Transcranial magnetic stimulation (TMS) is a novel antidepressant therapy shown to be effective and safe in pharmacotherapy-resistant major depression. The incremental cost-effectiveness and the direct cost burden compared with sham treatment were estimated, and compared with the current standard of care.
Healthcare resource utilization data were collected during a multicenter study (n=301) and a decision analysis was used to stratify the 9-week treatment outcomes. A Markov model with an acute-outcome severity-based risk of relapse was used to estimate the illness course over a full year of treatment follow-up. These model estimates were also compared to best estimates of outcomes and costs of pharmacotherapy treatment, using the published STAR*D outcomes. The cost-effectiveness of TMS was described using an incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained and on a direct cost per patient basis across a varying range of assumptions. The model’s sensitivities to costs due to losses in work productivity and to caregiver time were also examined.
Compared with sham treatment and at a cost of US$300 per treatment session, TMS provides an ICER of US$34,999 per QALY, which is less than the “willingness-to-pay’ standard of US$50,000 per QALY for a new treatment for major depression. When productivity gains due to clinical recovery were included, the ICER was reduced to US$6667 per QALY. In open-label conditions, TMS provided a net cost saving of US$1123 per QALY when compared with the current standard of care. In the openlabel condition, cost savings increased further when the costs for productivity losses were included in the model (net savings of US$7621). The overall cost benefits of treating MD using TMS were greater in those patients at the earliest levels of treatment resistance in the overall sample.
TMS is a cost-effective treatment for patients who have failed to receive sufficient benefit from initial antidepressant pharmacotherapy. When used at earlier levels of treatment resistance, significant cost savings may be expected relative to the current standard of care.
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Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–3105.
Klerman GL, Weissman MM. Increasing rates of depression. JAMA. 1989;261:2229–2235.
Robins LN, Regier DA. Psychiatric Disorders in America: the Epidemiological Catchment Area Study. New York: The Free Press; 1991.
Trivedi MH, Rush AJ, Crismon ML, et al. Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project. Arch Gen Psychiatry. 2004;61:669–680.
Khan A, Detke M, Khan SR, Mallinckrodt C. Placebo response and antidepressant clinical trial outcome. J Nerv Ment Dis. 2003;191:211–218.
Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163:1905–1917.
Hirschfeld RM. American health care systems and depression: the past, present, and the future. J Clin Psychiatry. 1998;59(suppl. 20):5–10.
Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors Global Burden of Disease Study. Lancet. 1997;349:1436–1442.
Davidson RJ, Pizzagalli D, Nitschke JB, Putnam K. Depression: perspectives from affective neuroscience. Annu Rev Psychol. 2002;53:545–574.
Nahas Z, Kozel FA, George MS. Somatic treatments in psychiatry. In: Panksepp J, ed. Textbook of Biological Psychiatry. New York: Wiley; 2003:521–540.
Barker AT, Jalinous R, Freeston IL. Non-invasive magnetic stimulation of the human motor cortex. Lancet. 1985;1:1106–1107.
Nahas Z, Lomarev M, Roberts DR, et al. Unilateral left prefrontal transcranial magnetic stimulation (TMS) produces intensity-dependent bilateral effects as measured by interleaved BOLD fMRI. Biol Psychiatry. 2001;50:712–720.
Eranti S, Mogg A, Pluck G, et al. A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression. Am J Psychiatry. 2007;164:73–81.
O’Reardon JP, Solvason HB, Janicak PG, et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry. 2007;62:1208–1216.
Kozel FA, George MS, Simpson KN. Decision analysis of the cost-effectiveness of repetitive transcranial magnetic stimulation versus electroconvulsive therapy for treatment of nonpsychotic severe depression. CNS Spectr. 2004;9:476–482.
Knapp M, Romeo R, Mogg A, et al. Cost-effectiveness of transcranial magnetic stimulation vs. electroconvulsive therapy for severe depression: a multi-centre randomised controlled trial. J Affect Disord. 2008;109:273–285.
Avery DH, Isenberg KE, Sampson SM, et al. Transcranial magnetic stimulation in the acute treatment of major depressive disorder: clinical response in an open-label extension trial. J Clin Psychiatry. 2008;69:441–451.
Janicak PG, O’Reardon JP, Sampson SM, et al. Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. J Clin Psychiatry. 2008;69:222–232.
Ubel PA, Hirth RA, Chernew ME, Fendrick AM. What is the price of life and why doesn’t it increase at the rate of inflation? Arch Intern Med. 2003;163:1637–1641.
Cost-effectiveness thresholds. World Health Organization web site. Available at: http://who.imt/choice/costs/CER_thresholds/en/index.html. Accessed June 2008.
World economic and financial surveys. World economic outlook database. International Monetary Fund web site. Available at: www.imf.org. Accessed June 27, 2008.
Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry. 2001;62(suppl. 16):10–17.
Lisanby SH, Husain MM, Rosenquist PB, et al. Daily left prefrontal repetitive transcranial magnetic stimulation (rTMS) in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsychopharmacology. 2008;34:522–534.
Healthcare Cost and Utilization Project (HCUP). H-CUP 2004. Available at: www.hcup-us.ahrq.gov. Accessed June 2008.
Greenhalgh J, Knight C, Hind D, Beverley C, Walters S. Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies. Health Technol Assess. 2005;9:1–156, iii-iv.
Croghan TW, Obenchain RL, Crown, WE. What does treatment of depression really cost? Health Aff (Millwood). 1998;17:198–208.
Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry. 2003;64:1465–1475.
Kamlet MS, Paul N, Greenhouse J, et al. Cost utility analysis of maintenance treatment for recurrent depression. Control Clin Trials. 1995;16:17–40.
McLaughlin TP, Eaddy MT, Grudzinski AN. A claims analysis comparing citalopram with sertraline as initial pharmacotherapy for a new episode of depression: impact on depression-related treatment charges. Clin Ther. 2004;26:115–124.
Revicki DA, Brown RE, Palmer W, et al. Modelling the cost effectiveness of antidepressant treatment in primary care. Pharmacoeconomics. 1995;8:524–540.
Greenhalgh J, Knight C, Beverley C, Walters S. Electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia, and mania. Report on behalf of National Institute for Clinical Excellence. Nuffield Institute for Health, University of Leeds, United Kingdom 2006. Available at: www.nice.org.uk/nicemedia/pdf/Final_assessment_reportECT.pdf. Accessed August 23, 2002.
The Red Book — a Guide to Work Incentives. 2006 Red Book. Social Security Online web site. Available at: www.socialsecurity.gov/redbook/. Accessed June 2008.
Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS). Available at: http://www.ids-qids.org/. Accessed December 2008.
Grunhaus L, Dannon, PN, Schreiber S, et al. Repetitive transcranial magnetic stimulation is as effective as electroconvulsive therapy in the treatment of nondelusional major depressive disorder: an open study. Biol Psychiatry. 2000;47:314–324.
Nahas Z. Transcranial magnetic stimulation for treating psychiatric conditions: what have we learned so far? Can J Psychiatry. 2008;53:553–554.
Sackeim HA, Prudic J, Fuller R, et al. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology. 2007;32:244–254.
An erratum to this article can be found online at http://dx.doi.org/10.1007/s12325-009-0053-2
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Simpson, K.N., Welch, M.J., Kozel, F.A. et al. Cost-effectiveness of transcranial magnetic stimulation in the treatment of major depression: a health economics analysis. Adv Therapy 26, 346–368 (2009). https://doi.org/10.1007/s12325-009-0013-x