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Background: Transcranial magnetic stimulation (TMS) is an evidence-based approach to treatment- resistant Major Depressive Disorder (TRD). Sleep dysfunction is associated with poor outcomes in TRD, however, the impacts of sleep dysfunction on TMS treatment has yet to be defined. This study examined the association between sleep dysfunction and improvement in depression symptoms with TMS treatment for TRD., Methods: A retrospective observational cohort study was conducted examining all Veterans receiving TMS treatments through the "VA TMS Clinical Pilot Program" over a three-year period. The Patient Health Questionnaire (PHQ-9) sleep item was utilized to assess sleep dysfunction. The association between sleep dysfunction improvements during TMS treatment with depression outcomes was analyzed., Results: 94.3 % (N = 778) of Veterans reported baseline sleep dysfunction. Chi-square analysis demonstrated higher rates of depression remission at the completion of TMS treatment for those with sleep improvement at weeks 1, 3 and 6 (all p < .001). ANOVA comparing sleep improvements and end of treatment PHQ-8 score (modified to remove sleep item) found a statistically significant difference in mean improvements of depression scores at all 3 time points., Limitations: Limitations include those that are inherent to retrospective studies, as well as limitations in using the PHQ-9 sleep item as the primary means to assess sleep dysfunction., Conclusion: This study reports on the largest sample size to date examining the relationship between sleep dysfunction and TMS treatment outcomes for MDD, and found that improvement in sleep dysfunction was associated with greater reductions in end of treatment depression symptoms including higher depression remission rates., Competing Interests: Declaration of competing interest Effort on this was supported by R01 MH120126, I01 CX00208, and I50 RX002864. In the past three years NSP has received funding to conduct clinical trials (through VA contracted research) from Wave Neuro and Neurolief, is an advisor to Motif Neurotech, and serves on the scientific advisory board of Pulvinar Neuro. FAK has received temporary loan of equipment through Neuronetics and NIRx and funding through Mina Jo Powell Endowed Chair. Other authors have no conflicts of interest to disclose. This material is the result of work supported with resources and the use of facilities at VA Medical Centers. The contents of this publication do not represent the views of the Department of Veterans Affairs or the United States Government. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors., (Published by Elsevier B.V.)