BACKGROUND: General psychiatrists' practice standards vary regarding when to implement transcranial magnetic stimulation (TMS) for care of patients with major depressive disorder (MDD). Furthermore, few studies have examined real-world utilization and clinical outcomes of TMS. This study analyzed data from a large, multi-site psychiatric practice to evaluate utilization and outcomes of TMS as well as usual care (UC) for patients with MDD. METHODS: Depression outcomes for TMS and UC among adult patients at a multi-site psychiatric group practice were examined in this retrospective cohort analysis. Patients with a primary diagnosis of MDD, PHQ-9 ≥ 10, and a visit in November 2020 with 6-month follow-up were included and categorized into the TMS or UC cohorts. RESULTS: Of 1,011 patients with qualifying PHQ-9 at the baseline visit, 9% (89) received a full course of TMS, and 583 patients receiving UC met study inclusion criteria (339 patients were excluded due to lacking a 6-month follow-up visit or receiving esketamine during the study period). The TMS cohort had higher baseline PHQ-9 than UC (17.9 vs. 15.5, p < .001) and had failed more medication trials (≥ 4 vs. 3.1, p < .001). Mean PHQ-9 decreased by 5.7 points (SD = 6.7, p < .001) in the TMS cohort and by 4.2 points (SD = 6.4, p < .001) in the UC cohort over the study period. Among patients who had failed four or more antidepressant medications, PHQ-9 decreased by 5.8 points in the TMS cohort (SD = 6.7, p < .001) and by 3.2 points in the UC cohort (SD = 6.3, p < .001). CONCLUSIONS: TMS utilization was low, despite TMS showing significant real-world clinical benefits. Future research should examine and address barriers to wider adoption of TMS into routine patient care for patients with treatment-resistant MDD. Wider adoption including routine use of TMS in less treatment-resistant patients will allow statistical comparisons of outcomes between TMS and UC populations that are difficult to do when TMS is underutilized.