Therapeutic funding decision – Repetitive transcranial magnetic stimulation for treatment-resistant depression 

When repetitive transcranial magnetic stimulation is used  

Repetitive transcranial magnetic stimulation is a non-invasive treatment for major depressive disorder. It’s specifically used for people with treatment-resistant depression who haven’t improved after trying at least two antidepressants at appropriate dose and duration. The treatment sends repeated magnetic pulses to the brain to affect areas that help control mood. It’s generally well tolerated, doesn’t require anesthesia and can be provided to both inpatients and outpatients.

Funding criteria  

The Drug and Therapeutics Advisory Committee met in December 2025 and June 2026 to discuss funding for repetitive transcranial magnetic stimulation devices for use by people with treatment-resistant depression. They reviewed current public sector funding status, Ontario Health Technology Advisory Committee reports and recent evidence-based consensus guidelines.

Initial treatment

The Drug and Therapeutics Advisory Committee recommends that we approve funding for repetitive transcranial magnetic stimulation (rTMS) devices for initial treatment and retreatment when the following criteria are met. For funding approval, the definition of treatment-resistant depression is when a person fails to achieve an adequate response after two or more adequate trials of antidepressant therapy at an appropriate dose and duration.  

Initial treatment:  

  1. The device is approved by Health Canada for the treatment of depression.  
  2. There are no known contraindications.  
  3. The treating psychiatrist selects a treatment protocol that aligns with clinical guidelines, including one of the following:  

a. High frequency rTMS to left dorsolateral prefrontal cortex

b. Low frequency rTMS to right dorsolateral prefrontal cortex

c. Intermittent theta burst stimulation to left dorsolateral prefrontal cortex  

d. Sequential bilateral rTMS  

e. Accelerated intermittent theta burst stimulation protocols (for those with accessibility challenges)  

f. Sequential bilateral theta burst stimulation

4. Treatment is provided once daily, up to five days per week, for four to six weeks, to a maximum of 20 to 30 sessions.  

We consider approval of funding for initial treatment for up to seven weeks.

Retreatment after initial treatment:  

We consider approval for retreatment after the initial treatment if criteria one to four was met in the initial treatment, and:  

  • there was at least a 50 per cent improvement from baseline on a validated rating scale after the initial treatment 
  • at least four months have passed since the previous treatment cycle
  • there’s been a demonstrated clinical relapse based on clinical evaluation and a validated rating scale

Recommendation highlights  

  • In Canada, repetitive transcranial magnetic stimulation is publicly funded for treatment-resistant depression in Quebec, Alberta, and Saskatchewan, and has become available in Ontario in 2026 through select hospitals.  
  • The Canadian Network for Mood and Anxiety Treatments guidelines recommend repetitive transcranial magnetic stimulation as a first-line neurostimulation treatment for adults with major depressive disorder who have failed antidepressant trials. For patients with treatment-resistant depression, it’s considered a primary option, especially when medication tolerability is a concern or when a person previously responded well to it. The guidelines suggest this treatment should be considered before electroconvulsive therapy because it’s less invasive and more favourable from a safety standpoint.  
  • The Ontario Health Technology Advisory Committee review (2021) found that high frequency repetitive transcranial magnetic stimulation and intermittent theta burst stimulation treatments are likely cost-effective for people with treatment-resistant depression and recommends publicly funding it with properly managed patient selection and ongoing monitoring throughout treatment.