Abstract: Objective To assess the efficacy of repetitive transcranial magnetic stimulation (rTMS) for alleviating the clinical symptoms and suicidal ideation in elderly patients with depression. Methods A total of 178 elderly depressive patients with suicidal ideation were randomized into rTMS treatment group (n=80) and control group (n=98) and treated with rTMS or sham rTMS treatment for 4 weeks in addition to conventional therapy with medications. The 24-item Hamilton Depression Scales (HAMD) and Self-rating Idea of Suicide Scale (SIOSS) were used to assess the severity of depression and the risk of suicide at the baseline and after 2 and 4 weeks of treatment. The treatment response was defined as a 25% reduction in HAMD scores from baseline, and an early improvement as 20% reduction in HAMD scores after 2 weeks of treatment. Results The two groups of patients were comparable for baseline socio-demographic characteristics and baseline SIOSS and HAMD scores (P> 0.05). After 2 and 4 weeks of treatment, both SIOSS and HAMD scores were improved in the two groups, but the patients in rTMS group showed a significantly faster score reduction. A significantly higher rate of early improvement at 2 weeks (52.5% vs 28.6%; χ2=10.569, P<0.01) and a higher response rate at 4 weeks (77.5% vs 53.1%; χ2=15.470, P<0.05) were observed in rTMS group. Conclusions rTMS combined with medications can effectively improve sleep quality, cognitive impairment and somatization symptom and reduce suicidal ideation in elderly patients with depression.