The antidepressant effects of TMS and medications have been demonstrated in numerous studies, but only approximately one-third of patients achieve full remission using standard protocols [1]. Over the past decade, newer TMS techniques have been developed that show promise in increasing remission rates including bilateral treatment, neuronavigation, and TBS. Neuronavigation allows improved precision in locating and maintaining the proper stimulation target [2]. Bilateral treatment has been shown to improve anxiety symptoms and may improve the antidepressant response [3]. TBS has shown clinical effectiveness with shorter treatment times and may have improved durability and efficacy [4]. Additionally, TBS applied at the particular pulse frequency of 20Hz (TBS-20Hz), rather than 50Hz (TBS-50Hz), brought more patients to remission in our clinic [5]. However, it is unclear whether newer TMS protocols significantly improve remission rates enough to justify their widespread adoption. We reviewed a cohort of 58 consecutive adult depression patients treated with bilateral neuronavigated TBS-20Hz to evaluate the effects of more recent off-label TMS techniques on clinical outcomes in a real-world, private practice setting.