TMS in an Integrative, Precision Psychiatry Practice
In an integrative, precision psychiatry practice, TMS is not a stand-alone procedure. It sits inside a broader assessment that asks why depression has not responded so far: whether the diagnosis is right, whether medication trials were adequate, and whether medical, sleep, metabolic or lifestyle factors are holding recovery back. That framing shapes who is a good TMS candidate, what should be addressed before or alongside a course, and how to protect a response afterward.
It also has limits worth stating up front. TMS for major depression has strong evidence on its own. The integrative elements are good reasons to get the diagnosis and the supports right; they are not proven ways to raise TMS response rates, and no part of this model can promise an outcome.
How Dr. Lewis describes her approach
Dr. Beata "Bliss" Lewis is board-certified in adult psychiatry, child and adolescent psychiatry and integrative medicine, trained at Harvard Medical School, Columbia and the NYU Child Study Center, and chairs the APA's Integrative Psychiatry Caucus. Her practice describes its work as integrating traditional psychiatric care with functional medicine testing, nutrition, mind-body techniques and personalized lifestyle changes, with particular attention to metabolic health, the gut-brain connection and inflammation. More background is on the about page.
The practice's own pages set out three features that matter for TMS:
- A detailed first evaluation that reviews health history, symptoms and "previous treatments and what has/hasn't worked," described on the precision psychiatry page.
- Testing used selectively and explained honestly. The practice states that some functional tests "are not validated for diagnosis," that tests such as serum zonulin, mycotoxin panels and provoked heavy-metal tests are investigational, and that no panel diagnoses a psychiatric condition, as set out on the functional medicine and psychiatry page.
- Treatment plans that combine conventional psychiatric care, including medication when needed, with psychotherapy, nutrition, sleep, stress management and mind-body practices, described on the integrative medicine page.
Applied to TMS, those principles translate into a sequence: understand the resistance, decide whether TMS is the right next step, support the course, then plan for durability.
Before TMS: understanding why depression has not responded
"Treatment-resistant" is a description of history, not a diagnosis. Some depressions labeled resistant have had medication trials that were too short or too low in dose, a missed bipolar or medical contributor, or ongoing factors such as alcohol use or severe insomnia. New York Medicaid builds this into its rules: before TMS, providers "must confirm the diagnosis and rule out other etiologies of depressive symptoms that can interfere with medication effectiveness." Commercial insurers make the same point through dose and duration: Aetna, for instance, counts an antidepressant trial only at the maximally tolerated labeled dose for at least 8 weeks.
An integrative evaluation covers this ground systematically. The questions it asks are practical:
- Is this unipolar depression, or is there a bipolar, trauma, attention or substance-use component that changes the plan?
- Were medication trials adequate in dose, duration and adherence, and were side effects managed or simply endured?
- Is there a medical contributor that standard care might miss, such as thyroid disease, a nutrient deficiency, anemia, sleep apnea or a medication side effect?
- How are sleep, alcohol, activity and stress, and which of them can change in the next few weeks?
- Has psychotherapy been tried at an adequate dose, and is it still in place?
Some of these overlap with TMS safety screening. The 2021 IFCN safety guideline lists metabolic problems such as low sodium, calcium or magnesium, low or high blood glucose and kidney or liver failure among factors that lower seizure threshold, along with alcohol withdrawal, stimulant use and sleep deprivation. A careful medical review is therefore part of preparing for TMS, not a detour from it. The specific workup is laid out in ruling out medical causes before TMS.
Where each part of the model fits
Not every element of integrative care has the same standing. The table separates what is essential for TMS from what is supportive or exploratory.
| Element | Role in TMS candidacy or aftercare | How firm the ground is |
|---|---|---|
| Psychiatric evaluation and diagnostic clarity | Confirms major depression, screens for bipolar disorder, psychosis and acute risk | Essential; required by guidelines and payers |
| Medication review | Checks adequacy of past trials, identifies seizure-relevant drugs, plans what stays stable during the course | Essential; medication changes can prompt reassessment of motor threshold |
| Standard medical labs | Looks for medical contributors and seizure-relevant metabolic problems | Reasonable and targeted to history |
| Pharmacogenomic testing | Sometimes considered when choosing or dosing medications used alongside or after TMS | Not a test of TMS suitability; it says nothing direct about response to stimulation |
| Functional and microbiome testing | May add context for nutrition or gut symptoms | Exploratory; several of these tests are investigational and not a prerequisite for TMS |
| Psychotherapy | Continues through the course; often required by insurers before TMS | Established for depression; Medicare in New York requires a prior psychotherapy trial |
| Sleep, alcohol, activity and nutrition | Supports safety and day-to-day function during and after the course | Sensible and low-risk; sleep deprivation and alcohol withdrawal lower seizure threshold |
Two of these deserve their own discussion: pharmacogenomic testing and where TMS fits, and inflammation, treatment-resistant depression and TMS.
Deciding whether TMS is the right next step
The integrative workup does not exist to delay TMS. When depression is clearly unipolar, trials have been adequate, contributors have been addressed or are being addressed, and the person can commit to a course, TMS is a well-supported option. CANMAT 2023 rates rTMS as first line for treatment-resistant depression, and the European IFCN-based guideline rates high-frequency left prefrontal rTMS as Level A, definite efficacy.
Sometimes the workup points elsewhere first. A missed bipolar history, untreated sleep apnea, heavy alcohol use or an unaddressed medical illness can each change the order of steps. For acute suicidal risk or psychotic depression, consensus guidance favors treatments with established efficacy for those presentations, such as ECT. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room. And for some patients a different medication strategy, or esketamine, is a better fit; every option for treatment-resistant depression is compared side by side elsewhere in the guide.
During the course: keeping the ground steady
TMS dosing depends on the motor threshold measured at the start, and the Clinical TMS Society advises that medication changes "should prompt consideration for reassessment of the patient's motor threshold." The integrative principle of changing one thing at a time fits well here. During an acute course, it usually makes sense to keep medications and supplements stable unless there is a clinical reason to change them, to protect sleep, to avoid heavy drinking, and to tell the TMS team about any new prescription, illness or substance use.
Therapy and lifestyle work continue alongside stimulation. How medication and TMS interact in research is covered in combining TMS with medication, and the patient-facing view of sleep, movement and nutrition during a course is in supporting your TMS course with lifestyle.
After the course: aftercare and durability
A good response is not the end of treatment. In follow-up studies, roughly half to about 6 in 10 people who respond to TMS are still doing well at one year. Guideline-level evidence for maintenance TMS is weak, and claims that TMS results are permanent are overstated. That makes the period after a course the natural place for the rest of the integrative plan: continued therapy, a clear medication strategy, attention to sleep and activity, and regular symptom checks with the same rating scale used during treatment.
If depression returns after a good response, the Clinical TMS Society recommends that TMS "should be reintroduced until remission is re-achieved." An aftercare plan should name the warning signs, the scale and the threshold that would prompt a call. The data on durability are reviewed in how long TMS results last.
Where the evidence stops
Precision psychiatry is a direction more than a finished science. No laboratory test diagnoses depression, and the practice says as much about its own panels. Predicting who will respond to TMS remains an active research area rather than a clinical tool, as discussed in who responds to TMS. An integrative model earns its place by being thorough about diagnosis, honest about which tests are validated, and attentive to the whole person during and after treatment, not by promising faster or more complete recovery.
Questions to ask an integrative psychiatrist about TMS
- Do you think my depression is truly treatment-resistant, or are there contributors we have not addressed?
- Which tests do you recommend before TMS, which are validated, and what would change depending on the result?
- Which of my medications and supplements should stay the same during a course?
- Who will coordinate between you, my therapist and the TMS team?
- What is the plan after the course, and what would make us consider retreatment?
More on the practice's approach is in precision psychiatry and integrative psychiatry. The full set of TMS articles is in the TMS guide, and practical information is on the TMS therapy page.
Frequently asked questions
Does an integrative approach make TMS work better?
That has not been shown. The value of an integrative approach lies in getting the diagnosis right, addressing medical and lifestyle contributors, keeping conditions stable during the course and planning aftercare. It is not a way to guarantee or boost response.
Do I need functional medicine testing before TMS?
No. A psychiatric evaluation, a medication history and a medical review targeted to your history are what TMS requires. Some functional tests are investigational, and Dr. Lewis's practice says so on its own pages.
Can genetic testing tell me whether TMS will work?
No. Pharmacogenomic testing looks at how the body handles certain medications. It is not a test of how the brain will respond to stimulation.
Should I stop supplements during TMS?
Not automatically. The general principle is to keep medications and supplements stable during an acute course unless there is a clinical reason to change, and to tell the TMS team about any change.
What happens after a TMS course in an integrative model?
Therapy, medication planning, sleep, activity and regular symptom tracking continue, with a written plan for what to do if symptoms return. Retreatment is an option if depression recurs after a good response.
Sources
- New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (Medicaid Update, July 2025). NYS Department of Health, 2025. healthweb-back.health.ny.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
- The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
- Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Canadian Journal of Psychiatry, 2024. pmc.ncbi.nlm.nih.gov
- Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clinical Neurophysiology, 2020. pubmed.ncbi.nlm.nih.gov
- Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
- Durability of antidepressant response to repetitive transcranial magnetic stimulation: Systematic review and meta-analysis. Brain Stimulation, 2019. pubmed.ncbi.nlm.nih.gov
Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.
The information provided on this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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