Barriers to Brain Stimulation Therapies for Treatment-Resistant Depression: Beyond Cost Effectiveness

In this issue of the journal, Fitzgibbon and colleagues create an elaborate simulation model based on a broad consideration of costs and treatment efficacies to determine the comparative cost-effectiveness of rapid transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT) in management of treatment-resistant depression (TRD). In so doing, they take the oldest continuing biological intervention in psychiatry, ECT—arguably our field’s most effective and most stigmatized treatment—and stack it up against one of our newer forms of brain stimulation. Even though rTMS has been subject to more than two decades of multiple randomized controlled trials in depression as well as network meta-analyses, it remains unknown or unfamiliar to many health professionals, patients, and families. While many generations of clinicians easily recall patients they knew who received and benefited from ECT, very few have a personal data bank of patients treated with rTMS. If ECT has secured a firm— if controversial—place in our therapeutic armamentarium and cultural history, rTMS is still virtually unavailable in most clinical settings and not yet a therapeutic skill that is a core part of psychiatry training. Depression is the leading cause of disability globally. In Ontario, depression alone represented a greater burden of disease (as reflected by years lived with disability and years lost due to premature death) than lung, prostate, colon, and breast cancer combined. Although we have reasonably effective psychological and pharmacological treatments for depression, too many people are left in a state of TRD after countless drug trials and drug combinations or extensive courses of psychotherapy. In the context of therapeutic frustration, it can even result in familiar patient-blaming verbal lapses such as, “the patient failed a trial of . . . ” We need to own the reality that our treatments fail some patients, not the other way around. There is both a clinical and economic imperative to develop new options as well as to use existing evidence-based options. ECT was developed over 80 years ago, spread rapidly around the globe, and remains for a number of psychiatrists the treatment they would want for themselves if they became severely depressed—a good yardstick to use when recommending treatments for other people. Jeff Daskalakis, co-director of the Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health (arguably the busiest center in the country for both ECT and rTMS), often states that the numbers needed to treat for ECT in TRD is 2 to 3 (based on a 65% remission rate for ECT in TRD vs. a 15% remission rate for placebo)—an astonishingly low number that very few treatments throughout medicine could match. However, it remains an intrusive and intensive treatment with significant cognitive sequelae, and the need for alternatives persists. In considering alternative forms of brain stimulation to ECT, the concept of stepped care is crucial. Fitzgibbon and colleagues have presented a model and data to show the rTMS pathway was a more cost-effective first-line treatment than ECT for TRD—and that the best outcomes overall are when patients with TRD start with rTMS and then proceed to ECT only if rTMS didn’t work. This is the essence of stepped-care thinking: Start with a treatment that is more benign, even if it may have lower narrowly defined positive clinical outcome rates, and follow this with more intrusive and disruptive and costly treatments only if clinically necessary. Since rTMS is easily administered on an outpatient basis, with no need for patient accompaniment home afterward, no need for anesthesia, no induction of a