other more effective. What Is CBT and Why Does It Pair Well With TMS? Cognitive Behavioural Therapy (CBT) is one of the most extensively researched psychological treatments available. It is based on the principle that thoughts, feelings, and behaviours are interconnected - and that changing unhelpful thought patterns can directly improve mood and reduce symptoms. In practice, CBT helps patients identify automatic negative thoughts (such as catastrophising, black-and-white thinking, or self-blame), examine their accuracy, and replace them with more balanced, realistic perspectives. It also addresses behavioural patterns - particularly avoidance and withdrawal - that tend to maintain and deepen depression. The pairing with TMS is logical. TMS can lift the neurological floor - reducing the severity of depressive symptoms enough for a patient to engage meaningfully in therapy. Many patients find that CBT feels impossible when they are at their lowest; the cognitive effort required is simply too great. TMS can change that. As brain activity normalises, the capacity to engage with and benefit from therapy increases. Conversely, the insights and skills developed in CBT help protect the gains made through TMS. Depression tends to recur, and one of the strongest predictors of relapse is the absence of coping skills when symptoms begin to return . CBT directly addresses this vulnerability.
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Genetic Testing and Medication Management: How It Improves Treatment Planning

By Ashley Keays • March 31, 2026
Finding the right antidepressant is, for many people, a frustrating process of trial and error. You try a medication, wait four to six weeks to assess whether it’s working, adjust the dose, manage side effects, and if it doesn’t work, start again with something else. For patients with treatment-resistant depression, this cycle can stretch across years. Pharmacogenetic testing - genetic testing applied to medication selection - is one of the more meaningful advances in psychiatric care precisely because it addresses this problem directly. At Creative Wellness TMS, we offer genetic testing as part of our integrated approach to treatment planning. This article explains what it is, how it works, and when it’s most useful alongside TMS and medication management. What Is Pharmacogenetic Testing? Pharmacogenetics is the study of how your genes affect your response to drugs. The same medication at the same dose can produce very different outcomes in different people - some respond well, some experience significant side effects , and some metabolize the drug so quickly or slowly that it never reaches a therapeutic level in the body. These differences are largely genetic. Variations in specific genes - particularly those governing liver enzymes responsible for drug metabolism - determine how your body processes psychiatric medications. By analyzing these genes, clinicians can make more informed decisions about which medications are likely to work for you, which are likely to cause problems, and at what dose. At Creative Wellness, the test examines 18 genes relevant to psychiatric medication response. It is completed across two appointments: a sample is collected at the first session, and results are reviewed with your clinician approximately two weeks later. Learn More: Genetic Testing Explained: Why We Offer It & What It Changes What the Results Actually Tell Your Clinician Genetic test results are typically presented in categories that reflect how your body is likely to process specific medications: Poor metabolizers process a drug more slowly than average, meaning standard doses can accumulate to levels that cause side effects. Rapid or ultrarapid metabolizers clear the drug too quickly for it to reach effective concentrations, which can explain why a medication appears not to work even at standard doses. Normal metabolizers fall within the expected range, meaning standard prescribing guidelines apply. This information is applied across the main classes of psychiatric medication - SSRIs, SNRIs, tricyclics, antipsychotics, mood stabilizers, and others. It tells your clinician which drugs from each class are likely to be well-tolerated and effective, which to approach with caution, and which to avoid. It is worth being clear about what the test does not do: it does not predict with certainty that a specific medication will work. Genetics is one factor among several - diagnosis, symptom profile, lifestyle, and other medications all play a role. But it substantially narrows the field and gives prescribing decisions a more solid foundation than symptom history alone.