A major new study has found that transcranial magnetic stimulation (TMS), which applies magnetic energy to the brain, can be a cost-effective treatment option for the NHS in treating moderate and severe forms of depression that have not responded to other treatments.
The economic analysis, which is published in BMJ Mental Health, compared TMS to usual care in specialist mental health services, and found that TMS reduces depressive symptoms, eases pressures on informal carers and on NHS resources, and helps people get back to work.
TMS represents an investment in care that recovers its costs over time, primarily from savings to the wider health service and from fewer workdays being lost because of long-term depression.
The study was led by senior health economist Edward Cox from the Nottingham Clinical Trials Unit at the University of Nottingham and Professor Richard Morriss from the Institute of Mental Health, National Institute for Health and Care Research (NIHR) Nottingham Biomedical Research Centre, and the NIHR HealthTech Research Centre in Mental Health (MindTech).
Major depression is the leading cause of disability lost years worldwide (WHO, 2017), and suicide from depression is one of the biggest killers of people aged between 15-49. Antidepressants and therapy delivered as first or second-line treatments help two thirds of people with depression, but the remaining third have treatment resistant depression (TRD). This is defined as a lack of response to two courses of antidepressants.
TMS is an outpatient treatment where people have powerful magnetic pulses delivered to the left side of their head just in front of the temporal area of the scalp. The person is conscious and has at least 20 sessions over a four-to-six-week period.
Although TMS is safe and effective as a treatment for TRD and was approved in 2015 by the National Institute for Health and Care Excellence (NICE) for use in the NHS, it remains inaccessible for the majority of patients. Although TMS was invented in the UK, the equipment produced by UK industry, and has been proven effective and implementable within mental health care services, it is only available in one in seven NHS Trusts. One of the main reasons for this is the lack of evidence showing its value for money.
In this new study, experts set out to assess the cost-effectiveness of two forms of TMS, repetitive transcranial magnetic stimulation therapy (rTMS) and intermittent theta-burst stimulation (iTBS), compared to usual care for TRD. The study also seeks to establish the operational circumstances in which TMS could be deemed to represent value-for-money to the NHS and wider society.
As a previously high functioning nurse, I suffered severe depression and had to be admitted to hospital because of the severity of my depression. I tried all sorts of different treatments for my depression. Nothing worked. I then travelled to receive a course of TMS and it has transformed my life. I am back working as a nurse, lost four stone in weight and I am enjoying life again with family and friends. I strongly believe that others suffering like me should be given the option of TMS under the NHS."
Mr Cox said: "Our economic analysis was informed via feedback from TMS experts across six mental health care services, and from the experiences of 442 participants suffering with difficult-to-treat forms of depression enrolled within two clinical trials. The study found that a proportion of patients receiving TMS therapies can expect to achieve faster and more sustained improvements in depressive symptoms compared to usual care, and that these gains represent a cost-effective allocation of scarce NHS resources.
"It's important to recognise that the cost-effectiveness of TMS is dependent specifically on how it is going to be delivered in wider practice. Our study findings demonstrate that services that can achieve a streamlined high throughput model of care can expect to deliver a highly cost-effective treatment. Our findings should provide much needed evidence for policymakers to rationalise and establish cost-effective models for implementing TMS within the NHS."
The team developed a decision-analytic model (DAM) to integrate evidence from three sources – (i) the BRIGhTMIND trial – a large randomised controlled trial (RTC), funded by the Efficacy and Mechanism Evaluation (EME) Programme - a partnership between the NIHR and the Medical Research Council (MRC) - that showed TMS was effective for at least six months; (ii) The Specialist Mood Disorder (SMD) trial – the first UK multicentre outpatient RTC in patients with moderate of severe unipolar depression in the UK funded by the NIHR Applied Research Collaboration East Midlands; and (iii) a study-specific structured expert elicitation exercise, where experts highly experienced in the delivery of TMS therapies for depression were interviewed on the longer-term effectiveness and operational realities of providing treatment.
NICE typically considers medical interventions to be cost-effective if the incremental cost-effectiveness ratio (ICER) for a treatment [the expected cost to the health service per unit of benefit] falls within or below a threshold of £20,000–£30,000 per quality-adjusted life-year (QALY) gained. This threshold is set to rise to £25,000–£35,000 per QALY imminently.
From a health-service perspective rTMS and iTBS had ICERs of £12,093 and £12,959 per QALY compared to TAU, respectively. From a broader societal perspective both rTMS and iTBS improved health, reduced informal care hours and were cost-saving compared with TAU.
The study findings were sensitive to service delivery, but provided there is a high throughput of patients receiving TMS and currently recommended protocols for TMS are followed, then this research suggests that TMS is a cost-effective alternative to usual care.
Professor Richard Morriss, Research Theme Lead for Mental Health and Technology at the NIHR Nottingham Biomedical Research Centre, and the School of Medicine at the University, said: "Our view is that TMS should be considered as a cost-effective alternative for treating moderate to severe depression after the second course of treatment has failed.
"Compared to usual care, our study shows that TMS is cost-effective below the lowest NICE threshold for cost-effectiveness for health costs and cost saving if health, informal care and work productivity are included.
"Two main objections for implementing TMS for TRD in the NHS was that it was only effective for a short period and there was no UK economic study showing that it was cost-effective or cost-saving. The BRIGhtMIND study in 2024 proved that the treatment was effective for at least six months and this new study now shows cost-effectiveness in health costs and in terms of in wider societal costs too. With this in mind, we feel that it is time for the NHS to seriously consider implementing TMS in NHS services across the UK."
The full study can be found here.
