Repetitive Transcranial Magnetic Stimulation for People With Treatment-Resistant Depression

Ontario Health
Record ID 32018000748
Authors' objectives: This health technology assessment evaluates the effectiveness, safety, and cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) for people with treatment-resistant depression (TRD). It also evaluates the budget impact of publicly funding rTMS and the experiences, preferences, and values of people withTRD.
Authors' results and conclusions: Results We included 58 primary studies, 9 systematic reviews, and 1 network meta-analysis in the clinical evidence review. Most rTMS modalities were more effective than sham treatment for all outcomes (GRADE: Moderate to High). All rTMS modalities were similar to one another in response and remission rates (GRADE: not reported) and were similar to electroconvulsive therapy (ECT) in response and remission rates (GRADE: Moderate). Moreover, in both the reference case and scenario analyses, two rTMS modalities (rTMS or iTBS), followed by ECT when patients did not respond to initial treatment, were less expensive and more effective than ECT alone. They were cost-effective compared with pharmacotherapy alone at a willingness-to-pay amount of $50,000 per quality-adjusted life-year (QALY). The annual budget impact of publicly funding rTMS would range from $9.3 million in year 1 to $15.76 million in year 5, for a total of $63.2 million over the next 5 years. People with TRD we spoke with reported that their experiences were generally favourable, and their attitudes toward rTMS were positive. Similarly, psychiatrists had positive attitudes toward and acceptance of rTMS. Our quantitative literature review on preferences revealed some gaps in psychiatrists’ knowledge of rTMS, which could have been influenced by their level of training on rTMS. Conclusions Most rTMS modalities are likely more effective than sham rTMS on all outcomes. All rTMS modalities are similar to ECT and to one another in response and remission rates. Compared with ECT alone, two rTMS modalities (high-frequency rTMS and iTBS), followed by ECT when necessary in a stepped care pathway, were less costly and more effective for managing adults with TRD. These types of rTMS (high-frequency rTMS and iTBS) were cost-effective compared with pharmacotherapy alone at a willingness-to-pay amount of $50,000 per QALY. Publicly funding rTMS (high-frequency rTMS and iTBS) for the treatment of adults with TRD in Ontario over the next 5 years would add $63.2 million in total costs. People with TRD had positive experiences and attitudes toward rTMS.
Authors' recomendations: Ontario Health, based on guidance from the Ontario Health Technology Advisory Committee, recommends publicly funding repetitive transcranial magnetic stimulation for people with treatment-resistant depression
Authors' methods: We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Risk of Bias in Systematic Reviews (ROBIS) tool and Cochrane Risk of Bias for Randomized Controlled Trials and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost–utility analysis with a 3-year horizon from a public payer perspective. We also analyzed the 5-year budget impact of publicly funding rTMS for people with TRD in Ontario. To assess the potential value of rTMS, we spoke with people who have TRD. Seven rTMS modalities were considered: low-frequency (1 Hz) stimulation, high-frequency (10–20 Hz) stimulation, unilateral stimulation, bilateral stimulation, iTBS, continuous theta burst stimulation, and deep transcranial magnetic stimulation.
Project Status: Completed
Year Published: 2021
Requestor: Ontario Health Technology Advisory Committee (OHTAC); Ontario Ministry of Health
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: Canada
Province: Ontario
Pubmed ID: 34055112
MeSH Terms
  • Depressive Disorder, Major
  • Transcranial Magnetic Stimulation
  • Depressive Disorder, Treatment-Resistant
  • Depression
  • Repetitive Transcranial Magnetic Stimulation
  • Treatment-Resistant Depression
  • Budget Impact
  • Health Technology Assessment
  • Cost-Utility Analysis
Organisation Name: Ontario Health
Contact Address: 130 Bloor Street West, 10th Floor
Contact Name: Nancy Sikich
Contact Email:
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This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.