Why health authorities should endorse rTMS for treatment-resistant depression

Repetitive Transcranial Magnetic Stimulation (rTMS) is a widely used noninvasive brain stimulation technique that has been approved for treatment-resistant depression (TRD) in many countries. A growing divergence in national health authority positions has reignited debate over the role of rTMS in the treatment of treatment-resistant depression (TRD). While numerous countries—including the United States, Canada, and Australia—have endorsed and reimbursed rTMS based on robust meta-analytic evidence, other jurisdictions have issued more restrictive or inconclusive recommendations. These contrasting stances reflect significant variability in how health authorities interpret the clinical and cost-effectiveness data, leading to inconsistent access and coverage worldwide. This heterogeneity has sparked ongoing controversies in multiple countries, including recent policy discussions in Australia and Europe, highlighting the need for clearer, evidence-aligned guidance at the international level. The striking contrast between the evidence for efficacy of rTMS in TRD and the lack of recommendation from some national health authorities raises particularly important questions since it leads to many serious consequences from public health and medico-economic standpoints. In this article, we argue that health authority endorsement of rTMS for TRD is justified on clinical, safety, and economic grounds. We further propose that such endorsement should be linked to three prerequisites—training certification, defined therapeutic positioning, and standardized clinical protocols. Training and accreditation frameworks should be implemented at scale to facilitate the approval of rTMS by health authorities, enabling widespread, high-quality delivery, optimizing outcomes, and generating health economic returns.