TMS and Suicidality

August 1, 2025 |

Transcranial magnetic stimulation (TMS), particularly repetitive TMS (rTMS), has emerged as a promising non-invasive neuromodulation technique for treating major depressive disorder (MDD), including cases with significant suicidal ideation and behavior. Over the past decade, a growing body of research has evaluated the efficacy, safety, and mechanisms of TMS in reducing suicidality among individuals with depression, including treatment-resistant depression (TRD), adolescents, and elderly populations. Meta-analyses and systematic reviews consistently report that TMS, especially when targeting the dorsolateral prefrontal cortex (DLPFC), can significantly reduce suicidal ideation, with some evidence suggesting effects independent of overall depression improvement [1][2][3][4][5][6]. Recent randomized controlled trials and large-scale retrospective studies further support the rapid and durable antisuicidal effects of TMS, including accelerated and individualized protocols [7][8][9][10][5][11][12]. Mechanistic studies implicate changes in reward circuitry, neuroplasticity, and cortical inhibition as potential mediators of TMS’s antisuicidal effects [7][13][14][15][16][17][18]. However, the literature also highlights methodological heterogeneity, variable response rates, and the need for more suicide-specific research, especially in subpopulations such as adolescents, elderly, and those with comorbid anxiety or PTSD [19][20][21][10][22][23][24][25][26]. Overall, TMS is considered a safe and well-tolerated intervention, with most adverse events being mild and transient [2][3][4][6]. This review synthesizes the current evidence on TMS for depression and suicidality, focusing on efficacy, mechanisms, population-specific findings, and research gaps.

Methods

A comprehensive literature search was conducted across over 170 million research papers in Consensus, encompassing databases such as Semantic Scholar, PubMed, and others. The search strategy included terms related to TMS, depression, suicidality, treatment-resistant depression, adolescent and elderly populations, neurobiological mechanisms, and alternative neuromodulation techniques. In total, 1,046 papers were identified, 684 were screened after de-duplication, 391 met eligibility criteria, and the top 50 most relevant and high-quality papers were included in this review.

Seven unique search strategies were used, targeting efficacy, mechanisms, subpopulations, and safety of TMS for depression and suicidality.

Results

Study Designs and Populations

The included studies comprise randomized controlled trials (RCTs), meta-analyses, systematic reviews, retrospective analyses, and open-label trials. Populations studied range from adults with MDD and TRD to adolescents and elderly patients, with some studies focusing on veterans, individuals with comorbid anxiety or PTSD, and those with acute suicidal crises [19][8][20][21][27][9][10][5][22][23][24][25][26].

Efficacy of TMS in Reducing Suicidal Ideation

Meta-analyses and systematic reviews consistently report that rTMS significantly reduces suicidal ideation compared to sham or control groups, with standardized mean differences indicating moderate effect sizes [1][2][3][4][28][5][6]. Bilateral and high-frequency rTMS protocols targeting the DLPFC, as well as intermittent theta burst stimulation (iTBS), appear particularly effective [7][8][9][10][5][6][29]. Some studies report rapid reductions in suicidality, with effects observable within days to weeks [8][9][11][12][30][25][31]. However, the magnitude of effect may be attenuated in treatment-resistant populations and when controlling for depression severity [19][28][9].

Mechanisms and Biomarkers

Mechanistic studies suggest that TMS’s antisuicidal effects may be mediated by modulation of reward circuitry (DLPFC–nucleus accumbens pathway), normalization of brain network connectivity, increases in neuroplasticity, and changes in neurotrophic factors such as BDNF [7][13][14][15][16][17][18]. Biomarkers such as cortical inhibition (LICI, N100) measured by TMS-EEG have been identified as predictors of remission of suicidal ideation, particularly following magnetic seizure therapy (MST) [14][15][32]. Changes in anhedonia and self-referential processing may also mediate TMS’s effects on suicidality [33][34].

Safety, Tolerability, and Limitations

TMS is generally safe and well-tolerated, with most adverse events being mild and transient (e.g., headache, scalp discomfort) [2][3][4][6]. Serious adverse events, including increased suicidality, are rare [35][36][2][3][4][6]. Limitations across studies include small sample sizes, methodological heterogeneity, lack of suicide-specific outcome measures, and limited long-term follow-up [19][36][3][4][28][6][29].

Discussion

The current literature provides moderate to strong evidence that TMS, particularly rTMS targeting the DLPFC, is effective in reducing suicidal ideation in patients with depression, including those with treatment-resistant forms [7][1][8][2][3][4][5][6]. The antisuicidal effects of TMS are often observed rapidly and may be partially independent of overall depression improvement, suggesting a direct neuromodulatory effect on suicidality-related circuits [7][8][5][18][34]. Mechanistic studies highlight the importance of reward circuitry, neuroplasticity, and cortical inhibition as potential mediators, with emerging biomarkers that could guide personalized treatment [7][13][14][15][16][17][18][32].

Despite these promising findings, the field faces several challenges. Many studies are limited by small sample sizes, lack of sham controls, and heterogeneity in TMS protocols and outcome measures [19][36][3][4][28][6][29]. The evidence is strongest for adults with MDD, while data for adolescents, elderly, and those with comorbidities remain limited and sometimes inconclusive [19][20][21][10][22][23][24][25][26]. Safety data are reassuring, but long-term effects and optimal maintenance strategies require further study [2][3][4][22][6].

Overall, TMS represents a valuable addition to the therapeutic arsenal for depression with suicidality, but more high-quality, suicide-specific research is needed to optimize protocols, identify responders, and clarify mechanisms.

ClaimEvidence StrengthReasoningCitations
TMS reduces suicidal ideation in depression compared to sham/controlEvidence strength: Strong (8/10)Supported by multiple RCTs, meta-analyses, and systematic reviews[7][1][8][2][3][4][5][6]
Bilateral/high-frequency rTMS and iTBS are particularly effectiveEvidence strength: Moderate (7/10)Subgroup/meta-analytic and RCT data show superior effects for these protocols[7][8][9][10][5][6][29]
TMS’s antisuicidal effects may be independent of depression responseEvidence strength: Moderate (6/10)Some studies show SI reduction not fully explained by depression improvement[36][5][18][34]
TMS is safe and well-tolerated for depression with suicidalityEvidence strength: Strong (8/10)Large studies and reviews report low rates of serious adverse events[35][2][3][4][6]
Mechanistic biomarkers (e.g., cortical inhibition) predict responseEvidence strength: Moderate (5/10)Biomarker studies show predictive value, but more validation needed[14][15][16][17][32]
Efficacy in adolescents, elderly, and comorbid populations is unclearEvidence strength: Weak (3/10)Limited, heterogeneous, or inconclusive data in these subgroups[19][20][21][10][22][23][24][25][26]

Conclusion

In summary, TMS—especially rTMS targeting the DLPFC—shows moderate to strong efficacy in reducing suicidal ideation in depression, with rapid onset, good tolerability, and emerging mechanistic insights. However, further research is needed to optimize protocols, identify biomarkers, and address gaps in specific populations.

Research Gaps

Despite substantial progress, research gaps remain in the long-term efficacy and maintenance of TMS for suicidality, optimal protocols for subpopulations (adolescents, elderly, comorbidities), and the development of validated biomarkers for treatment response.

If you’re struggling or in crisis, call or text 988—you’re not alone, and support is available 24/7.

References

  1. Cui, Y., Fang, H., Bao, C., Geng, W., Yu, F., & Li, X. Efficacy of Transcranial Magnetic Stimulation for Reducing Suicidal Ideation in Depression: A Meta-Analysis. Frontiers in Psychiatry. 2021; 12. https://doi.org/10.3389/fpsyt.2021.764183
  2. Chen, G., Hsu, T., Ching, P., Pan, C., Chou, P., & Chu, C. Efficacy and Tolerability of Repetitive Transcranial Magnetic Stimulation on Suicidal Ideation: A Systemic Review and Meta-Analysis. Frontiers in Psychiatry. 2022; 13. https://doi.org/10.3389/fpsyt.2022.884390
  3. Serafini, G., Canepa, G., Aguglia, A., Amerio, A., Bianchi, D., Magnani, L., Dell’Osso, B., Pompili, M., Fitzgerald, P., & Amore, M. Effects of repetitive transcranial magnetic stimulation on suicidal behavior: A systematic review. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2020; 105. https://doi.org/10.1016/j.pnpbp.2020.109981
  4. Godi, S., Spoorthy, M., Purushotham, A., & Tikka, S. Repetitive transcranial magnetic stimulation and its role in suicidality – A systematic review.. Asian journal of psychiatry. 2021; 63. https://doi.org/10.1016/j.ajp.2021.102755
  5. Weissman, C., Blumberger, D., Brown, P., Isserles, M., Rajji, T., Downar, J., Mulsant, B., Fitzgerald, P., & Daskalakis, Z. Bilateral Repetitive Transcranial Magnetic Stimulation Decreases Suicidal Ideation in Depression.. The Journal of clinical psychiatry. 2018; 79 3. https://doi.org/10.4088/JCP.17m11692
  6. J., M., A., C., M., J., X., T., E., C., L., A., & L., C. The Effectiveness of Transcranial Magnetic Stimulation in Suicidality: An Updated Systematic Review. medRxiv. 2025 https://doi.org/10.1101/2025.05.05.25327034
  7. Huang, X., Xi, C., Fang, Y., Ye, R., Wang, X., Zhang, S., Cui, Y., Guo, Y., Zhang, J., Ji, G., Zhu, C., Luo, Y., Chen, X., Wang, K., Tian, Y., & Yu, F. Therapeutic Efficacy of Reward Circuit‐Targeted Transcranial Magnetic Stimulation (TMS) on Suicidal Ideation in Depressed Patients: A Sham‐Controlled Trial of Two TMS Protocols. Depression and Anxiety. 2025 https://doi.org/10.1155/da/1767477
  8. Pan, F., Shen, Z., Jiao, J., Chen, J., Li, S., Lu, J., Duan, J., Wei, N., Shang, D., Hu, S., Xu, Y., & Huang, M. Neuronavigation‐Guided rTMS for the Treatment of Depressive Patients With Suicidal Ideation: A Double‐Blind, Randomized, Sham‐Controlled Trial. Clinical Pharmacology & Therapeutics. 2020; 108. https://doi.org/10.1002/cpt.1858
  9. Wang, Q., Huang, H., Li, D., Wang, Y., Qi, N., Ci, Y., & Xu, T. Intensive rTMS for treatment-resistant depression patients with suicidal ideation: An open-label study.. Asian journal of psychiatry. 2022; 74. https://doi.org/10.1016/j.ajp.2022.103189
  10. Sun, Y., Liu, X., Li, Y., Zhi, Q., & Xia, Y. Effectiveness of individualized rTMS under sMRI guidance in reducing depressive symptoms and suicidal ideation in adolescents with depressive disorders: an open-label study. Frontiers in Psychiatry. 2024; 15. https://doi.org/10.3389/fpsyt.2024.1485878
  11. George, M., Raman, R., Benedek, D., Pelic, C., Grammer, G., Stokes, K., Schmidt, M., Spiegel, C., DeAlmeida, N., Beaver, K., Borckardt, J., Sun, X., Jain, S., & Stein, M. A Two-site Pilot Randomized 3 Day Trial of High Dose Left Prefrontal Repetitive Transcranial Magnetic Stimulation (rTMS) for Suicidal Inpatients. Brain Stimulation. 2014; 7. https://doi.org/10.1016/j.brs.2014.03.006
  12. Hines, C., Mooney, S., Wilkie, D., Watson, N., & Looney, S. Repetitive transcranial magnetic stimulation promotes rapid psychiatric stabilization in acutely suicidal military service members. Brain Stimulation. 2021; 14. https://doi.org/10.1097/YCT.0000000000000810
  13. Zhang, Y., Mu, N., Qi, S., Sun, C., Rao, Y., Yang, X., Guo, J., & Mu, Y. Improved brain functional network in major depressive disorder with suicidal ideation after individual target-transcranial magnetic stimulation treatment: a graph-theory analysis. Frontiers in Psychiatry. 2025; 16. https://doi.org/10.3389/fpsyt.2025.1486835
  14. Sun, Y., Blumberger, D., Mulsant, B., Rajji, T., Fitzgerald, P., Barr, M., Downar, J., Wong, W., Farzan, F., & Daskalakis, Z. Magnetic seizure therapy reduces suicidal ideation and produces neuroplasticity in treatment-resistant depression. Translational Psychiatry. 2018; 8. https://doi.org/10.1038/s41398-018-0302-8
  15. Sun, Y., Farzan, F., Mulsant, B., Rajji, T., Fitzgerald, P., Barr, M., Downar, J., Wong, W., Blumberger, D., & Daskalakis, Z. Indicators for Remission of Suicidal Ideation Following Magnetic Seizure Therapy in Patients With Treatment-Resistant Depression.. JAMA psychiatry. 2016; 73 4. https://doi.org/10.1001/jamapsychiatry.2015.3097
  16. Tang, N., Sun, C., Wang, Y., Li, X., Liu, J., Chen, Y., Sun, L., Rao, Y., Li, S., Qi, S., & Wang, H. Clinical Response of Major Depressive Disorder Patients With Suicidal Ideation to Individual Target-Transcranial Magnetic Stimulation. Frontiers in Psychiatry. 2021; 12. https://doi.org/10.3389/fpsyt.2021.768819
  17. Pan, F., Mou, T., Shao, J., Chen, H., Tao, S., Wang, L., Jiang, C., Zhao, M., Wang, Z., Hu, S., Xu, Y., & Huang, M. Effects of neuronavigation-guided rTMS on serum BDNF, TrkB and VGF levels in depressive patients with suicidal ideation.. Journal of affective disorders. 2022 https://doi.org/10.1016/j.jad.2022.11.059
  18. Barredo, J., Berlow, Y., Swearingen, H., Greenberg, B., Carpenter, L., & Philip, N. Multimodal Elements of Suicidality Reduction After Transcranial Magnetic Stimulation. Neuromodulation : journal of the International Neuromodulation Society. 2021; 24. https://doi.org/10.1111/ner.13376
  19. Croarkin, P., Nakonezny, P., Deng, Z., Romanowicz, M., Voort, J., Camsari, D., Schak, K., Port, J., & Lewis, C. High-frequency repetitive TMS for suicidal ideation in adolescents with depression.. Journal of affective disorders. 2018; 239. https://doi.org/10.1016/j.jad.2018.06.048
  20. Ozcan, S., Gıca, Ş., & Gulec, H. Suicidal behavior in treatment resistant major depressive disorder patients treated with transmagnetic stimulation(TMS) and its relationship with cognitive functions. Psychiatry Research. 2020; 286. https://doi.org/10.1016/j.psychres.2020.112873
  21. Van Daele, A., Zeeuws, D., & Baeken, C. Suicidality during neuromodulation in the elderly depressed: study design. European Psychiatry. 2022; 65. https://doi.org/10.1192/j.eurpsy.2022.1902
  22. Hickson, R., Simonsen, M., Miller, K., & Madore, M. Durability of deep transcranial magnetic stimulation for veterans with treatment resistant depression with comorbid suicide risk and PTSD symptoms. Psychiatry Research. 2023; 332. https://doi.org/10.1016/j.psychres.2023.115690
  23. Zhan, D., Gregory, E., Humaira, A., Wong, H., Klonsky, E., Levit, A., Ridgway, L., & Vila-Rodriguez, F. Trajectories of suicidal ideation during rTMS for treatment-resistant depression.. Journal of affective disorders. 2024 https://doi.org/10.1016/j.jad.2024.05.109
  24. Zhang, T., Zhu, J., Wang, J., Tang, Y., Xu, L., Tang, X., Hu, Y., Wei, Y., Cui, H., Liu, X., Hui, L., Li, C., & Wang, J. An Open-label Trial of Adjuvant High-frequency Left Prefrontal Repetitive Transcranial Magnetic Stimulation for Treating Suicidal Ideation in Adolescents and Adults With Depression.. The Journal of ECT. 2020 https://doi.org/10.1097/YCT.0000000000000739
  25. Dai, L., Wang, P., Zhang, P., Guo, Q., Du, H., Li, F., He, X., & Luan, R. The therapeutic effect of repetitive transcranial magnetic stimulation in elderly depression patients. Medicine. 2020; 99. https://doi.org/10.1097/MD.0000000000021493
  26. Wall, M., Croarkin, D., Sim, P., Husain, M., Janicak, M., Kozel, M., Emslie, M., Dowd, M., & Sampson, P. Adjunctive use of repetitive transcranial magnetic stimulation in depressed adolescents: a prospective, open pilot study.. The Journal of clinical psychiatry. 2011; 72 9. https://doi.org/10.4088/JCP.11m07003
  27. Yesavage, J., Fairchild, K., Mi, Z., Biswas, K., Davis-Karim, A., Phibbs, C., Forman, S., Thase, M., Williams, L., Etkin, A., O’Hara, R., Georgette, G., Beale, T., Huang, G., Noda, A., & George, M. Effect of Repetitive Transcranial Magnetic Stimulation on Treatment-Resistant Major Depression in US Veterans: A Randomized Clinical Trial. JAMA Psychiatry. 2018; 75. https://doi.org/10.1001/jamapsychiatry.2018.1483
  28. Mehta, S., Konstantinou, G., Weissman, C., Daskalakis, Z., Voineskos, D., Downar, J., Mulsant, B., & Blumberger, D. The Effect of Repetitive Transcranial Magnetic Stimulation on Suicidal Ideation in Treatment-Resistant Depression: A Meta-Analysis.. The Journal of clinical psychiatry. 2022; 83 2. https://doi.org/10.4088/jcp.21r13969
  29. Neuteboom, D., Zantvoord, J., Goya-Maldonado, R., Wilkening, J., Dols, A., Van Exel, E., Lok, A., De Haan, L., & Scheepstra, K. Accelerated intermittent theta burst stimulation in major depressive disorder: A systematic review. Psychiatry Research. 2023; 327. https://doi.org/10.1016/j.psychres.2023.115429
  30. Dai, L., Wang, P., Du, H., Guo, Q., Li, F., He, X., & Zou, S. High-frequency repetitive transcranial magnetic stimulation (rTMS) accelerates onset time of beneficial treating effects and improves clinical symptoms of depression.. CNS & neurological disorders drug targets. 2021 https://doi.org/10.2174/1871527320666211104123343
  31. Qin, B., Dai, L., & Zheng, Y. [Efficacy of repetitive transcranial magnetic stimulation for alleviating clinical symptoms and suicidal ideation in elderly depressive patients: a randomized controlled trial].. Nan fang yi ke da xue xue bao = Journal of Southern Medical University. 2017; 37 1.
  32. Daskalakis, Z., McClintock, S., Hadas, I., Kallioniemi, E., Zomorrodi, R., Throop, A., Palmer, L., Farzan, F., Thorpe, K., Tamminga, C., & Blumberger, D. Confirmatory Efficacy and Safety Trial of Magnetic Seizure Therapy for Depression (CREST-MST): protocol for identification of novel biomarkers via neurophysiology. Trials. 2021; 22. https://doi.org/10.1186/s13063-021-05873-7
  33. Terpstra, A., Vila-Rodriguez, F., LeMoult, J., Chakrabarty, T., Nair, M., Humaira, A., Gregory, E., & Todd, R. Cognitive-affective processes and suicidality in response to repetitive transcranial magnetic stimulation for treatment resistant depression.. Journal of affective disorders. 2022; 321. https://doi.org/10.1016/j.jad.2022.10.041
  34. Sonmez, A., Webler, R., Krueger, A., Godoy-Henderson, C., Sullivan, C., Wilson, S., Olsen, S., Schmid, S., Herman, A., Widge, A., Peterson, C., Nahas, Z., & Albott, C. Effects of TMS on Anhedonia and Suicidal Ideation in TRD: Outcomes from the University of Minnesota Interventional Psychiatry Program. Journal of Mood & Anxiety Disorders. 2024 https://doi.org/10.1016/j.xjmad.2024.100073
  35. Abdelnaim, M., Langguth, B., Deppe, M., Mohonko, A., Kreuzer, P., Poeppl, T., Hebel, T., & Schecklmann, M. Anti-Suicidal Efficacy of Repetitive Transcranial Magnetic Stimulation in Depressive Patients: A Retrospective Analysis of a Large Sample. Frontiers in Psychiatry. 2020; 10. https://doi.org/10.3389/fpsyt.2019.00929
  36. Bozzay, M., Primack, J., Barredo, J., & Philip, N. Transcranial magnetic stimulation to reduce suicidality – A review and naturalistic outcomes.. Journal of psychiatric research. 2020; 125. https://doi.org/10.1016/j.jpsychires.2020.03.016
Posted in Depression, Transcranial Magnetic Stimulation (TMS) and tagged ,

Leave a Comment