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Repetitive Transcranial Magnetic Stimulation for Patients with Depression: A Review of Clinical Effectiveness, Cost-Effectiveness and Guidelines – An Update

Last updated: June 28, 2019
Project Number: RC1142-000
Product Line: Rapid Response
Research Type: Devices and Systems
Report Type: Summary with Critical Appraisal
Result type: Report

Question

  1. What is the clinical effectiveness and safety of repetitive transcranial magnetic stimulation for patients with treatment-resistant depression?
  2. What is the cost-effectiveness of repetitive transcranial magnetic stimulation for patients with treatment-resistant depression?
  3. What are the evidence-based guidelines regarding the use of repetitive transcranial magnetic stimulation for patients with treatment-resistant depression?

Key Message

Three systematic reviews and five randomized controlled trials assessed the clinical effectiveness of repetitive transcranial magnetic stimulation for the management of treatment-resistant major depression. The rates of response to treatment and remission of symptoms were significantly greater with repetitive transcranial magnetic stimulation than sham treatment in all three systematic reviews, but significantly lower than with electroconvulsive therapy in the systematic review that included this comparator. One systematic review reported that repetitive transcranial magnetic stimulation was associated with a higher odds ratio for response than aripiprazole. The clinical relevance of the magnitude of the change in depressive symptoms in all studies was unclear. The cost-effectiveness evidence of repetitive transcranial magnetic stimulation was conflicting, but an analysis from the perspective of the Ontario healthcare system suggested repetitive transcranial magnetic stimulation was cost-effective relative to pharmacotherapy if the willingness to pay was greater than C$98,242 per quality adjusted life year. In contrast, electroconvulsive therapy was found to be cost-effective relative to repetitive transcranial magnetic stimulation if the willingness to pay was greater than C$37,640 per quality adjusted life year. One guideline provided a weak recommendation for repetitive transcranial magnetic stimulation for the management of treatment resistant major depressive disorder, but the level of evidence on which the recommendation was based was not reported. Another guideline recommended high-frequency repetitive transcranial magnetic stimulation to the left dorsolateral prefrontal cortex and low-frequency repetitive transcranial magnetic stimulation to the right dorsolateral prefrontal cortex as first-line options for individuals who failed to response to one antidepressant. The evidence supporting this recommendation was considered to be level one (i.e., the highest level).