Transcranial magnetic stimulation and 180-day risk of recurrent suicidal ideation in adults with moderate-to-severe major depressive disorder: A TriNetX propensity-matched cohort study
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TMS-exposed patients had lower recurrent suicidal ideation: 22.5% versus 33.9%; HR 0.584 (95% CI 0.500-0.681), p < 0.001.
Landmark sensitivity analysis excluding first 30 days attenuated association; recurrent ideation 17.5% versus 14.5%, HR 1.203 (95% CI 0.954-1.516), p = 0.118.
Overall conclusion: findings do not provide robust evidence that TMS independently reduces recurrent suicidal ideation in moderate-to-severe MDD.
J Psychiatr Res. 2026 Jun 22;201:225-230. doi: 10.1016/j.jpsychires.2026.06.025. Online ahead of print.
ABSTRACT
INTRODUCTION: Major depressive disorder (MDD) is strongly associated with suicidal ideation, a major predictor of suicide attempts and completed suicide. Transcranial magnetic stimulation (TMS) has shown promise in improving suicidal ideation, though the generalizability of these findings to routine clinical practice remains uncertain. This study evaluated whether TMS exposure was associated with recurrent suicidal ideation among adults with moderate-to-severe MDD using real-world electronic health record data.
METHODS: We conducted a retrospective cohort study using the TriNetX US Collaborative Network. Adults with moderate-to-severe MDD and documented suicidal ideation who received TMS were compared with matched patients not exposed to TMS. Propensity score matching and Kaplan-Meier and Cox proportional hazards analyses were performed. A landmark sensitivity analysis excluding outcomes within the first 30 days after index was conducted to address potential immortal time bias.
RESULTS: After matching, 1193 patients per cohort were included. Recurrent suicidal ideation occurred in 22.5% of TMS-exposed patients versus 33.9% of controls (HR 0.584, 95% CI 0.500-0.681; p < 0.001). In the landmark sensitivity analysis, recurrent suicidal ideation occurred in 17.5% of the TMS cohort and 14.5% of controls, and the association was no longer statistically significant (HR 1.203, 95% CI 0.954-1.516; p = 0.118).
CONCLUSION: The initially observed association between TMS exposure and lower recurrent suicidal ideation attenuated substantially after landmark sensitivity analysis addressing potential immortal time bias. These findings do not provide robust evidence that TMS independently reduces recurrent suicidal ideation in adults with moderate-to-severe MDD.
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