Implementation of intermittent theta burst stimulation compared to conventional repetitive transcranial magnetic stimulation in patients with treatment resistant depression: A cost analysis

Abstract

BackgroundRepetitive transcranial magnetic stimulation (rTMS) is an evidence-based treatment for depression that is increasingly implemented in healthcare systems across the world. A new form of rTMS called intermittent theta burst stimulation (iTBS) can be delivered in 3 min and has demonstrated comparable effectiveness to the conventional 37.5 min 10Hz rTMS protocol in patients with depression.ObjectivesTo compare the direct treatment costs per course and per remission for iTBS compared to 10Hz rTMS treatment in depression.MethodsWe conducted a cost analysis from a healthcare system perspective using patient-level data from a large randomized non-inferiority trial (THREE-D). Depressed adults 18 to 65 received either 10Hz rTMS or iTBS treatment. Treatment costs were calculated using direct healthcare costs associated with equipment, coils, physician assessments and technician time over the course of treatment. Cost per remission was estimated using the proportion of patients achieving remission following treatment. Deterministic sensitivity analyses and non-parametric bootstrapping was used to estimate uncertainty.ResultsFrom a healthcare system perspective, the average cost per patient was USD$1,108 (SD 166) for a course of iTBS and $1,844 (SD 304) for 10Hz rTMS, with an incremental net savings of $735 (95% CI 688 to 783). The average cost per remission was $3,695 (SD 552) for iTBS and $6,146 (SD 1,015) for 10Hz rTMS, with an average incremental net savings of $2,451 (95% CI 2,293 to 2,610).ConclusionsThe shorter session durations and treatment capacity increase associated with 3 min iTBS translate into significant cost-savings per patient and per remission when compared to 10Hz rTMS.

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: Recent Critical Advances in Patient Care

“…Theta burst stimulation is novel and so-called second-generation rTMS modality [ 67 , 68 ]. It was initially investigated as a neurophysiologic tool as described above, with its primary differentiating factor being that it can modulate synaptic plasticity with effective results in a very short period of time (typically 3–10 min for an entire “dose,” compared to the standard 37.5 min required for an rTMS session) [ 68 , 69 ].…”

“…It was initially investigated as a neurophysiologic tool as described above, with its primary differentiating factor being that it can modulate synaptic plasticity with effective results in a very short period of time (typically 3–10 min for an entire “dose,” compared to the standard 37.5 min required for an rTMS session) [ 68 , 69 ]. The first human study to TBS, performed by Huang et al, included delivery of short bursts of a high-frequency (50 Hz) TMS, repeated at intervals of 200 ms (5 Hz), at 80% MT, in three different patterns (intermediate TBS (imTBS); continuous TBS (cTBS); and intermittent TBS (iTBS)) [ 67 ]. iTBS was found to yield electrophysiological changes in the motor cortex when administered as intermittent (iTBS; 2 s train, repeated at 10s) or continuous (cTBS; 40s train of uninterrupted stimulation); stimulation yielded robust long-term potentiation (iBTS) or long-term depression (cTBS)-like activity.…”

Repetitive transcranial magnetic stimulation in the treatment of bipolar disorder

“…This differs from standard rTMS in that pulses are applied in a pattern known as theta bursts, delivering more stimulation within a shorter time-frame. 28 rTMS is an effective and well-tolerated intervention in the treatment of unipolar depression [i.e. major depressive disorder (MDD)] in adults, 29 and there is a developing, yet promising, evidencebase for its use in adolescent depression.…”

“…This differs from standard rTMS in that pulses are applied in a pattern known as theta bursts, delivering more stimulation within a shorter time-frame. 28 …”

Factors affecting the efficacy of repetitive transcranial magnetic stimulation for patients with Alzheimer’s disease

“…可使 AD 患者的大脑皮层兴奋性提高，诱导突触 的长时程增强，以达到认知功能的改善 [16] 。AD 患者的脑血流量和代谢偏低，而高频 rTMS 可提 高脑代谢水平和脑血流，这可能也是高频刺激疗 效较好的原因 [17][18] 。 目 前 临 床 常 用 的 r T M S 刺 激 模 式 需 要 2 03 0 min [19] ，这可能是影响 AD 患者疗效的一个因 素。AD 患者的配合程度比较差，很难做到长时间 保持头部位置固定，而头部活动会导致 rTMS 刺激 靶点的移动。iTBS 是 rTMS 的一种特殊模式，其每 次治疗只需几分钟，可减少靶点移动带来的误 差 [20] 。Wu 等 [21] 发现左侧 DLPFC 的 iTBS 能显著 改善 AD 患者的认知功能尤其是记忆功能。一项 抑郁症的多中心研究发现 iTBS 与常规 rTMS 疗效 相当 [22] ，但 iTBS 的费用约为常规 rTMS 的三分之 二 [23] 11] 。荟萃分析结果显示，长期 rTMS(超过5 次)…”