Cost-effectiveness of transcranial magnetic stimulation vs. electroconvulsive therapy for severe depression: A multi-centre randomised controlled tria

PMID: 18262655
AUTHORS: Martin Knapp, Renee Romeo, Andrew Mogg, Savitha Eranti, Graham Pluck, Rick Purvis, Richard G Brown, Robert Howard, Michael Philpot, John Rothwell, Denzil Edwards, Declan M McLoughlin
AFFILIATION: Centre for the Economics of Mental Health, King's College London, Institute of Psychiatry, United Kingdom; Personal Social Services Research Unit, London School of Economics, United Kingdom.
REFERENCE: J Affect Disord 2008 Aug 109(3):273-85
BACKGROUND: Electroconvulsive therapy (ECT) has a long history of use in treating depression. Repetitive transcranial magnetic stimulation (rTMS ) has been introduced more recently to the treatment spectrum. Its cost- effectiveness has not been explored. METHOD: Forty-six right-handed people with severe depressive episodes referred for ECT were randomised to receive either ECT twice weekly or rTMS on consecutive weekdays. Health and other service use were recorded for retrospective periods of 3 months prior to initiation of treatment and during the 6 months following the end of allocated treatment. Costs were calculated for the treatment period and the subsequent 6 months, and comparisons made between groups after adjustment for any baseline differences. Cost- effectiveness analysis was conducted with incremental change on the 17- item Hamilton Rating Scale for Depression (HRSD) as the primary outcome measure, and quality-adjusted life years (based on SF6D-generated utility scores with societal weights) as secondary outcome, cost- effectiveness acceptability curves plotted.
RESULTS: Based on the HRSD scores and other outcome measures, rTMS was not as effective as ECT. The cost of a single session of rTMS was lower than the cost of a session of ECT, but overall there were no treatment cost differences. In the treatment and 6-month follow-up periods combined, health and other service costs were not significantly different between the two groups. Informal care costs were higher for the rTMS group. Total treatment, service and informal care costs were also higher for the rTMS group. The cost-effectiveness acceptability curves indicated a very small probability that decision-makers would view rTMS as more cost-effective than ECT.
LIMITATIONS: Small sample size, some sample attrition and a relatively short follow-up period of 6 months for a chronic illness. Productivity losses could not be calculated.
CONCLUSIONS: ECT is more cost-effective than rTMS in the treatment of severe depression.

Electromagnetic Treatments for Depression Seek to Improve on ECT

medpage TODAY publised a nice summary of neuromodulatory approaches for depression. The following topics are discussed:

• Vagus nerve stimulation
  
• Magnetic seizure therapy
  
• Repetitive transcranial magnetic stimulation
  
• Deep brain stimulation
  
• Transcranial direct current stimulation
  
• Implantable cortical stimulation
  

The new(er) kid on the block is obviously Implantable cortical stimulation, the author writes about this technique:

Another early-stage investigational technology takes vagus nerve stimulation a step farther. Instead of delivering electrical pulses to a nerve, it sends them to the surface of the brain. Seattle-based Northstar Neurosciences is testing a system that, like vagus nerve stimulation, inserts a pulse generator in the patient's chest. An electrical lead is passed into the skull through a surgically drilled hole, terminating on the dural membrane over the cortex.

DBS for body dysmorphic disorder

An interesting case report: 

Body dysmorphic disorder is excessive preoccupation with minor or imagined flaws in appearance. Dr. Anderson’s patient was a 20-year-old man who obsessed on perceived flaws with his nose and other facial features. He had attempted suicide once, and described his life as a “living hell.” Eight months after DBS surgery, the patient reported mild depression and obsessive compulsive disorder, but no symptoms of body dysmorphic disorder.

The full article can be found on Psych Central.

Deep brain stimulation of the ventral internal capsule/ventral striatum for obsessive-compulsive disorder: worldwide experience

Greenberg BD, Gabriels LA, Malone DA Jr, Rezai AR, Friehs GM, Okun MS, Shapira NA, Foote KD, Cosyns PR, Kubu CS, Malloy PF, Salloway SP, Giftakis JE, Rise MT, Machado AG, Baker KB, Stypulkowski PH, Goodman WK, Rasmussen SA, Nuttin BJ.

[1] 1Department of Psychiatry and Human Behavior, Division of Neurosurgery, Butler Hospital, Brown Medical School, Providence, RI, USA [2] 2Department of Clinical Neurosciences, Division of Neurosurgery, Butler Hospital, Brown Medical School, Providence, RI, USA.

Psychiatric neurosurgery teams in the United States and Europe have studied deep brain stimulation (DBS) of the ventral anterior limb of the internal capsule and adjacent ventral striatum (VC/VS) for severe and highly treatment-resistant obsessive-compulsive disorder. Four groups have collaborated most closely, in small-scale studies, over the past 8 years. First to begin was Leuven/Antwerp, followed by Butler Hospital/Brown Medical School, the Cleveland Clinic and most recently the University of Florida. These centers used comparable patient selection criteria and surgical targeting. Targeting, but not selection, evolved during this period. Here, we present combined long-term results of those studies, which reveal clinically significant symptom reductions and functional improvement in about two-thirds of patients. DBS was well tolerated overall and adverse effects were overwhelmingly transient. Results generally improved for patients implanted more recently, suggesting a 'learning curve' both within and across centers. This is well known from the development of DBS for movement disorders. The main factor accounting for these gains appears to be the refinement of the implantation site. Initially, an anterior-posterior location based on anterior capsulotomy lesions was used. In an attempt to improve results, more posterior sites were investigated resulting in the current target, at the junction of the anterior capsule, anterior commissure and posterior ventral striatum. Clinical results suggest that neural networks relevant to therapeutic improvement might be modulated more effectively at a more posterior target. Taken together, these data show that the procedure can be successfully implemented by dedicated interdisciplinary teams, and support its therapeutic promise.

Molecular Psychiatry advance online publication, 20 May 2008; doi:10.1038/mp.2008.55.

PMID: 18490925 [PubMed - as supplied by publisher]