Repetitive Transcranial Magnetic Stimulation (rTMS) for Treatment-resistant Depression

Health Technology Assessment Committee Recommendations

1. It is recommended repetitive transcranial magnetic stimulation be publicly provided for treatment-resistant depression. Implementation must be planned carefully; important considerations include the education and training of health human resources, capacity of and access to psychiatrists within the health system, regulation of rTMS delivery, and infrastructure requirements. Particular emphasis should be placed on equitable access to treatment amongst underserved populations.
2. Given the expected complexity involved with implementation, broad representation in the planning process is required to ensure rTMS is embedded within a comprehensive system of mental health care. Consideration should also be given to collaborating with and learning from those provinces where rTMS is already publicly provided.

 

Health Technology Assessment Committee Findings

1. Meta-analyses were conducted to compare the clinical effectiveness of rTMS to sham or electroconvulsive therapy (ECT). Compared to sham, the analysis found rTMS was twice as likely to result in response and remission (Table 1). There was no statistical difference between rTMS and ECT with respect to achieving response or remission. Although compared, rTMS would not replace ECT in the treatment pathway as CANMAT recommends rTMS as a first-line treatment and ECT as a second-line treatment for individuals with depression who have failed at least one trial of antidepressant treatment.
2. The cost-effectiveness analysis found rTMS was more costly and more effective than sham at achieving response and remission with an incremental cost per quality adjusted life year (QALY) gained of $13,084 and $20,203, respectively. Compared to ECT, rTMS was less expensive and more effective at achieving response, and also less expensive and more effective at achieving remission (ECT had an incremental cost per QALY gained of $328,325 compared to rTMS). Again, although compared, rTMS would not replace ECT in the treatment pathway.
3. Interviewed BC health care providers believe a treatment gap exists in BC for patients with TRD who either have tried and not responded to antidepressants, cannot tolerate antidepressants, are not ill enough to require ECT, or do have access to ECT. rTMS was perceived to be well-positioned to bridge this treatment gap given the established body of effectiveness literature and relative ease of administration. rTMS was also described as an alternative treatment option for patients prior to trying ECT as rTMS is less invasive, has fewer side effects, and is less stigmatizing. Stakeholders also noted the body of evidence on rTMS is evolving with emerging research on different rTMS protocols (e.g., shorter duration) and its use for other indications (e.g., obsessive-compulsive disorder). As a result, some health care providers feel that implementing rTMS in BC could be cost-effective over the longer term as the treatment may become useful for a broader range of disorders.
4. No direct patient engagement was undertaken. Interviewed health care providers perceived rTMS to be a positive experience for their patients, many of whom have been suffering from TRD for many years. Positive impacts seen include increased enjoyment in daily activities, returning back to work, or taking up increased childcare responsibilities. Health care providers believe patients with TRD are interested in alternative treatment options to antidepressants, particularly patients who experienced adverse side effects as a result of pharmacological treatment.
5. The budget impact analysis assessed three scenarios: (1) maintaining the status quo, (2) provincial funding and delivery of rTMS, and (3) provincial funding with community private delivery of rTMS. Both scenario 2 and 3 is supported by the meta-analysis and cost-effectiveness analysis, and is also aligned with the perspectives of the BC health care providers who feel that BC has a treatment gap for patients with TRD.