When traditional antidepressants fail, TMS therapy for anxious depression offers a targeted, drug-free alternative. This non-invasive treatment uses magnetic pulses to calm persistent anxiety and lift low mood directly at the source, completely bypassing systemic side effects like fatigue or weight gain.
Average reduction in both GAD-7 (anxiety) and PHQ-9 (depression) scores in real-world patients with anxious depression
Anxious depression patients show similar symptom improvement but significantly lower categorical remission than non-anxious patients (p < .001)
Typical session length, depending on protocol (standard left DLPFC or bilateral)
Standard treatment course over approximately 7 weeks (5 sessions per week)
Source: Real-world multicenter study of TMS in anxious depression (PubMed PMID: 36630648); FDA clearance data.
The FDA cleared transcranial magnetic stimulation for major depressive disorder in adults in 2008. The clearance does not specifically name “anxious depression” as a separate indication, but anxious depression falls under the MDD umbrella. Patients with significant anxiety symptoms who meet criteria for treatment-resistant depression are appropriate candidates.
Importantly, deep TMS (using H-coil technology) has been studied specifically for anxious depression. A clinical trial summary notes that deep TMS produced significantly lower anxiety and depression severity versus placebo stimulation in comorbid depression and anxiety.
TMS is indicated for adults who have not achieved satisfactory improvement from prior antidepressant medication. One adequate trial with inadequate response qualifies you for consideration. For anxious depression, TMS is often considered earlier because the combination of mood and anxiety symptoms predicts poorer medication response.
At Center for Psychiatric Wellness, Dr. Rachel Fiori, MD, and the psychiatric team, including James Gattis, APRN, and Tiffany Diaz, APRN, conduct the psychiatric evaluation to determine candidacy conduct the psychiatric evaluation to determine candidacy for TMS therapy in Fort Smith.
The table below shows how anxious depression typically disrupts daily life, note the blend of mood and anxiety symptoms.
Symptom Domain
Depressed mood with worry
Loss of interest plus restlessness
Fatigue with racing thoughts
Poor concentration and brain fog
Sleep problems (both directions)
Physical anxiety symptoms
Feelings of worthlessness plus social fear
Suicidal thoughts with agitation
Common impact on daily life
Feeling sad or empty while also feeling tense, on edge, or unable to stop worrying. The two feed each other.
Nothing feels enjoyable, but you cannot sit still either. You are bored and agitated at the same time.
Exhausted all day, but your mind will not shut off at night. Sleep is unrefreshing because the worry continues.
Cannot focus on work or reading. The anxiety makes your mind jump from one worry to another.
Trouble falling asleep because of racing thoughts. Waking up at 3 AM with a sense of dread. Sleeping too much to escape both.
Muscle tension, heart pounding, shortness of breath, sweating — even when nothing specific is wrong.
Believing you are a burden, then avoiding people because being around them makes you too anxious.
Passive thoughts like “I don’t want to wake up” combined with a sense of trapped, restless desperation. Any suicidal thinking requires immediate evaluation.
If you recognize several of these domains, especially the mix of low mood and constant worry, and antidepressants have not resolved them, TMS may be appropriate.
TMS works locally. If you have ever wondered exactly what is TMS therapy, it targets the root of the problem directly. For anxious depression, the protocol can be adjusted to target both mood and anxiety circuits.
There are three main TMS approaches for anxious depression:
High-frequency left DLPFC — This is the standard depression protocol. The coil is placed over the left dorsolateral prefrontal cortex, which is underactive in depression. High-frequency pulses (10-20 Hz) excite this region, restoring normal activity in mood-regulation circuits. This also helps anxiety indirectly by improving overall brain network balance.
Low-frequency right DLPFC — The right prefrontal cortex tends to be overactive in anxiety. Low-frequency pulses (1 Hz) calm this region down, which can reduce hyperarousal, worry, and physical anxiety symptoms. This is sometimes added to the left-side protocol for a bilateral approach.
Deep TMS (H-coil) — A specially designed coil that reaches broader and deeper brain networks. A clinical trial summary notes that deep TMS produced significantly lower anxiety and depression severity versus placebo stimulation in comorbid depression and anxiety.
The analogy: Standard depression TMS is like turning up the volume on an underactive radio station (left DLPFC). An anxiety-focused TMS is like turning down the volume on a station that is playing too loud (right DLPFC). For anxious depression, you may need to do both.
At Center for Psychiatric Wellness, the team uses the NeuroStar Advanced Therapy System. The standard protocol is 19-minute sessions targeting the left DLPFC. For patients with prominent anxiety, the clinical team can discuss bilateral or anxiety-focused protocols.
TMS is not a one-time procedure. It is a course of treatment that requires commitment. The standard protocol is five sessions per week for approximately seven weeks, totaling 36 sessions.
Call (479) 831-6007 to schedule a no-cost discussion. You will speak with a team member about your depression history, anxiety symptoms, what medications you have tried, and whether TMS is a reasonable fit. No obligation.
You meet with Dr. Rachel Fiori, MD, or one of the psychiatric nurse practitioners (James Gattis or Tiffany Diaz) for a full evaluation. They will confirm a major depressive disorder diagnosis with anxious features, document prior medication trials and response, screen for contraindications (metal implants in the head, seizure disorder, certain medical devices), and determine if TMS is medically appropriate.
This is the setup session, lasting about one hour. The clinician finds your personal motor threshold. The left DLPFC (and potentially right DLPFC for bilateral protocols) is mapped for precise coil positioning.
You sit in a reclining treatment chair. The magnetic coil delivers pulses in a rhythmic pattern. For standard left DLPFC, you will feel tapping or clicking on the left side of your scalp. For bilateral protocols, the coil may be moved or two positions used. You remain fully awake. Session length: 19 minutes for standard protocol, up to 30 minutes for bilateral or deep TMS.
There is no sedation. No anesthesia. No recovery room. You drive yourself home or back to work. Some people feel a mild headache after the first few sessions, which usually resolves with over-the-counter pain relievers. Most people report no disruption to their daily schedule.
Note on the “TMS dip”: Clinic documentation states that while anxiety is not a standard side effect, some patients report a “TMS dip” where symptoms temporarily worsen mid-treatment before improving. This is transient. Let your clinician know if this happens.
The evidence for TMS in anxious depression comes from large real-world studies, clinical trials, and meta-analyses. The following data is drawn from PubMed-indexed research (PMID: 36630648) and clinical trial summaries.
In a multicenter analysis of real-world TMS patients with major depression and moderate-to-severe anxiety, average symptom reductions of about 50% or more were reported on both GAD-7 (anxiety) and PHQ-9 (depression) after a full course of TMS.
Patients with anxious depression improved in their depression about as much as those without significant anxiety, and sometimes showed even larger decreases in anxiety itself. Consensus reviews suggest that around two-thirds to over 80% of people with treatment-resistant depression show some improvement.
Anxious depression patients have significantly lower categorical remission rates than non-anxious patients (p < .001 in the 2023 real-world study). You may improve a lot, 50% or more symptom reduction, but still not reach full remission. That does not mean TMS failed. It means you started from a more severe baseline, and the absolute improvement is still meaningful.
A clinical trial summary notes that deep TMS produced significantly lower anxiety and depression severity versus placebo stimulation in comorbid depression and anxiety.
The most common side effects are mild scalp discomfort or tenderness during the first few sessions and temporary headache. Both typically resolve. The most serious rare risk is seizure, occurring in fewer than 0.1% of patients. No long-term cognitive effects. No memory loss. Clinic documentation notes that while anxiety is not a standard side effect, there are indications that TMS can temporarily increase anxiety in some patients when treating depression.
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I appreciate how easy it is to schedule appointments and communicate with the staff. The environment feels calm and welcoming, which makes a big difference when dealing with anxiety and depression.
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Yes, most major commercial insurance plans cover TMS for treatment-resistant depression when medical necessity criteria are met. Medicare also covers TMS for qualifying patients. For anxious depression, documentation of both mood and anxiety symptoms is helpful for prior authorization.
Typical Coverage Criteria:
Confirmed diagnosis of major depressive disorder (with or without anxious distress specifier)
Documented treatment resistance (failure of at least one, usually two, adequate antidepressant trials)
No contraindications (metal implants in the head, seizure disorder, certain implanted devices)
Some plans require concurrent psychotherapy documentation
Insurers That Commonly Cover TMS:
Medicare (for qualifying patients)
Arkansas Blue Cross Blue Shield
UnitedHealthcare / Optum
Cigna
Aetna (varies by plan; prior authorization typically required)
Most commercial PPO plans with medical necessity documentation
Anxious depression is major depressive disorder with significant anxiety symptoms — worry, tension, restlessness, physical anxiety. It is a recognized specifier in the DSM (“with anxious distress”). People with anxious depression have more severe overall symptoms, higher disability, and lower response to standard antidepressants than those with depression alone.
The real-world data shows that patients with anxious depression improve about as much as non-anxious patients in terms of absolute symptom reduction — often 50% or more on both depression and anxiety scales. However, they have significantly lower categorical remission rates because they start from a more severe baseline. You can still get dramatically better. Just know the numbers going in.
Clinic documentation notes that while anxiety is not a standard side effect, some patients report a “TMS dip” — temporary worsening of symptoms around the second or third week of treatment. This is transient. It typically resolves as treatment continues. Do not stop treatment if this happens. Tell your clinician. They can adjust protocols or offer support.
Sometimes. Standard TMS for depression targets the left DLPFC with high-frequency pulses. For anxious depression, clinicians may add low-frequency pulses to the right DLPFC (bilateral protocol) to calm overactive anxiety circuits. Deep TMS uses an H-coil that reaches broader networks. Ask your clinician which protocol they recommend for your specific symptom pattern.
Most people feel a tapping or clicking sensation on their scalp during the session. It is not painful for the majority of patients. Some experience mild scalp discomfort or tenderness during the first week, which usually resolves. You remain awake and comfortable.
Yes. TMS requires no sedation and no anesthesia. You drive yourself to the appointment, complete the session, and drive yourself home or back to work. No recovery period.
The standard course is 36 sessions. With five sessions per week (Monday through Friday), that is approximately seven weeks. Some protocols vary (e.g., 30 sessions over 6 weeks). Your clinician will give you a specific timeline.
Yes. TMS is often an adjunct treatment. Most patients remain on their current medication during TMS. Do not stop or change your medication without consulting your prescribing physician. Some patients later reduce or discontinue medication, but that is a separate conversation.
Real-world data shows that while most patients improve, not everyone responds. Alternatives include adjusting medication strategies, trying a different TMS protocol (e.g., bilateral instead of left-only, or deep TMS), considering ECT for severe refractory cases, or repeating a TMS course later. Your psychiatrist will discuss realistic expectations before you start.
Yes, if you meet criteria for treatment-resistant depression. The anxious distress specifier is not required for coverage, but documenting both mood and anxiety symptoms can strengthen prior authorization requests. The free consultation at Center for Psychiatric Wellness includes a benefits check.
Standard TMS uses a figure-8 coil that targets superficial cortical regions. Deep TMS uses an H-coil that reaches broader and deeper brain networks, including limbic structures involved in fear and worry. A clinical trial summary notes that deep TMS produced significantly lower anxiety and depression severity versus placebo stimulation in comorbid depression and anxiety.
Anxious depression leaves you constantly tired yet wired. When traditional medications fail, TMS therapy for anxious depression offers a targeted, non-invasive, drug-free path forward.
7217 Cameron Park Dr, Fort Smith, AR 72903
Serving Fort Smith, Van Buren, Arkoma, and surrounding communities.
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