Cost–Utility Analysis of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Ontario

Abstract

Objectives: To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario. Methods: A cost–utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results. Results: rTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model’s maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT. Conclusion: From a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient’s lifetime may contribute to its cost-effectiveness.

Barriers to Brain Stimulation Therapies for Treatment-Resistant Depression: Beyond Cost Effectiveness

“…In this issue of the journal, Fitzgibbon and colleagues create an elaborate simulation model based on a broad consideration of costs and treatment efficacies to determine the comparative cost-effectiveness of rapid transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT) in management of treatment-resistant depression (TRD). 1 In so doing, they take the oldest continuing biological intervention in psychiatry, ECT-arguably our field's most effective and most stigmatized treatment-and stack it up against one of our newer forms of brain stimulation. Even though rTMS has been subject to more than two decades of multiple randomized controlled trials in depression as well as network meta-analyses, 2 it remains unknown or unfamiliar to many health professionals, patients, and families.…”

A happiness magnet? Reviewing the evidence for repetitive transcranial magnetic stimulation in major depressive disorder

“…9,29 rTMS has fewer side effects than ECT, is preferred by patients and is cheaper. 37 rTMS is therefore a good first step for stable patients with TRD. If unsuccessful, treatment can be escalated to ECT.…”

Cost-utility analysis of esketamine and electroconvulsive therapy in adults with treatment-resistant depression

“…The Markov model requires three types of data: transition probabilities, health utilities and cost [ 23 ]. Data for the model was gathered from various sources, see Table 1 for the input parameters used in the analyses.…”

“…Loss of productivity was weighted to account for 54% of the population being unemployed and 13% working part-time [ 25 ] while in the depression state and for 23% [ 23 , 25 ] of the individuals being unemployed in the remission state. These figures have been used elsewhere in a similar study [ 23 ].…”