rTMS in the Treatment of Major Depressive Disorder

Health Technology Assessment Committee Recommendations

  1. There is a lack of consistent evidence to recommend the public provision of repetitive transcranial magnetic stimulation (rTMS) for treatment resistant depression at this time. As such, it is recommended that rTMS be performed only in research.
  2. It is recommended that the rTMS technology be reviewed again in three years, or when compelling new evidence becomes available.

Health Technology Assessment Committee Findings

The business case submitted to the Health Technology Committee (HTAC) reviewed the effectiveness of rTMS in the treatment of Major Depressive Disorder, with a focus on Treatment Resistant Depression (TRD). Recommendations were based on the following committee findings:

  1. Overall, the clinical effectiveness evidence for rTMS is mixed.  Study sample sizes are small, results are inconsistent, and evidence is generally of low to moderate quality. Studies indicated that:
    • the efficacy of rTMS relative to sham was inconsistent. Some studies show rTMS provides better efficacy, and others failed to show any differences between rTMS and sham;
    • rTMS may be similar in efficacy to antidepressant therapy, but is more costly;
    • Electroconvulsive therapy (ECT) is more effective than rTMS, but is more costly.  It is already an insured service in BC.
  2. The cost effectiveness evidence is mixed, and based on evidence of moderate to low quality. 
  3. Due to the short-term duration of studies, there is little evidence regarding the length of time that the benefit of rTMS persists.
  4. If this technology were to be introduced, it is estimated that it would cost between $2.7 - $13.6 million dollars per year.   This is based on treating 8% and 16% of all treatment resistant depression patients.  Treating all patients with TRD with rTMS would be challenging, and cost as much as approximately $ 84.6 million dollars.
  5. Variability in the literature make definitive conclusions about optimal treatment strategies difficult.   In other words, rTMS treatment protocols and, to an extent, its place in the clinical pathway are still developing, which could have a significant impact on expected costs and benefits.
  6. It is expected that rTMS would be an additional option for physicians treating patients with TRD (rather than replace existing treatments), and therefore significant cost savings to the health system are not anticipated.
  7. Research initiatives involving rTMS are in place at the University of British Columbia (UBC) hospital and Vancouver General Hospital (VGH).