What the Latest Research Shows and Why It Matters 

Quick Summary

• TMS produced faster, more sustained relief from depression than esketamine (Spravato) in a study of nearly 5,000 patients
• TMS led to far more durable remission of suicidal thoughts than esketamine with a 39% lower risk of relapse after initial improvement
• At 6 months, 36.7% of TMS patients had lasting remission of suicidal ideation, versus 23.0% of esketamine patients
• Deep TMS has helped patients who’d already failed rTMS, ECT, and ketamine. Real-world case series show meaningful improvement with Deep TMS even in the toughest, most treatment-resistant cases
• Veterans and first responders, who carry a heavy load of treatment-resistant depression, PTSD, and suicide risk are especially good candidates for TMS

Jump to: How TMS Compares to Esketamine   |   Suicidal Thoughts   |   When Other Treatments Fail   |   Veterans and First Responders

If you or someone you love has been through the wringer with depression that just won’t lift, you’ve probably already heard the usual list: try another antidepressant, try therapy, maybe esketamine (Spravato), maybe TMS, maybe electroconvulsive therapy (ECT). When you’ve already failed a few medications picking the next step can feel like a coin flip and it’s a much heavier decision when suicidal thoughts are part of the picture.

Some new research, presented at the 2026 Clinical TMS Society Annual Meeting, gives us a clearer answer than we’ve had before. It’s some of the largest, most direct evidence comparing TMS head-to-head with esketamine, and the results are genuinely encouraging  for people who’ve already cycled through several treatments of medications and therapy without lasting relief. Here’s what the research actually found, and why it matters for everyone and also for military and RCMP veterans.

How TMS Compares to Esketamine for Depression

Esketamine is a nasal spray approved for treatment-resistant depression. A lot of people respond to it quickly, and it’s become a go-to option over the past few years. However, the risk of dependency and the lack of durability have always been concerns with this treatment. TMS works differently. it’s a non-invasive treatment using magnetic pulses to stimulate the parts of the brain involved in mood regulation. No medication, no sedation, nothing entering your bloodstream. Patients drive themselves home afterward and go on with their day.

One study tracked nearly 5,000 patients with treatment-resistant depression in real-world clinical practice — 4,314 on TMS, 640 on esketamine. Everyone was treated by trained, board-certified providers, with symptoms tracked on standard depression and anxiety scales over six months.

Both treatments worked and Esketamine genuinely helps a lot of people. But, it’s important to note that when the two groups were compared directly, TMS pulled ahead in a few important ways. Patients on TMS improved faster and kept improving more consistently across the full six months, rather than plateauing or slipping back. Response rates were higher too: just under 40% of TMS patients hit a clinically meaningful response, compared to 33% on esketamine. Full remission was nearly double — 19.4% versus 12.8%. And looking at total symptom burden across the 90- and 180-day marks, TMS patients simply carried less depression with them throughout.

Put simply: people on TMS were, on average, more likely to actually feel better and more likely to stay that way.

A Closer Look at Suicidal Thoughts

This next part is probably the most important finding in the bunch. Most depression drug trials exclude anyone reporting suicidal thoughts, which leaves a real blind spot in the research right where it’s needed most.

A separate study filled that gap. Researchers followed over 2,000 TMS patients and 346 esketamine patients, all of whom had reported some level of suicidal ideation when they started treatment. The team tracked how fast the thoughts eased, how often they came back, and how many people had lasting relief at six months.

What they found was nuanced. Early on, the two treatments looked about the same with no real difference in how quickly suicidal thoughts initially improved. But the gap opened up over time. People who’d improved on TMS were about 39% less likely to relapse back into suicidal thinking in the months that followed. And by six months, 36.7% of TMS patients had lasting remission of suicidal ideation, compared to just 23.0% on esketamine.

That durability piece matters a lot in real life. A treatment that lifts suicidal thoughts only for them to creep back a few weeks later puts someone through a brutal cycle. What this study suggests is that TMS may offer something steadier with real, lasting protection during a period when someone is genuinely at risk.

When Other Treatments Have Failed

For a lot of patients, esketamine and TMS aren’t even the first things tried. By the time someone gets there, they’ve usually already worked through several antidepressants, maybe ECT, maybe ketamine infusions and still come up short. So what happens when even classical rTMS hasn’t worked yet, or when nothing has?

A case series looked at exactly that. Nine patients with severe, stubborn treatment-resistant depression — every one of them had already failed extensive medication trials, standard rTMS, ECT (seven of the nine), and ketamine in some form. These were about as difficult as cases get.

They went on to try deep TMS (dTMS), which uses a coil designed to reach broader, deeper brain regions than a standard rTMS coil. The results were hard to ignore: average depression scores fell from severe to minimal, nearly 89% of patients responded, and almost half hit full remission. 

Nine patients isn’t a large enough group to draw firm conclusions from but it tells us something worth knowing  that real improvement is still possible after a long run of disappointments. For anyone who’s been told “we’ve tried everything,” that’s not a small thing to hear.

Why This Matters So Much for Veterans and RCMP Members

Treatment-resistant depression rarely travels alone. It tends to show up with PTSD, chronic pain, broken sleep, and a higher risk of suicide. This combination is all too familiar among military veterans and RCMP members. Operational stress injuries and operator syndrome and the weight of years in high-stress, high-stakes careers can produce depression and PTSD that simply don’t respond to medications and therapy. This is why Medavie Blue Cross approved Transcranial Magnetic Stimulation for veterans with a pensionable mental health condition and lack of response to at least 2 medications.  Most of the veterans and first responders we see have already been through several medications, sometimes several types of therapy, long before they ever hear the word “TMS.” Most of these individuals, in fact, 2 out of 3 veterans that we see for TMS have a meaningful and sustained improvement in their lives. 

This is exactly the group the research above speaks to most directly.

Treatment resistance isn’t the exception here. It’s closer to the norm. Veterans often carry depression that’s lasted years, frequently tangled up with PTSD. The case series on patients who’d failed rTMS, ECT, and ketamine describes a lot of the people who walk through our doors.

Suicide risk is a real and serious concern in this community, which is exactly why the durability finding matters so much. A treatment that doesn’t just ease suicidal thoughts but keeps them from coming back months later offers a kind of protection that genuinely counts during a high-risk stretch of someone’s life.

Many veterans and RCMP members would also rather avoid adding another medication. A lot are already managing several drugs for physical injuries, chronic pain, or other psychiatric symptoms, and understandably don’t want to add one more — particularly one like esketamine that requires in-clinic dosing and monitoring. TMS sidesteps all of that: no added medication burden, no systemic side effects.

And access keeps getting better. For Canadian veterans, Deep TMS is eligible for coverage through Veterans Affairs Canada for many veterans in the right clinical circumstances, and it’s approved by Health Canada for major depressive disorder. If you’re a veteran or RCMP member looking into this, talk to our clinical team and we can let you know if this treatment is an option for you. 

What This Means If You’re Considering Treatment

No single study should make the decision for you. What’s right depends on your own history, symptoms, and the bigger clinical picture. Esketamine is still a solid, effective option for a lot of people, and some patients do best with a combination of treatments over time. But what this research tells us, clearly, is that TMS holds up extremely well. In fact, in the ways that matter most, like durability, remission, and especially lasting relief from suicidal thoughts, it comes out ahead of esketamine in large real-world populations.

If antidepressants and therapy haven’t worked enough, if PTSD and depression have been feeding each other for years, or if you’ve been through treatment after treatment without anything sticking, it might be worth a conversation about TMS. For CAF and RCMP veterans and RCMP members especially who carry more than their share of this burden this research is a genuine reason for hope.

This article summarizes findings presented at the 2026 Clinical TMS Society Annual Meeting and is intended for general educational purposes. It is not a substitute for individualized medical advice. Please speak with our clinical team to determine whether TMS is an appropriate treatment option for your specific situation.