Cost effectiveness analysis comparing repetitive transcranial magnetic stimulation to antidepressant medications after a first treatment failure for major depressive disorder in newly diagnosed patients - A lifetime analysis

PLoS One. 2017 Oct 26;12(10):e0186950. doi: 10.1371/journal.pone.0186950. eCollection 2017.


Objective: Repetitive Transcranial Magnetic Stimulation (rTMS) commonly is used for the treatment of Major Depressive Disorder (MDD) after patients have failed to benefit from trials of multiple antidepressant medications. No analysis to date has examined the cost-effectiveness of rTMS used earlier in the course of treatment and over a patients' lifetime.

Methods: We used lifetime Markov simulation modeling to compare the direct costs and quality adjusted life years (QALYs) of rTMS and medication therapy in patients with newly diagnosed MDD (ages 20-59) who had failed to benefit from one pharmacotherapy trial. Patients' life expectancies, rates of response and remission, and quality of life outcomes were derived from the literature, and treatment costs were based upon published Medicare reimbursement data. Baseline costs, aggregate per year quality of life assessments (QALYs), Monte Carlo simulation, tornado analysis, assessment of dominance, and one way sensitivity analysis were also performed. The discount rate applied was 3%.

Results: Lifetime direct treatment costs, and QALYs identified rTMS as the dominant therapy compared to antidepressant medications (i.e., lower costs with better outcomes) in all age ranges, with costs/improved QALYs ranging from $2,952/0.32 (older patients) to $11,140/0.43 (younger patients). One-way sensitivity analysis demonstrated that the model was most sensitive to the input variables of cost per rTMS session, monthly prescription drug cost, and the number of rTMS sessions per year.

Conclusion: rTMS was identified as the dominant therapy compared to antidepressant medication trials over the life of the patient across the lifespan of adults with MDD, given current costs of treatment. These models support the use of rTMS after a single failed antidepressant medication trial versus further attempts at medication treatment in adults with MDD.

MeSH terms

  • Adult
  • Antidepressive Agents / therapeutic use*
  • Cost-Benefit Analysis*
  • Depressive Disorder, Major / drug therapy*
  • Depressive Disorder, Major / therapy*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Quality of Life
  • Quality-Adjusted Life Years
  • Transcranial Magnetic Stimulation*
  • Treatment Failure
  • Treatment Outcome
  • Young Adult


  • Antidepressive Agents

Grant support

The funder (Magstim) provided an unrestricted grant to Medical Device Consultants of Ridgewood (commercial company) for the research, analysis, and preparation of the manuscript. The funder did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. Linda Carpenter, MD, has received consulting income from Magstim, Inc (<$5,000/year). Additionally, Dr. Carpenter has received clinical trial research support from Neuronetics, NeoSync, and Jannssen; and equipment support from NeoSync and Neuronetics.