Consensus statement on the maintenance treatment of depression with rTMS in the Netherlands and Belgium

<h2>Abstract</h2> Recent updates to treatment guidelines for depression increasingly incorporate repetitive transcranial magnetic stimulation (rTMS). While rTMS is an established intervention for depression, evidence regarding its use for maintenance treatment remains limited. The Dutch-Flemish Brain Stimulation Foundation convened an expert panel to review the literature, survey clinical practice, and formulate consensus recommendations on maintenance treatment with rTMS in the Netherlands and Flanders. A systematic PubMed search (up to June 2025) identified 22 studies reporting original data on maintenance treatment with rTMS for depression. Approaches could be divided into three categories: tapering (gradual reduction of sessions after acute treatment), maintenance rTMS (fixed-interval sessions), and retreatment (reinitiating rTMS upon relapse). Evidence from one randomized controlled trial and several open-label studies suggests that tapering may help sustain clinical improvement, particularly when the tapering schedule is symptom-guided. For maintenance rTMS, single-session protocols show mixed results, whereas clustered protocols (typically five sessions per month over several days) demonstrate the most benefits, though controlled data are lacking. Retreatment with rTMS is effective in most patients who previously responded to acute rTMS, often requiring fewer sessions. Survey data from 11 Dutch institutions indicate that tapering and maintenance rTMS are applied on a small scale, while retreatment is more common. Patient representatives emphasized the importance of early discussion, flexible scheduling, and structured monitoring to guide maintenance treatment. Overall, evidence supports individualized application of maintenance treatment with rTMS, with a need for further controlled research to establish optimal protocols and long-term effectiveness.