Original Title: Stimulation magnétique transcrânienne répétée pour la dépression réfractaire aux traitements chez l’adulte : efficacité, innocuité et efficience

Authors' objectives: Repetitive transcranial magnetic stimulation (rTMS) is another neuromodulation technique, which was approved by Health Canada in 2002. In Quebec, the administration of rTMS by psychiatrists has been covered by the Quebec health insurance plan since 2013. Nonetheless, its clinical relevance has not been evaluated, and no guidelines are currently available. In this context, the INESSS was mandated by the Ministry of Health and Social Services (MSSS) to assess the effectiveness and safety of rTMS and its various protocols, as well as its efficiency in the Quebec context.

Authors' results and conclusions: RESULTS: The compilation of data from the rapid review of the scientific and grey literature, along with information collected from stakeholders, led to several key findings regarding: • The overall effectiveness of rTMS, as well as that of more specific protocols, in reducing depressive symptoms in adults with unipolar or bipolar TRD; • The overall safety of rTMS, as well as that of specific protocols; • Considerations related to the choice of therapeutic approach and, if applicable, the selection of the rTMS protocol; • Organizational and economic considerations associated with the delivery of rTMS services.

Authors' recommendations: RECOMMENDATION 1 – CLINICAL RELEVANCE: Considering its clinical effectiveness and safety, demonstrated efficiency, and the need for treatment options among individuals with TRD, INESSS recommends that:  rTMS be offered to adults3 experiencing a major depressive episode within a unipolar or bipolar disorder who are not responding to first-line treatments (e.g., psychotherapy, antidepressants) to reduce the severity of depression. RECOMMENDATION 2 – CARE PATHWAYS AND SERVICES: rTMS should generally be considered before ECT in the care pathway for individuals with TRD, primarily due to its safety. rTMS may also be considered prior to ketamine. These factors can help support shared decision-making. RECOMMENDATION 3 – CONDITIONS OF ADMINISTRATION: When rTMS is delivered, it should be done under the following conditions:  prescribed by a psychiatrist or another authorized healthcare professional with expertise in rTMS, responsible for assessing contraindications and ensuring appropriate medical follow-up. RECOMMENDATION 4 – PROTOCOLS: Due to limited available data and the lack of clear clinical effectiveness evidence, further research is needed to evaluate the effectiveness of the following rTMS protocols for reducing depression severity in adults with unipolar or bipolar TRD:  High-frequency rTMS applied to the right DLPFC or the right ventrolateral prefrontal cortex. RECOMMENDATION 5 – SERVICE DELIVERY: Based on the evidence of effectiveness, the economic analysis, and the uneven availability of services across regions, INESSS recommends improving access to rTMS and implementing service delivery modalities to more equitably address the needs of Quebec adults with TRD. CONCLUSION: Individuals with TRD and their loved ones face significant challenges due to this condition and often experience multiple treatment failures. These individuals need access to a range of treatment options that may improve their condition.

Authors' methods: This report integrates data collected through a rapid review of scientific and grey literature, economic analyses and information collected from stakeholders. Effectiveness and safety data were drawn from 56 scientific articles (13 systematic reviews, one meta- analyses review, and 42 randomized controlled trials) and 29 grey literature sources, primarily clinical practice guidelines and health technology assessment reports. Economic analyses included an efficiency analysis, using data from two economic evaluations identified in the literature, and a budget impact analysis, based on clinical and administrative data.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/stimulation-magnetique-transcranienne-repetee-pour-la-depression-refractaire-aux-traitements-chez-ladulte-efficacite-innocuite-et-efficience.html

Year Published: 2026

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/ServicesSociaux/SMTr_Avis_INESSS.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)