TMS and Medication: How TMS Works With (or Without) Your Current Drugs

Quick Summary
- Most psychiatric meds can be continued through TMS, but certain drugs affect seizure risk or response and require review.
- Careful pre-treatment medication review, mapping, and collaboration with a psychiatrist are essential for safe and effective TMS.
- Augmentation strategies (e.g., ONE-D with D-cycloserine or a stimulant) may be used under strict psychiatric supervision and add monitoring requirements.
General principles
- Safety first. Screen for medications and medical conditions that increase seizure risk or interact with planned augmentation strategies. If seizure risk is elevated, weigh alternatives or modify the plan.
- Efficacy considerations. Some sedating medications (high-dose benzodiazepines) can blunt TMS response; consider minimizing sedative load when clinically safe.
- Individualize. Decisions to continue, taper, hold, or change medications should be individualized and documented in the psychiatry visit. Shared decision-making and informed consent are essential.
- Collaboration. The treating psychiatrist (or a TMS-trained prescriber) should make medication decisions in close communication with the TMS team; TMS clinics should require medication lists and med reconciliation at intake.
Medication Guidance
Generally continue
- SSRIs / SNRIs (e.g., sertraline, escitalopram, venlafaxine) - usually safe to keep during TMS; no routine stop required.
- Mood stabilizers (e.g., lithium) - generally continue; coordinate for bipolar cases.
Use with caution / consider adjustment
- Benzodiazepines (e.g., clonazepam, lorazepam) - may dampen response; consider minimizing dose if clinically safe.
- Antipsychotics (e.g., risperidone, olanzapine) - usually continue; clozapine needs special attention because of seizure risk.
Review & adjust if needed (seizure-risk meds)
- Bupropion - dose-related seizure risk; discuss taper/hold if other risk factors present.
- Opioids, tramadol, certain stimulants at high doses - evaluate case-by-case; may increase seizure or sympathetic risk.
Action: Flag these at intake and discuss with the psychiatrist before treatment. (Clinics should screen for seizure risk and have protocols.)
Augmentation / experimental agents (ONE-D)
- D-cycloserine, short-acting stimulants (e.g., lisdexamfetamine) - used in some ONE-D protocols as augmentation only under psychiatrist supervision, with informed consent and monitoring. Document timing and monitoring plan.
Medications that most commonly affect seizure risk
- Higher seizure risk: bupropion, clozapine, tramadol, theophylline (rare).
- Agents that lower seizure threshold modestly or via interactions: some antipsychotics, certain antibiotics (quinolones — discuss if relevant), stimulants in high doses.
- Agents that raise seizure threshold (often protective): many anticonvulsants (valproate, carbamazepine, lamotrigine) - however, these can affect TMS response.
Action: Flag any high-risk meds during screening and consult psychiatry to mitigate risk.
ONE-D and augmentation - special considerations
- Augmentation meds (e.g., D-cycloserine 125 mg, short-acting stimulants) have been used experimentally to enhance ONE-D effects; they require psychiatric oversight, informed consent, and monitoring for side effects and interactions. Document augmentation rationale and monitoring plan.
- If using stimulants: evaluate cardiovascular status, anxiety history, and seizure risk. Consider holding stimulant dose or using a lower dose on treatment day, depending on risk/benefit.
- Medication log: Track timing of augmentation relative to stimulation in the chart (useful for outcome interpretation).

Download Your Roadmap to TMS
Want a clear picture of what to expect?
Download the TMS Treatment Roadmap by Sydney
Psychiatrist-led workflow: coordinating medication and TMS
Below is a practical workflow your clinic can adopt. It assumes communication between the psychiatrist, TMS team, and patient.
1) Pre-treatment medication review (intake)
- Obtain a full medication list (Rx, OTC, supplements) and the last 1–2 PHQ-9 scores. Request prior TMS mapping and session notes if applicable.
- Identify high-risk meds (bupropion, clozapine, recent high-dose stimulants, opioid intoxication) and medical comorbidities (brain lesions, prior seizures).
2) Risk stratification & plan
- For low risk: continue meds, document plan.
- For moderate risk: discuss options (dose reduction, timing changes, monitoring).
- For high risk: consider alternative protocols or require further medical clearance (neurology consult). Document the decision and rationale.
3) Shared decision & consent
Discuss the benefits/risks of medication adjustment vs continuing meds. Obtain informed consent that documents the plan and the clinician’s rationale.
Read more: Pros & Cons of TMS
4) Day-of procedures
- Reconfirm med list and check for recent use of alcohol or recreational drugs.
- Implement agreed changes (e.g., withhold morning dose of stimulant, give augmentation med at specified time).
- Ensure resuscitation/seizure protocol is in place.
5) Monitoring & documentation
Use PHQ-9 or other PROMs for outcome tracking. Document any side effects, seizure-like events, or medication reactions. Ensure follow-up psychiatry appointments to manage tapering/resumption of meds.
6) If an adverse event occurs
Follow emergency TMS clinic protocols (stabilize the patient, call emergency services if needed). Review the med list and consult neurology/psychiatry to determine next steps.
Practical checklist for psychiatry/TMS intake
- ☐ Full med list recorded (Rx/OTC/supplements)
- ☐ Prior TMS records requested/uploaded (if available)
- ☐ Seizure risk screen completed (past seizures, head trauma, medications)
- ☐ Cardiovascular & other medical clearances as needed
- ☐ Plan documented (continue/hold/taper/augment) + informed consent
- ☐ Day-of medication instructions communicated to patient
- ☐ Emergency & seizure protocol reviewed with staff
Should I stop SSRIs before TMS?
No - SSRIs/SNRIs are typically continued. Stopping them is rarely necessary and may worsen mood instability. Individual exceptions are rare.
My patient is on bupropion - what do I do?
Evaluate seizure risk. Where other risk factors exist, consider dose reduction or temporary hold in coordination with the prescriber; avoid abrupt discontinuation.
Can we do ONE-D with augmentation?
Yes, but only with psychiatric supervision, documented consent, and a monitoring plan for side effects and interactions. Record timing relative to stimulation.

Every Question Answered
Want to know more about TMS? Check out this in-depth guide to TMS therapy with transparent and easy to understand explanations about TMS processes, protocols, and treated conditions.
Latest Posts

















