. 2021 May 6;21(4):1–232.

Table 10:

Results of Economic Literature Review—Summary

Author, Year, Country	Analytic Technique, Study Design, Perspective, Time Horizon	Population	Intervention(s) and Comparator(s)	Results
Author, Year, Country		Population	Intervention(s) and Comparator(s)	Health Outcomes	Costs	Cost-Effectiveness	Uncertainty
Fitzgibbon et al, 2019 ¹⁴³ Canada	Cost–utility analysis Microsimulation model Societal perspective Lifetime	Adults with TRD Age (mean) 42 y		rTMS followed by ECT vs. ECT alone	Currency: 2018 CAD Incremental cost (rTMS vs. ECT): −$46,094 Discount rate: 1.5%	rTMS vs. ECT: Dominant (lower cost and higher effectiveness)	PSA showed 100% certainty that rTMS dominated ECT and that model was robust Scenario analysis showed that more people with TRD switching to ECT if they did not initially respond to rTMS could increase cost savings
Zhao et al, 2018¹⁴⁴ Singapore	Cost–utility analysis Markov decision analytic model Societal perspective 1 y	Adults with TRD Age (mean): 43 y	rTMS vs. ECT	rTMS: 0.686 QALYs ECT: 0.724 QALYs Incremental QALYS (rTMS vs. ECT): −0.038 Discount rate: NA	Currency: 2018 SGD (in 2019, $1 SGD = $0.97 CAD) rTMS: $23,072 SGD ECT: $34,922 SGD Incremental costs (rTMS vs. ECT): $11,850 SGD Discount rate: NA	rTMS vs. ECT: $311,024 SGD /QALY ($302,241 CAD/QALY)^b rTMS vs. ECT: cost-effective (lower costs but lower effects)	Subgroup analysis, adults with nonpsychotic symptoms: cost-effective (lower costs and more effective) PSA confirmed robustness of model; rTMS had 95% chance of being more cost effective than ECT at WTP of $70,000 SGD/QALY
Voigt et al, 2017¹⁴⁵ USA	Cost-utility analysis Markov model Health care sector perspective Lifetime	Adults newly diagnosed with major depression who failed to benefit from single-medication trial	rTMS vs. medication	Mid-20s rTMS: 15.22 Medication: 14.79 QALYs Incremental QALYs: 0.43 Mid-30s rTMS: 14.06 Medication: 13.62 Incremental QALYs: 0.44 Mid-40s rTMS: 12.26 QALYs Medication: 11.83 QALYs Incremental QALYs: 0.43 Mid-50s rTMS: 8.77 Medication: 8.45 QALYs Incremental QALYs: 0.32 Discount rate: 3%	Currency: 2018 USD Mid-20s rTMS: $278,103 Medication: $289,243 Incremental costs: −$11,140 Mid-30s rTMS: $257,686 Medication: $266,665 Incremental costs: −$8,979 Mid-40s rTMS: $226,126 Medication: $232,518 Incremental costs: −$6,392 Mid-50s rTMS: $164,769 Medication: $167,721 Incremental costs: −$2,952 Discount rate: 3%	rTMS vs. medication: dominant (lower cost and higher effectiveness)	rTMS vs. medication: cost-effective for all age groups PSA showed 36%–40% chance that rTMS would be more cost-effective than antidepressants
Ghiasvand et al, 2016¹⁴⁷ Iran	Cost–utility analysis Decision tree model Health care sector perspective 7 mo	Adults with major depression	rTMS vs. ECT	rTMS: 1,184,001 improved patients ECT: 5,462,036 improved patients Incremental improved patients: −4,278,035 Discount rate: NA	Currency: 2016 Rials rTMS: 11,015,000 Rials ($376 USD) ECT: 11,742,700 ($397.70 USD) Incremental costs: −727,700 Rials Discount rate: NA	rTMS vs. ECT: 1,194,419 Rials ($40.00 USD)	Uncertainty was not addressed in report
Nguyen et al, 2015¹⁴⁸ Australia	Cost–utility analysis Markov microsimulation decision analytic model 3 y Health care sector perspective	Adults with TRD	rTMS vs. medication	rTMS: 1.25 QALYs Medication: 1.18 QALYs Incremental QALYs: 0.07 Discount rate: 5%	Currency: 2015 AUD rTMS: $31,003 Medication: $31,190 Incremental costs: −$87 Discount rate: 5%	rTMS vs. medication: dominant	rTMS vs. medication: cost-effective, dominant (lower costs, more effective) PSA showed that, at WTP of $50,000 AUD/QALY, there was a 73% chance that rTMS would be more cost-effective than ECT
Vallejo-Torres et al, 2015¹⁴⁹ Spain	Markov decision analytic model 1 y Health care sector perspective	Adults with TRD	ECT alone vs. rTMS alone vs. rTMS followed by ECT alone	ECT: 0.4253 QALYs rTMS: 0.3988 QALYs rTMS followed by ECT: 0.4598 QALYs Incremental QALYs (ECT vs. rTMS): 0.0265 Incremental QALYs (rTMS vs. rTMS followed by ECT): −0.061 Discount rate: NA	Currency: 2015 Euros ECT: €16,690 rTMS: €16,858 rTMS followed by ECT: €20,279 Incremental costs (ECT vs. rTMS): −€168 Incremental costs (rTMS vs. rTMS followed by ECT): €3,589	ECT vs. rTMS: dominant rTMS vs. rTMS followed by ECT: €103,953/QALY	PSA showed that, at WTP of €30 000/QALY, ECT alone had a 70% chance of being cost-effective
Health Quality Ontario, 2016¹³ Canada	Decision tree models 6 mo Health care sector perspective (Ministry of Health and Long-Term Care)	Adults with TRD	rTMS vs. sham (medications) ECT vs. rTMS	rTMS: 0.30 QALYs Medication: 0.28 QALYs Incremental QALYs: 0.02 ECT vs. rTMS ECT: 0.32 QALYs rTMS: 0.31 QALYs Incremental QALYs: 0.01 Discount rate: NA	Currency: 2014 CAD rTMS: $5,132 Medication: $2,978 Incremental costs: $2,154 ECT vs. rTMS ECT: $5,960 rTMS: $5,272 Incremental costs: $688 Discount rate: none	rTMS vs. medication: $98,242/QALY ECT vs. rTMS: $37,641/QALY	PSA showed that, at WTP of $50,000/QALY, there is a 45% chance that rTMS would be more cost-effective than ECT PSA showed that, at WTP of $50,000/QALY, there is a 2% chance that rTMS would be more cost-effective than pharmacotherapy alone
University of Calgary, 2016³⁴ Canada (Alberta)	Decision tree models 3–6-wk Health care sector perspective (Alberta)	Adults with TRD	rTMS vs. standard medication therapy (pharmacotherapy alone) ECT vs. rTMS	rTMS vs. medication Remission rTMS: 0.38 QALYs Medication: 0.34 QALYs Incremental QALYs: 0.04 Response rTMS: 0.42 QALYs Medication: 0.35 QALYs Incremental QALYs: 0.07 ECT vs. rTMS Remission ECT: 0.54 QALYs rTMS: 0.53 QALYs Incremental QALYs: 0.01 Response ECT: 0.57 QALYs rTMS: 0.59 QALYs Incremental QALYs: −0.02 Discount rate: NA	Currency: 2014 CAD rTMS vs. medication rTMS: $952 Medication: $45 Incremental costs: $907 ECT vs. rTMS ECT: $3,324 rTMS: $952 Incremental costs: $2,372 Discount rate: NA	rTMS vs. medication Remission: $20,203/QALY Response: $13,084/QALY ECT vs. rTMS Remission: $328,325/QALY Response: dominated	PSA for response outcome showed a 98.2% chance that ECT would be more costly and less effective than rTMS PSA for remission outcome showed an 84.5% chance that rTMS would be most cost-effective

Abbreviations: AUD, Australian dollar; ECT, electroconvulsive therapy; ICER, incremental cost-effectiveness ratio; NA, not applicable; NR, not recorded; PSA, probabilistic sensitivity analysis; QALY, quality-adjusted life-year; rTMS, high-frequency repetitive transcranial magnetic stimulation; SGD, Singaporean dollar; TRD, treatment-resistant depression; WTP, willingness to pay.