By Joy Stephenson-Laws, Holistic Coach, J.D., Founder

If you've ever sought treatment for depression, you might have hit a frustrating roadblock: your insurance company insisting you try multiple antidepressants before they'll cover other treatments. This practice, called "step therapy" (or less kindly, "fail-first"), can feel like a bureaucratic nightmare when you're already struggling.

But here's the thing—sometimes this policy makes sense, and sometimes it doesn't. Let's dive into why this happens, when it works, when it backfires, and what we can do about it.

First Things First: What Exactly is TMS?

Think of Transcranial Magnetic Stimulation (TMS) as a gentle "reboot" for your brain. No surgery, no anesthesia—just a magnetic coil placed against your head that sends pulses to wake up the parts of your brain that depression has put to sleep.

Here's what a typical TMS experience looks like:

You sit in a chair (like at the dentist, but more comfortable)
A technician places a magnetic coil against your scalp
You'll feel tapping sensations for about 20-40 minutes
You do this 5 days a week for 4-6 weeks
Then you go about your day—you can even drive yourself home

The Good News About TMS:

No pills means no weight gain, no "bedroom problems," no feeling like a zombie
About 50-60% of people who haven't been helped by medications see real improvement
Side effects? Usually just a mild headache or scalp discomfort (think tension headache, not migraine)

The Not-So-Great Parts:

It's a big time commitment—imagine going to the gym every weekday for over a month
It doesn't work for everyone (about 40-50% don't see significant improvement)
You can't do it if you have certain metal implants or seizure disorders
Finding a TMS center in rural areas? Good luck
The sticker shock: $10,000-15,000 (though insurance often covers it... eventually)
Some people need "booster" sessions to maintain improvements

How Do Antidepressants Stack Up?

Antidepressants work more like adjusting your brain's chemical soup—adding a bit more serotonin here, some norepinephrine there. They're the go-to first treatment for good reasons:

Why Doctors Reach for the Prescription Pad:

They work well for many people—about half see real improvement with the first medication
Once you find the right one, it's just a daily pill
Generic versions cost less than your morning coffee
Decades of research back them up
You can get them anywhere, even via telehealth

The Downsides We All Know:

The side effect roulette: weight gain, low libido, upset stomach, feeling emotionally "flat"
The waiting game: 4-8 weeks to know if it's working
The trial-and-error frustration: "Let's try this one... nope, how about this one..."
Some people feel worse before they feel better

Real People, Real Stories

Let me share some actual cases (with names changed) that show both sides of this story:

When Pills Work Great: Sarah, 28, was dealing with her first bout of depression after a tough breakup and job loss. Her doctor prescribed Zoloft. She had some nausea the first week (crackers became her best friend), but after six weeks, she felt like herself again. Two years later, she's still doing well. For Sarah, step therapy wasn't a barrier—it was the right path.

When Waiting for TMS Was Torture: Lisa, 48, tried four different antidepressants over two years. Each one either didn't work or made her feel worse. By the time insurance finally approved TMS, she'd lost her job and withdrawn from friends. TMS gave her a 60% improvement in just four weeks. She went back to work and started living again—but those two years of "failing first"? They took a real toll.

When Special Circumstances Matter: Maria, 34, developed severe postpartum depression. Antidepressants made her feel disconnected from her baby—the opposite of what she needed. When she finally got TMS, her mood improved without that emotional numbing. She could bond with her infant and return to work part-time.

Why Do Insurance Companies Do This?

Let's be fair and look at their reasoning:

1. The Numbers Game

Generic antidepressants: $10-50/month. TMS: $10,000+. When you're insuring millions of people, that math matters. And honestly? For many people, the cheaper option works just fine.

2. Following the Science

Most medical guidelines say "try medications first" because we have 60+ years of data on them. TMS is newer (FDA approved in 2008), and most studies focus on people who've already tried pills.

3. Making Sure TMS Goes to Those Who Need It Most

Not everyone who's depressed needs TMS. By requiring medication trials first, insurers argue they're ensuring this resource goes to people who truly can't be helped by simpler treatments.

4. The One-Size-Fits-All Problem

Insurance companies love standardization. It's easier to have one rule for everyone than to evaluate each case individually. But depression isn't a one-size-fits-all illness.

When Step Therapy Makes Sense (Yes, Really)

First-time depression: If you've never tried treatment before, medications often work well
Mild to moderate symptoms: Pills can be very effective here
You prefer trying medication: Some people want the convenience of pills
No access to TMS: If the nearest center is 3 hours away, daily treatment isn't realistic
Cost concerns: If insurance won't budge and you can't afford TMS out-of-pocket

When Step Therapy Can Be Harmful

You're in crisis: Severe depression with suicide risk can't wait months for trial-and-error
You've been down this road: Previous episodes where multiple meds failed
Special populations: Pregnant women, seniors on multiple medications, people with substance use history
Intolerable side effects: When medications make you so miserable you stop taking them
Quality of life: When side effects (like sexual dysfunction) damage your relationships

The Hidden Costs Nobody Talks About

Insurance companies focus on medication costs vs. TMS costs. But what about:

Emergency room visits when depression becomes unbearable
Psychiatric hospitalizations
Lost wages from missing work
Relationship counseling when depression strains marriages
The domino effect on physical health
The risk that acute depression becomes chronic and harder to treat

When you factor these in, making someone wait months or years for effective treatment doesn't seem so cost-effective anymore.

So What's the Solution?

We need a middle ground that respects both good medicine and individual needs:

1. Flexible Rules

Give doctors power to override step therapy when:

Patients have documented medication intolerances
Previous episodes show medication failure patterns
Special circumstances exist (pregnancy, drug interactions, etc.)

2. Smarter Matching

Use genetic testing and biomarkers to predict who'll respond to what. Why guess when science can guide us?

3. Creative Combinations

Sometimes low-dose medications plus TMS work better than either alone. Let's study and support these approaches.

4. Look at Total Costs

Judge treatments by total healthcare costs and quality of life, not just prescription prices.

5. Improve Access

Regional TMS centers for rural areas
Intensive TMS protocols that work faster
Telemedicine support between sessions
Clear, fair criteria for who qualifies

6. Track What Works

Collect real-world data on outcomes. Use it to refine guidelines based on what actually helps people, not just what's cheapest upfront.

The Bottom Line

Here's what it comes down to: both antidepressants and TMS are valuable tools for treating depression. For many people, medications work wonderfully. For others, TMS is life-changing. The problem isn't the treatments—it's rigid policies that force everyone down the same path.

What we need is a system that:

Recognizes that different people need different treatments
Lets doctors use their judgment
Considers total well-being, not just drug costs
Speeds access to TMS when it's clearly needed
Continues researching what works best for whom

Depression is hard enough without having to fight insurance companies for appropriate treatment. Whether someone needs antidepressants, TMS, or both, they should get the right treatment at the right time—not after months of unnecessary suffering.

The goal isn't to bash medications or oversell TMS. It's to ensure that when you're drowning in depression, you get thrown the right life preserver—not forced to try three wrong ones first while you struggle to stay afloat.

References:

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Bousman, C.A., et al. (2023). Pharmacogenetic tests and depressive symptom remission: a meta-analysis of randomized controlled trials. Pharmacogenomics, 24(1), 37-48.

Carpenter, L.L., et al. (2012). Transcranial magnetic stimulation (TMS) for major depression: A multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety, 29(7), 587-596.

Carpenter, L.L., et al. (2021). rTMS with a two-coil array: Safety and efficacy for treatment resistant major depressive disorder. Brain Stimulation, 14(5), 1112-1119.

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TMS vs Antidepressants for Depression: Insurance Coverage, Costs, and Treatment Options Explained