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At present it is estimated that nearly 8%-16% of the elderly (aged > 65) living in the community suffer from clinically significant depressive symptoms[1], a harbinger of significant morbidity and early mortality[2]. Older age of a depressed patient is a significant predictor of an unfavourable course with an increased risk of relapse[3], reduced likelihood of treatment response[4,5] and diminished chance of functional recovery[6]. AZD9291 concentration Furthermore, the emergence of treatment resistant depression (TRD) is common among the elderly, with an estimated rate of between 26 and 41 per 100 person-years[7]. An important challenge in optimally treating geriatric depression is the reduced utility of conventional antidepressant treatments. Randomised Controlled Trials (RCTs) of antidepressants reveal a smaller size of treatment effect among the elderly compared to the younger age groups. The number needed to treat (NNT) for antidepressant vs placebo use for an acute response goes up steadily with age with estimated numbers of 6 in those aged 65 years[5]. This difference may be related to the differences in the pathophysiology and phenomenology of depression among older people. Whilst depression is mostly a disorder of young adults (peak age of onset in 20 s, with a trend towards more younger age of onset in younger cohorts), late-onset depression (after age 50) has a higher probability of medical comorbidity. There are 2 groups of individuals among those click here with geriatric depression: one with an early onset (YES1 more psychomotor retardation, less agitation and guilt, and more disability[10]. These factors in general predict poorer response to antidepressants[10]. Furthermore, even among the elderly depressed with early-onset depression, the prevalence of treatment resistance is substantial[7], and the risk of relapse despite successful treatment is particularly high[3], highlighting the critical need to focus on alternative treatments that have fewer propensities to affect cognitive faculties and physical frailty while reducing the persistence of symptom burden. Transcranial magnetic stimulation (TMS) involves the use of magnetic field applied on the surface of scalp to modulate brain function in a non-invasive manner. Repetitive TMS (also called rTMS) is a promising intervention for depression with a treatment effect size as large as the effect size seen when using antidepressant medications for depression[11-13].