What the TMS “Dip” Feels Like - When to Expect It and What Clinicians Do Next

Quick Overview
If you or a patient feels worse during a course of TMS, that reaction is real - and it doesn’t mean treatment has failed or that the clinician has made a mistake. A temporary worsening (often called the TMS “dip”) happens for some people while the brain is adjusting to stimulation. Most importantly, it is usually transient, manageable, and treatable with clear clinical steps and support.
What is the “TMS dip”?
The TMS dip describes a temporary increase in depressive or anxiety symptoms during a TMS course. Patients may report mood worsening, increased anxiety, irritability, sleep disruption, or more frequent intrusive thoughts. For most patients, the dip is short-lived and improves with continued care; for a small minority, it may require pausing or adjusting treatment. Clinics that specialize in TMS note this phenomenon and have procedures to respond.
When does the dip usually happen?
- Timing: The dip most commonly appears mid-course (around halfway through a typical protocol), but it can occur at any time during treatment.
- Duration: In most cases, the dip lasts hours to a few days and resolves as the brain adapts to stimulation; in a few cases, clinicians pause or change the plan if symptoms persist.
- How often: Only a small percentage of patients report intolerable worsening that leads to stopping treatment; serious long-term worsening is not supported by the evidence when patients are correctly screened and monitored.
Why does the dip happen? (simple clinical framing)
No single explanation covers every patient, but common reasons include:
- Neurophysiologic adjustment. TMS actively alters neural circuits; as excitatory and inhibitory balances shift, transient symptom fluctuations may occur while new patterns stabilize.
- Protocol mismatch. Coil location, dose, or timing may be suboptimal for a specific patient; small differences in targeting can change the effect. Proper motor-threshold mapping is essential and sometimes needs re-checking.
- Medication interactions or withdrawal. Medication changes or interactions can amplify symptoms during stimulation.
- Comorbid or misdiagnosed conditions. Undetected bipolar spectrum disorders, PTSD, substance use, or medical issues can cause symptom volatility that looks like a dip.
- Psychological reaction. Increased self-awareness or brief increases in distress as therapy “opens up” material can feel worse before it gets better.
What your clinicians should do - a practical, step-by-step response
1 - Immediate triage (same day)
- Screen for safety: Assess suicidality, intent, psychosis, or sudden functional decline. If safety is a concern, follow urgent protocols (suicide assessment, crisis plan, ER if needed).
- Check vitals/physical symptoms if relevant (headache, dizziness, unusual movements).
2 - Rapid medication & history check
- Confirm timing of meds (including any recent changes). Flag high-risk drugs (bupropion, clozapine, tramadol). If new meds or missed doses are identified, coordinate with the prescriber.
3 - Review TMS delivery
- Re-check mapping & motor threshold. Small targeting or intensity mismatches can matter; re-mapping may be indicated.
- Consider protocol changes: reduce per-session dose, increase inter-session rest, change coil location, or switch protocols (rTMS ↔ iTBS). For patients on accelerated schedules, spacing or dose adjustments can reduce adverse fluctuations.
4 - Pause vs continue (clinical decision)
- Mild, brief dip: Often continue with enhanced monitoring and supportive measures (hydrate, rest, analgesia).
- Moderate/persistent dip: Consider pausing or slowing down the course and re-evaluating within 48–72 hours.
- Severe or safety concern: Stop treatment and escalate psychiatric evaluation.
5 - Symptom-targeted support
- Address headaches (hydration, OTC analgesic), sleep disturbances, and acute anxiety with evidence-based, short-term strategies and coordination with prescribing clinicians.
- Consider brief psychotherapeutic support if the dip involves increased rumination or trauma material.
Learn More: TMS Pros & Cons
6 - Rescue & maintenance options
Rescue/extension: If partial benefit is seen but symptoms fluctuate, clinicians may add extra sessions, extend the course, or offer maintenance/booster sessions later.
Many clinics offer retreatment or maintenance schedules for sustaining gains.
7 - Documentation & follow-up
Document symptom change, interventions, and rationale. Schedule a short re-check within a few days and continue outcome monitoring (PHQ-9/GAD-7 or other PROMs).

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How to reduce the chance of a dip (preventive care)
- Thorough pre-treatment screening (meds, history of mania/bipolar, seizure risk, substance use).
- Careful mapping and individualized stimulation parameters.
- Coordinate medication changes slowly with the prescriber and avoid abrupt discontinuations.
- Set expectations up front: discuss the possibility of a dip and the plan to respond.
When to seek urgent help
- New or worsening suicidal thoughts, plan, or intent.
- New psychotic symptoms or sudden behavioral disorganization.
- Seizure or prolonged loss of consciousness.
If any of the above occur, activate emergency procedures immediately (ER or crisis team).
Is a dip permanent?
Not usually. Most dips are temporary and resolve with simple adjustments or supportive care.
Will stopping TMS fix it?
Stopping sometimes resolves symptoms, but clinicians usually try adjustments first (mapping, dose, pacing). If severe or prolonged, pausing is appropriate until the team reassesses.
Could TMS make things worse long-term?
There are no high-quality studies showing long-term worsening when patients are correctly diagnosed and treated; serious complications are rare when clinics follow screening and safety protocols.

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.
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