OBJECTIVES: Major depressive disorder (MDD) is a debilitating disease that significantly decreases quality of life. Repetitive Transcranial Magnetic Stimulation (rTMS) therapy is a safe, non-invasive, physical treatment for major depressive disorder. We evaluated the cost-effectiveness of rTMS compared with third-line antidepressant medication for the treatment of adults with MDD who have failed at least two adequate courses of antidepressants .

METHODS: A three-year Markov microsimulation model with two-month cycles was used to compare the costs and quality-adjusted life years (QALYs) of rTMS and a mix of antidepressants (including selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclics, noradrenergic and specific serotonergic antidepressants and monoamine oxidase inhibitors). The model synthesized data sourced from a meta-analysis, published literature, national cost reports and expert opinions. Incremental cost-utility ratios were calculated and uncertainty of the results was assessed using univariate and probabilistic sensitivity analyses.

RESULTS:  Compared with antidepressant medication therapy, rTMS is a dominant/cost-effective alternative for patients with treatment-resistant depressive disorder. The model predicted that QALYs gained with rTMS was higher than for antidepressant medications (1.25 versus 1.18 QALYs) while costs were slightly less (AUD 31,003 versus AUD 31,190). The treatment response rate, using the Hamilton Depression Rating Scale 17, was 16.8% for antidepressant medications and 37.5% for rTMS. In the Australian context at the willingness-to-pay threshold of AUD 50,000 per QALY gain, the probability that rTMS was cost-effective was 73%. Sensitivity analyses confirmed the model stability and superiority of rTMS compared with antidepressant medications. CONCLUSIONS: While both antidepressant medications and rTMS are clinically effective treatments for MDD, rTMS is shown to outperform antidepressants in terms of cost-utility for patients who have failed at least two adequate courses of pharmacotherapies. The study shows that rTMS is a cost-effective therapy alterative for patients with treatment-resistant depression without the many side-effects of pharmacotherapy.