The Use of Repetitive Transcranial Magnetic Stimulation (rTMS), Electroconvulsive Therapy (ECT), Ketamine, and Esketamine in Reducing Suicidality in Major Depressive Disorder: A Comprehensive Narrative Review

• All interventions are associated with reductions in suicidal ideation, and in some cases suicidal behavior, in major depressive disorder. • Ketamine and esketamine produced the most rapid reductions in suicidal ideation, while TMS and ECT demonstrated the longest-lasting effects. • Further research assessing the long-term effects of these interventions on measures of suicidality is required. Although repetitive transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), ketamine, and esketamine have established antidepressant effects, their effects on suicide outcomes are less reported. This comprehensive narrative review aims to analyze the antisuicidal effects of these interventions in individuals with major depressive disorder (MDD). Search terms for this review included words related to the interventions of interest, suicidality, and depression. Databases included PubMed, OVID, and Google Scholar, with the search occurring from inception to June 19, 2025. Screening of studies, data extraction, and quality assessment of studies using NIH tools were performed. 108 studies met the eligibility criteria and were included in the review, with 30 studies investigating the effects of rTMS, 9 for ECT, 53 for ketamine, and 24 for esketamine. Some studies investigated the use of multiple interventions. All interventions were effective in reducing suicidality (p<0.05), particularly in the suicidal ideation (SI) dimension, with variations in the time of onset and duration of antisuicidal effects. rTMS and ECT demonstrated the longest-lasting effects in reducing SI and suicidal behavior while treatment with ketamine and esketamine resulted in the fastest reductions in measures of suicidality. Ketamine, esketamine, rTMS and ECT are associated with reductions in SI in persons with MDD, with the strongest evidence from randomized controlled trials supporting rapid, short-term effects, particularly for ketamine and esketamine. Further characterization and differentiation of the durability of antisuicidal effects of the aforementioned interventions requires investigation in large-scale, adequately-controlled clinical trials. In addition, whether reductions in SI following administration of these agents reduces the severity of aspects of suicidal behavior should be evaluated.