How Many Antidepressants Should I Try Before Considering Another Treatment?
FDA clearance for TMS covers adults who have not improved adequately on at least one antidepressant. Many insurance plans require two to four documented failed trials. The STAR*D study showed diminishing returns after each step — roughly 37% remission after the first medication, 31% after the second, 14% after the third. After two or three adequate trials, a psychiatrist may recommend a non-medication treatment like TMS, SAINT®, or SPRAVATO®.
Key takeaways
- FDA clearance for TMS requires at least one failed antidepressant trial.
- Many insurance plans require two to four documented trials.
- STAR*D showed diminishing returns after each medication step.
- An adequate trial means a therapeutic dose for 6 to 8 weeks.
What the Research Shows
The STAR*D study, the largest real-world antidepressant trial, followed about 3,671 adults through sequential treatment steps. Remission rates were approximately 37% after the first medication, 31% after the second, 14% after the third, and 13% after the fourth. The pattern of diminishing returns is well established.
When to Consider a Non-Medication Treatment
After two or three adequate antidepressant trials without satisfactory improvement, many psychiatrists recommend a non-medication treatment. FDA-cleared options include TMS and SAINT® for adults with major depressive disorder who have not improved on antidepressant medication. SPRAVATO® (esketamine) is FDA-approved for treatment-resistant depression.
What Insurance Typically Requires
Most commercial insurance plans and Medicare require documentation of two to four failed antidepressant trials before authorizing TMS. Each trial must show the medication name, dose, duration, and reason for discontinuation. Your clinic verifies your benefits and helps document the history your plan requires.
Understanding SAINT® TMS: How It Works & What to Expect
SAINT® is an FDA-cleared treatment for adults with major depressive disorder who have not improved on antidepressants in the current episode. These videos explain how it works and how it differs from conventional TMS.
SAINT® is an FDA-cleared, fMRI-guided form of TMS developed at Stanford. Most patients complete treatment in one week — not the six weeks standard TMS requires.
Follow a real patient through the five-day SAINT® treatment week
Is SAINT® TMS Right for You?
Tried antidepressants without enough relief? SAINT® TMS is an FDA-cleared, fMRI-guided treatment for adults with major depressive disorder who have not improved enough with antidepressant medication.
SAINT® uses a personalized brain target and delivers treatment over five consecutive days. It differs from standard TMS in its targeting approach, treatment schedule, and research background. In a small randomized trial, 11 of 14 people receiving active treatment reached remission at the four-week assessment, compared with 2 of 15 receiving sham treatment. Results vary, and a five-day treatment course does not guarantee remission in five days.
How SAINT® Works and How It Differs From Conventional TMS
SAINT® is an FDA-cleared treatment for adults with major depressive disorder who have not improved on antidepressants in the current episode. This video explains how it works, and how it differs from conventional TMS.
Conventional TMS usually means about 30 visits over 6 to 9 weeks. SAINT is five visits over five days.
What makes it different: SAINT is the only FDA-cleared depression treatment that uses an fMRI scan to personalize the stimulation target to your individual brain. A 45-minute scan maps your brain and identifies the specific circuit linked to depression. Treatment is then delivered as ten 10-minute sessions per day, with 50-minute breaks between them, across five consecutive days.
In clinical trials, 79% of participants reached remission, with an average of 2.6 days to remission. SAINT is generally well tolerated; the most common side effects reported were mild headache and temporary scalp discomfort at the treatment site.
SAINT® at Neuro Wellness TMS Centers of America
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Sources: Cole et al., American Journal of Psychiatry 2020;177:716-726 and 2022;179(2):132-141. magnusmedical.com/depression-therapy. PubMed 34711062. FDA 510(k) K220177.
Insurance coverage for SAINT is currently limited and varies by plan. Individual results may vary. This video is educational and is not medical advice. Talk to a qualified clinician about whether SAINT is appropriate for you. If you are in crisis, call or text 988.
Frequently Asked Questions
How many antidepressants should I try before considering TMS?
FDA clearance for TMS covers adults with major depressive disorder who have not improved adequately on at least one antidepressant in the current episode. Many insurance plans require documentation of two to four failed trials. A psychiatrist can review your medication history and determine whether you meet the criteria for TMS, SAINT®, or SPRAVATO®.
Does trying more antidepressants increase my chances of remission?
The STAR*D study found diminishing returns: roughly 37% remission after the first medication, 31% after the second, 14% after the third, and 13% after the fourth. After two or three adequate trials, the probability of remission from another medication alone decreases. This is when many psychiatrists recommend a non-medication treatment.
What counts as a 'failed' antidepressant trial?
A failed trial means you took an antidepressant at a therapeutic dose for 6 to 8 weeks with no adequate improvement, or you could not reach a therapeutic dose because of side effects. A medication stopped early or never increased beyond a starting dose is usually considered an incomplete trial, not a failed one.
Cited Research
SAINT® is delivered only by verified providers on the Magnus Medical system. Programs described as SAINT “alternatives”, “equivalents” or “fMRI-guided accelerated TMS” are not SAINT®, are not affiliated with us, and SAINT® results do not apply to them. Read our SAINT® disclaimer.
Have questions about whether TMS may be appropriate for you?
Speak with our clinical team. A free consultation is the best way to get answers specific to your situation.