The Effectiveness of rTMS in Depressed VA Patients

Inclusion Criteria: * Between 18 and 80 years of age * Using the Structured Clinical Interview for Diagnostic and Statistical Manual (DSM) Disorders (SCID) for DSM-IV-TR (First et al. 2002) patients will be diagnosed Major Depressive Disorder (MDD). * Have a Hamilton Rating Scale for Depression (HRSD-24) score greater or equal to 20 no more than 7 days prior to randomization. * Exhibit moderate level of resistance to antidepressant treatment defined, using the Antidepressant Treatment History Form (ATHF) (Sackeim et al. 1990), as failure of at least two adequate medication trials. * Duration of current episode of less than or equal to 10 years. * Ability to obtain a Motor Threshold (MT) (should be determined at the end of the screening process). * Currently under the care of a VA psychiatrist. * If on a psychotropic medication regimen, that regimen will be stable for at least 4 weeks prior to randomization and patient will be willing to remain on a stable regimen during the acute treatment phase. * Has an adequately stable condition and environment to enable attendance at scheduled clinic visits. * For female participants, agrees to use one of the following acceptable methods of birth control * Complete abstinence (not having sexual intercourse with anyone) * An oral contraceptive (birth control pills) * Norplant * Depo-Provera * A condom with spermicide * A cervical cap with spermicide * A diaphragm with spermicide * An Intrauterine device * Surgical sterilization (having tubes tied) * Able to read, verbalize understanding and voluntarily sign the Informed Consent Form prior to performance of any study-specific procedures or assessments. Exclusion Criteria: * Pregnant or lactating female (This is an FDA-required exclusion. In the future, if rTMS becomes a proven treatment for major depression, its safety in the context of pregnancy should be studied separately (Nahas et al. 1999). * Unable to be safely withdrawn, at least two-weeks prior to treatment commencement, from medications that substantially increase the risk of having seizures. For the purpose of this study, those medications are listed in Appendix G (for example, theophylline). * Have a cardiac pacemaker. * Have an implanted device (deep brain stimulation) or metal in the brain. * Have a cochlear implant. * Have a mass lesion, cerebral infarct, increased intracranial pressure, or other active central nervous system (CNS) disease, including a seizure disorder. * Known current psychosis as determined by DSM-IV or SCID (axis I, psychotic disorder, schizophrenia) or a history of a non-mood psychotic disorder. * Known current Bipolar I disorder as determined by SCID or a History of Bipolar I disorder. * Current amnestic disorders, dementia, Blessed Orientation-Memory-Concentration (BOMC) greater than 10, delirium, or other cognitive disorders. * Current substance abuse (not including caffeine or nicotine) as determined by positive toxicology screen, or by history via SCID, within 3 months prior to screening. * Patients with an elevated risk of seizure due to traumatic brain injury (TBI). * Participation in another concurrent clinical trial. * Patients with prior exposure to rTMS. * Active current suicidal intent or plan as evidenced by a score of 4 or 5 on the suicidal ideation portion of the Columbia Suicide Severity Rating Scale (C-SSRS) or the endorsement of an actual attempt, interrupted attempt, or an aborted attempt in the past 6 months. All patients will be required to establish a written safety plan involving their primary psychiatrist and the treatment team before entering the clinical trial (See Section X.B.8). * Unstable cardiac disease or recent (\< 3 months previous) myocardial infarction. * Patient refuses to sign consent for participation in the study.