Economic evaluation of resistant major depressive disorder ...

Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)

Iran University of Medical Sciences

____________________________________________________________________________________________________________________1. PhD of Health Economics, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Med-ical Sciences, Kerman, Iran. [email protected]. MSc in Health Technology Assessment, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, [email protected]. PhD of Health Policy and Management, Department of Health Management and Economics, School of Public Health, Tehran University ofMedical Sciences, Tehran, Iran. [email protected]. (Corresponding author) PhD of Health Policy, Assistant Professor, Department of Health Services Management, School of Health Man-agement and Information Sciences, Iran University of Medical Sciences, Tehran, Iran. [email protected]. Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. [email protected]. PhD student in Psychology, Ferdowsi University of Mashhad, Faculty of Psychology and Educational Sciences, Mashhad, [email protected].

Economic evaluation of resistant major depressive disordertreatment in Iranian population: a comparison between repetitive

Transcranial Magnetic Stimulation with electroconvulsive

Hesam Ghiasvand1, Mohammad Moradi- Joo2, Nazanin Abolhassani3Hamid Ravaghi*4, Seyed Mansoor Raygani5, Sahar Mohabbat-Bahar6

Received: 9 September 2015 Accepted: 11 November 2015 Published: 17 February 2016

AbstractBackground: It is estimated that major depression disorders constitute 8.2% of years lived with

disability (YLDs) globally. The repetitive Transcranial Magnetic Stimulation (rTMS) and Electro-convulsive Therapy (ECT) are two relative common interventions to treat major depressive disor-ders, especially for treatment resistant depression. In this study the cost- effectiveness and cost-utilityof rTMS were compared with ECT in Iranian population suffering from major depressive disorderusing a decision tree model.

Methods: A decision tree model conducted to compare the cost-effectiveness ratio of rTMS withECT in a health system prospective and 7 months’ time horizon. The outcome variables were: re-sponse rate, remission rate and quality-adjusted life-years (QALYs) of the rTMS and ECT as prima-ry and secondary outcomes extracted from systematic reviews and randomized control trials. Thecosts were also calculated through a field study in one clinic and one hospital; the direct costs haveonly been considered.

Results: The total cost for rTMS and ECTstrategieswere11015000Rials (373US$) and 11742700Rials (397.7US$), respectively. Also the rTMS/ECT ratio of costs per improved patients was1194410Rials (40.5 US$); the ratio for costs per QALYs utility was 21017139 Rials (711.72 US$).The incremental cost- effectiveness ratio of rTMS versus ECT was 1194410 Rials (40.44 US$) aftertreatment and maintenance courses.

Conclusion: Given the current prevalence of depressive disorders in Iranian population, the ECT ismore cost-effective than TMS. The sensitivity analysis showed that if the prevalence of major de-pressive disorders declines to below 5% or the costs of rTMS decrease (rTMS provided by publicsector), then the rTMS becomes more cost-effective compared with ECT. However, efficacy ofrTMS depends on the frequency of pulsed magnetic field, the location of rTMS on the head, thenumber of therapeutic sessions and the length of each session.

Keywords: Major Depressive disorders, Electroconvulsive Therapy, repetitive Transcranial Magnet-ic Stimulation, Decision tree.

Cite this article as: Ghiasvand H, Moradi- Joo M, Abolhassani N, Ravaghi H, Raygani SM, Mohabbat-Bahar S. Economic evaluation ofresistant major depressive disorder treatment in Iranian population: a comparison between repetitive Transcranial Magnetic Stimulation withelectroconvulsive. Med J Islam Repub Iran 2016 (17 February). Vol. 30:330.

IntroductionChanging pattern of diseases and out-

stripping the prevalence of chronic diseasesrequiring long-term care, have led to

Economic evaluation of rTMS versus ECT in treating resistant major depression disorder

2 Med J Islam Repub Iran 2016 (17 February). Vol. 30:330.http://mjiri.iums.ac.ir

changes in policy approaches and plans ofhealth systems particularly in developingcountries. These changes have had adverseconsequences, especially in developingcountries that have less potential and areless prepared to manage them. Mental dis-orders and illness are chronic health prob-lems that have adverse effects on the quali-ty of life in households and the social andeconomic development on a national scale(1).

Major depression’s prevalence, morbidi-ty, mortality and disability rates are grow-ing now and it is predicted that they will beranked as the first worldwide burden ofdiseases in developed countries in 2030 (2).Studies on the Global Burden of Diseasesconducted in 1990 and 2000 have had amain role in shifting international attractionand emphasis from the physical disorders tomental disorders, especially the depression(3-5). According to Ferrari A.J.et.al., thedepressive disorders have been the secondleading cause of years lived with disability(YLDs and the major depressive disordersare accounted for 8.2% (5.9%- 10.8%) ofglobal YLDs. Also, they found that eventhough no mortality is attributed to depres-sive disorders, it is the leading cause ofDALYs and the MMD is accounted for2.5% (1.9%- 3.2%) of global DALYs (6).

This situation may become worse, if weconsider the sexual and demographic dis-tribution of the major depression. Accord-ing to studies, the prevalence of major de-pression is more in female and also inyoung and productive population groups(6,7). So the major depression may lead toserious social and economic challenges inboth developing and developed countries.There is no accurate estimation about themajor depression in Iranian population, butaccording to the results of a systematic re-view conducted in Iran, the MMD preva-lence was 4.1% (95% CI: 3.1-5.1) andwomen were 1.95 times more likely tohave the MDD (8).Also, in a national sur-vey conducted in 2003, the major depres-sive disorders (MMD) ranked in the highfour burden in all ages and both sexes. It is

also the second cause of DALYs betweenIranian female (9).

Another study reported the MMD as thetop cause of YLDs and the third cause ofDALYs among 20 countries in MENA (theMiddle East and North Africa countries in-cluding Iran) in 2010 (10).

The considerable prevalence and burdenof major depressive disorders made them asa high priority health challenge that re-quires adopting and implementing effectivepolicies to solve it. The appropriate treat-ment strategy is the heart of solving thischallenge. Nowadays, there are some ther-apeutic interventions to treat the major de-pressive disorders. The pharmacologicalinterventions (11) and non-pharmacologicalNeuromodulation Therapies (NMTs) includeelectroconvulsive therapy (ECT) andthe transcranial magnetic stimulation(TMS) (12). But in major depressive disor-ders (MMDs) treatment, what makes thesituation worse is the inefficacy of pharma-cological interventions; Berlim et al (2008)concluded that up to 20–30% of subjectssuffering from MMD remain significantlyill despite the use of multiple therapeuticinterventions (13). These cases are calledthe treatment resistant depression. So, eachtherapeutic intervention has its advantagesand disadvantages.

The electroconvulsive therapy has beenused to treat the patients who do not re-spond to antidepressant medication or psy-chological therapy. The ECT has been crit-icized as a therapeutic intervention becauseof the need to anesthesia, the risk of seizureand cognitive side effects (15,16).

The transcranial magnetic stimulation(TMS) and subsequent repetitive Transcra-nial Magnetic Stimulation (rTMS) havebeen developed in order to achieve effec-tive and safe interventions for the treatmentof the treatment-resistant depression overthe last three decades. The TMS was firstused in 1985 by Barker et al (16).

Considering the above-mentioned find-ings, the choice of appropriate interventionshould be selected based on appropriatecriteria including: safety, clinical efficacy

H. Ghiasvand, et al.

3Med J Islam Repub Iran 2016 (17 February). Vol. 30:330. http://mjiri.iums.ac.ir

and economic considerations. The econom-ic considerations imply the economic eval-uation that is conducted through cost-effectiveness and cost- utility analysesbased on the current modeling approachesincluding the decision tree and Markovmodel.

This study aimed to calculate and com-pare the cost-effectiveness and cost- utilityof the repetitive Transcranial MagneticSimulation (rTMS) with electroconvulsivestrategy through conducting a decision treeapproach in the treatment of Iranian popu-lation suffering from the major depressivedisorder.

MethodsStudy Design: This economic evaluation

study was conducted using a decision treemodel. The cost- effectiveness and cost-utility analyses were used to compare therTMS with ECT as two therapeutic inter-ventions for Iranian population sufferingfrom major depression disorders (MMDs).According to clinical guidelines, treatmentof major depressive disorders requires aone year intervention and follow up (17);but there are many studies recommended a7month time horizon (15-18). So, we select-ed a 7 month time horizon including 3-4weeks for intervention and about 6 monthsfor the follow-up phase.

Data and Setting: Data related to thecosts of resource evaluated in each thera-peutic strategy. The direct costs were col-lected from the clinics and hospitals provid-ing the ECT and rTMS to the patients suf-fering from major depressive disorder. Thehospitalization and anesthesia are neededfor the ECT, so the data regarding its costwere collected from a hospital. Hospitaliza-tion and anesthesia are not needed for therTMS and it can be provided within out-patient settings and facilities. All those re-lated costs were collected from the clinicsof a public hospital and a private medicalcenter both located in Tehran, Iran.

The efficacy data were collected throughsearching the reviews available in the lit-eratures. The literature review conducted

using a predefined search strategy in Pub-Med/Medline, Scopus, INAHTA, CRD,Trip, PsycInfo, Google Scholar, andCochrane Library databases. The searchstrategy did not contain any time limitationand the appropriate terminology checkedaccording to Mesh. We used the termsrTMS/TMS and ECT therapeutic efficacyand major depressive disorders,rTMS/TMS and ECT response rate and ma-jor depressive disorders, rTMS/TMS andECT remission rate and major depressivedisorders, rTMS/TMS and ECT relapse rateand major depressive disorders, andrTMS/TMS and ECT recurrence rate andmajor depressive disorders. A large numberof primary outcomes are available as theclinical efficacy (therapeutic) for TMS andECT methods. Among these indicators, re-sponse rate to the treatment, remission andrelapse rates, number of patients requiringtreatment and the risk difference were con-sidered. Each of these indicators are basedon Hamilton Scale, 17or 24 (HDRS 17 or24) and the Montgomery-Asberg Depres-sion Rating Scale (MADRS), BDI scoresand AUSSI. In this study, the primary out-comes included the response, remission andrelapse rates among the target population.The secondary outcome includes the rate ofthe change in the quality of life which isbased on the overall index (Based on theoverall quality of life).

Costing Approach: Costing was evaluatedaccording to the resources utilized to pro-vide the therapeutic services in each ofECT and TMS strategies.Each of thesestrategies have specific processes and activ-ities including the manpower, machines andequipment, physical environment, materi-als, supplies and medication. These costsinclude both phases of the treatment (3-4weeks) and follow-up (26-week mainte-nance phase) and also their weighted sum.After identification of these resources, anappropriate measure was used to measurethe amount of initiatives done by eachmethod. Finally, the total cost of each strat-egy was derived by multiplying the marketprice by the units of used resources. Before



computing the total cost, the process andactivities constituting each therapeuticstrategy were identified. The abovemen-tioned processes are explained as below(14,17,18): The treatment process in (r) TMS: Peo-

ple suffering from resistant major depres-sive disorders undergo rTMS under super-vision of a psychiatric. Usually the thera-peutic plan includes one session (the firstsession) for examination the patient, 10sessions for the therapeutic intervention(using rTMS) and 3 sessions for assessingthe therapeutic trend and following up thepatients. The first eleven sessions aredonein3to 4weeks and called the ini-tial/primary phase. Each session lasts about20 to 30 minutes and a psychiatric performsrelated activities and practices. In caseswith no response to the treatment, the psy-chiatric performs the therapeutic planagain. Patients with proper response to thetreatment will enter the follow up (mainte-nance) phase. The second three sessionsconstitute the maintenance (follow up)phase and the patients will be visited everytwo months by a psychiatric or clinicalpsychologist. During the maintenance peri-od, a certain dose and number of antide-pressant (usually Fluoxetine) is prescribedfor patients. Treatment process in ECT: In the ECT

strategy, patients are hospitalized and theyare taken to the ECT room after primarypreparation for the therapeutic intervention.Initially, an IV line is taken, and then a rap-id-action intravenous anesthetic medication(e.g. Thiopental) and a muscle relaxantmedication (e.g. Esculin) are injected by ananesthesiologist. Under the supervision of apsychiatrist and by a trained nurse, patientsreceive shock using two electrodes that areplaced on their temporal sides and are con-nected to the ECT device.The patients’ sei-zure times are recorded. After finishing theshocking process, anesthetics techniciangives patients nasal oxygen, removes phar-yngeal secretions by suction and then pa-tients are transferred to the recovery room.After there recovery, IV line is removed

and the patient will be transferred to thewaiting room.

At the end of the intervention and totalconsciousness, patients will be referred totheir wards. Here, several issues must beconsidered: First, the time length of theECT procedure in each session is not exact-ly fixed and may vary between 20 secondsto 1 minute. Second, the number of ses-sions depends on the patient's condition andhis/her response to the treatment. Totally,between 8 to 17 sessions is needed; and ineach session the patient is often hospital-ized for 2 to 3 weeks. The maintenance orfollow-up period lasts between 5 to 6months and repeated visits will be done bya psychiatrist once a month. In addition,during the maintenance period, patients aretaken anti-depressants each day and asleeping medication every two days (type,dose and use of medications depend on thepsychiatrist’s prescription).

Modeling and description: A decisiontree model was conducted to calculate thecost-effectiveness and cost-utility ratios ofrTMS and ECT strategies. This model in-cludes two strategies, rTMS and ECT. Con-sidering major depressive disorders preva-lence in Iran (about 0.127 that is equal to169 people per 100000 Iranian population),a total of 9544008 patients were included ineach strategy. The therapeutic interventionin each strategy had two phases: The firstphase was the intervention period whichlasted three weeks. During this period, pa-tients were treated with both of these strat-egies. After the intervention period, pa-tients entered the second phase in whichthey were monitored by a psychiatrist and aclinical psychologist. Medications wereprescribed in this period on a regular basis.It was considered that patients may be im-proved after the first phase to be eligible toenter to the second phase or they may showno response to the treatment and should bere-treated. In fact, the first phase is inter-vention and the second phase is the mainte-nance (follow up) phase. Table 1 presentsthe parameters used in the study.



Here, some required explanations are pre-sented:

1. There are no comprehensive statisticson the prevalence of major depressive dis-orders in Iran. A set of data has been an-nounced by the Mental Health Office ofIran’s Health Ministry. However, these datahave been revised using the major depres-sive disorders statistics collected from asystematic review conducted in 2010(8) aswell as expert opinions. So, three possibleprevalence rates were considered including4.1%, 8% and 10% in the analysis section.

2. The economic evaluation was conduct-ed in two phases: At three to four weeks forthe therapeutic phase and from 6 months toone year (49 weeks) for the maintenance(follow up) phase.

3. The incremental cost- effectiveness ra-tio, was calculated as below:

ICER=

4. Robustness of the model: A sensitivityanalysis was conducted to assess the validi-ty and reliability of the model.The sensi-tivity analysis was performed on the re-sponse rate, remission rate and costs varia-tions for each of the TMS and the ECTmethods based on the prevalence of majordepression in the general population.

ResultsTotal costs for the rTMS and the ECT as

therapeutic strategies for major depressivedisorder are presented in Table 2. This tableshows the costs for the primary phase andmaintenance (follow up) phase and totalcosts of both phases for rTMS and ECT,separately.

The costs were calculated using a re-source based valuing scale, in which allpayments for the utilized resources forproviding services had been computed.These costs included payments for psychi-atrics, clinical psychologists, purchase ofrTMS and cots for establishing, runningand repairing of instruments, physical spaceand its furnishing, as well as costs of therTMS consumption energy and suppliesand consumable materials. Payments fordrugs and psychiatric visits during the fol-low up phase were also calculated. Similarpayments were also calculated for the ECTstrategy with some differences. As the ECTrequired the hospitalization and anesthesia,these costs were also included. These in-cluded costs for hospital beds, ICU (ifneeded), recovery and ward charges, nurs-ing services, food and other hospital ac-commodation charges. Therefore, the ECTstrategy is a little more expensive than therTMS strategy. Complete profiles of bothrTMS and ECT strategies have been pre-

Table 1. The parameters used in economic evaluation modelParameters Rate ReferenceIran population 75149669 (19)The prevalence of major depression in Iran. 0.127 (169 people per 100000

Iranian population), 0.041(20) and (8)

Response Rate to the rTMS in the first phase. 0.167, 0.17 and 0.4 (21), (22) & (23)Remission Rate with the rTMS in the second phase (maintenance phase). 0.5, 0.5 and 0.36 (21), (22) & (23)Response Rate to the ECT in the first phase. 0.303, 0.467 and 0.59 (15) & (24)Remission Rate with ECT in the second phase (maintenance phase). 0.03 and 0.234 (18) & (24)Rate of the change in the quality of life in the first phase of the rTMS. 0.023 (18)Rate of the change in the quality of life in the second phase of the rTMS. 0.053 (18)Rate of the change in the quality of life in the first phase of the ECT. 0.0263 (18)Rate of the change in the quality of life in the second phase of the ECT. 0.053 (18)

Table 2. The costs of therapeutic phases of major depressive disorders*Therapeutic Strategy Costs of primary phase Costs of follow up phase Total Costs after finishing the

therapeutic courserTMS strategy 9757500Rials (330.4 US$) 1257500Rials (45.6US$) 11015000Rials (376US$)ECT strategy 9880000Rials (334.6US$) 1862700Rials (63US$) 11742700Rials (397.7US$)

* All costs have been calculated since the January to March 2014 when the 1US$=29530 I.R.I Rial



sented in Appendices 1 and 2.After calculating the costs of rTMS and

ECT strategies, the cost- effectiveness andcost- utility ratios have computed through adecision tree model. The decision modelhas been presented in Fig. 1.

There was no comprehensive and accu-rate data on major depressive disorder inIran and the I.R.I Ministry of Health Men-tal Health Office has been considered as areferral for the estimation of MMD preva-lence in Iranian population. According tothis issue, it was estimated that 9544008Iranian people suffer from MMD. This fig-

ure has been calculated considering the Ira-nian Statistics Centre estimation of thecountry population which was about75149669 people in 2011. So, the cost- ef-fectiveness and cost- utility ratios werecomputed based on the response, remissionand relapse probabilities extracted from theliterature. Calculations presented in Table3.

The sensitivity analysis has been con-ducted to assess the robustness of the re-sults. Here, one-way linear sensitivity anal-ysis was conducted for the MMD preva-lence, the remission rate and the costs of

Fig. 1. The decision tree model of rTMS versus ECT in treatment of major depressive disorder

Table 3. The ICER results for the rTMS and ECT among Iranian population suffering from MMDEffectiveness variable Amount of

EffectivenessCosts per improved patients the

rTMS to ECT Rials (US$)Number of patients who improved by the rTMS in the interventionphase (the first 3 weeks)

2368002996890.1(33.75)

Number of patients who improved by the ECT in the interventionphase (the first 3 weeks)

5630965

Number of patients who improved by the rTMS in both interventionand maintenance phases

1184001 1194410(40.44)

Number of patients who improved by the ECTinboth interventionand maintenance phases

5462036

The change in the Quality of life in patients who improved by therTMS in the first 3 weeks

54878.05 36641760(1240.8)

The change in the Quality of life in patients who improved by ECTin the first 3 weeks

143651.5

The change in the Quality of life in patients who improved by rTMSin both intervention and maintenance phases

62752.05 21017139(711.72)

The change in the Quality of life in patients who improved by rTMSin both intervention and maintenance phases

305874



each strategy.1. If the MMDs prevalence is 4.1%,the

ICER is:At the end of the initial treatment phase

(the first 3 weeks): 62327641000 Rials(2110654.961 US$) the ICER of the rTMSto the ECT. At the end of the follow upphase (including the first and maintenancephases): 252516000000 Rials(8551168.303 US$) the ICER of the rTMSto the ECT.

2. If the response rate in initial treatmentphase is 0.4 after rTMS, the ICER is: At theend of the initial treatment phase (the first 3weeks): 5563390000000 Rials(188397900.4 US$) the ICER of the rTMSto the ECT. At the end of the follow upphase (including the first and maintenancephases): 6413930000000 Rials(217200474.1US$) the ICER of the rTMSto the ECT.

3. If the remission rate in the maintenancephase is 0.5 percent after TMS, the ICERis: At the end of the initial treatment phase(the first 3 weeks): 5863390000000 Rials(198557060.6 US$). At the end of the fol-low up phase (including the first andmaintenance phases):6620962300000Rials(224211388.4 US$)

4. If the response rate in the initial treat-ment phase is 0.234 percent after ECT, theICER is: at the end of the initial treatmentphase (the first 3 weeks): 5563390000000Rials (188397900.4US$). At the end of thefollow up phase (including the first andmaintenance phases):8935800000000 Rials(302600745 US$).

5. If costs of the rTMS strategy are basedon a public-sector -regardless of profit anddepreciation costs for equipment and build-ings, the ICER is: at the end of the initialtreatment phase (the first 3 weeks):263008260Rials (8906.476803). At the endof the follow up phase (including the firstand maintenance phases):630719860Rials(21358.61361 US$).

DiscussionEconomic evaluation is a technique to al-

locate resources for the each health ser-

vices. Mental health disorders especiallythe major depression is a growing problemthat involves the female more than maleand also the young population more thanelders. The WHO has reported the majordepression as a manageable health systemchallenge that can be controlled by reason-able and bearable costs if it is diagnosed inthe primary phase and the initial stage. Theprevalence and subsequent burden of MMDhave an increasing pattern and trend.Treatment-resistant depression makes dou-ble problems for health systems and re-quires serious action. In Iran, the preva-lence of major depression and especiallythe treatment resistant depression are notclear and the need of a comprehensive sur-vey to monitor major depression is of greatimportance. Nevertheless, in this study ma-jor depression disorder therapeutic regi-mens including rTMs and ECT were ana-lyzed in terms of cost-effectiveness andcost- utility ratios using a decision treemodel. The total cost for treating major de-pression disorder by rTMS was11015000Rials (373US$) and by the ECTwas11742700 Rials (397.7US$). So, thereis little difference in the calculated costs forthe two strategies. The ECT strategy re-quires patients’ hospitalization and anesthe-sia and also nursing care, therefore the ECTis more expensive than the rTMS. The maincost resource of the rTMS is associatedwith the purchase of the rTMS and also re-lated human resources but the ECT’s maincosts are related to human resources andthe physical space needed to establish theECT. Knapp et al. concluded that “The costof a single session of rTMS was lower thanthe cost of an ECT session, but overallythere is no treatment cost differences” (15).Kozel et al. mentioned” The total costs, in-curred during the 52-week period were$57,845,347 for rTMS and$186,359,571for ECT” (23).

If we consider informal costs includingloss of productivity and transportationcosts, it may be no difference between bothrTMS and ECT strategies. McLoughlin etal. concluded that although the individual



treatment session costs were lower forrTMS than ECT, the cost for a course ofrTMS was not significantly different fromthat for a course of ECT as more rTMS ses-sions were given per course (18).

If the MMD prevalence is supposed to be0.127 in Iranian population, the ICER re-sults show that the ECT is more cost-effective than the rTMS. The ECT responserate, especially in the initial or interventionphase, is more than rTMS. The costs ofboth strategies are also not very different;and the ECT is more cost-effective than therTMS. In addition, in the follow up(maintenance) phase, the remission rate forrTMS is supposed to be more than the ECTbut in the total therapeutic phase the ECT ismore effective.

Furthermore, the incremental cost- utilityanalysis showed that, the patients’ qualityof life has been changed after the ECTstrategy more than the rTMS. So, the rTMShas greater cost-utility than the ECT. Alt-hough the ECT requires anesthesia andshock, more efficacy was resulted from theECT in long term; and greater improve-ments in patients’ living status may com-pensate these disadvantages. Generally, theECT seems preferable to the rTMS.

Knapp et al. found thatrTMS has a verylow probability of being more cost-effective than ECT. Indeed, considering thecost of achieving an additional quality-adjusted life year, the cost-effectiveness ofrTMS does not look attractive by referenceto the threshold revealed by a review andeconometric analysis of recommendationsmade by the National Institute for Healthand Clinical Excellence (NICE) (15).On theother hand, McLoghlin et al. presented amore conservative conclusion and ex-pressed that ECT is a more effective andpotentially cost-effective antidepressanttreatment than a 3 week rTMS. Optimaltreatment parameters for rTMS need to beestablished for treatment of depression.More research is required to refine furtheradministration of ECT in order to reduceassociated cognitive side-effects whilemaintaining its effectiveness. There is a

need for large scale, adequately poweredRCTs comparing different forms of ECT(18).

The sensitivity analysis shows that, if theMMD prevalence in Iranian population is4.1%, the rTMS is more cost- effective thanthe ECT. Considering low prevalence ofMMD, rTMS’ lower costs compared withECT have a more prominent role than theECT with greater remission rate. In fact, itseems that the rTMS’ lower cost compen-sates the ECT’s greater remission rate.

Moreover, if the rTMS is provided by apublic medical facility (such as public hos-pitals) the rTMS is more cost- effectivethan the ECT. As mentioned previously, therTMS has lower costs than the ECT; if thetherTMS is provided by a public medicalfacility, the costs will be reduced consider-ably and cover its lower response and re-mission rates.

According to the results of the sensitivityanalysis on the key parameters, the re-sponse rate in the initial and follow up ther-apeutic phases showed that our results wereadequately robust across a range of parame-ter values for both comparisons. If the costsof the rTMS reduces, the results will bechange in favor of the rTMS. This is acommon result that may occur in economicevaluation studies and it is related to natu-ral uncertainty of the circumstances. Kozelet al. concluded that” If repetitive Tran-scranialMagnetic Stimulation (rTMS) wereto be made widely available in the USA, itwould offer a substantial economic benefitover electroconvulsive therapy (ECT) intreating resistant depression” (23).

ConclusionConsidering a low prevalence of MMD

between Iranian populations, the rTMS ismore cost- effective than ECT. If the costsof rTMS decrease through providing thisservice by a public medical facility, therTMS is more cost- effective than the ECT.

LimitationsThere are no accurate and comprehensive

statistics about the MMD prevalence



among the Iranian population and the au-thors used the prevalence ratio that extract-ed from a systematic review in 2010 andexpert’s opinions. Also, in the costing pro-cess, the direct costs have been consideredand the indirect cost including the produc-tive loss costs have not been taken into ac-count in this study.

Conflict of interestThe authors declared there is no conflict

of interest.

Source of fundingThis study was supported by the I.R.

Iran’s National Institute of Health Re-search, Tehran University of Medical Sci-ences as a part of The Health TechnologyAssessment of repetitive TranscranialMagnetic Stimulation versus Electrocon-vulsive Therapy in Major Depressive Dis-order, Contract No: 241/M/91279.

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AppendixAppendix 1. The rTMS strategy costs components and description

Costs Monetary valueof costs

Description and source

Costs related to the device: All costs were based on a self-report of a manager at rTMSprivate center, except for costs related to the depreciation

that are based on tax laws of the country, the annual depreci-ation rate was 10%.

Cost of purchase 90000000 Cost of deployment and commissioning 2000000 The annual cost of repair and service 80000 The annual cost of depreciation 9000000 Cost of special seat 600000 Cost of the noise reduction tool(two) 30000 Cost of cooling 2000000Total cost of the device 106710000Costs related to Human Resources: Human resources costs were calculated only for psychia-

trists. According to the Iran Health Insurance Organization,wages and expected earnings for a psychiatrist is equal to

10.5 million in 1392.It is for 250 working days and 6 hoursper day. Also two sessions were considered for clinical psy-

chologist and psychiatrist.

Cost of per minute intervention by a psychiatrist. 2527

Cost for 10 sessions of 25-minute intervention bya psychiatrist.

631750

Costs of evaluation by a clinical psychologist 40400 Cost of evaluation by a psychiatrist 303600Total cost of Human Resources 975750Total cost of physical space 120000000 According to the rTMS center, About 12 meters of space

were allocated or TMS. Other spaces were included a wait-ing room, service room, secretary location and a computersystem and furniture. Also these spaces were used for otherdisorders, including sensory–motor disabilities, Parkinson,

Bipolar disorder and Schizophrenia. But, approximately70%of patients had major depression.

Annual energy costs 16800000Total costs for initial phase of treatment(10sessions of therapy, 4sessions of counseling)

975750

Costs for Maintenance period (6months follow-up) Three sessions of counseling by a psychiatrist 75900

Two sessions of counseling by a clinical psy-chologist (Depending on a psychiatrist rec-ommendation)

40400

Cost of fluoxetine 9450Total cost of maintenance period (follow-up) 125750Total cost of initial treatment and maintenancephase by rTMS

1101500



Appendix 2. The ECT strategy costs components and descriptionCosts Monetary

value ofcosts

Description and source

Costs related to the device: Cost of purchase 11000000 The annual cost of depreciation and services 1100000

Total cost of the device 12100000Costs related to Human Resources: Wage was calculated for a psychiatrist, an

anesthesiologist and a nurse in a privatecenter in one year.

Annual salary of a psychiatrist 75000000 Annual salary of an anesthesiologist 36000000 Annual salary of a nurse 15000000 Cost of examination by a psychiatrist 101200 Costs of care by a nurse 3182400

Total cost of Human Resources 129283600Total cost of physical space About 14 meters of space were allocated to

ECT. Of this cost, 20% is related to othercosts including administrative space for

ECT.

The cost of physical space allocated to ECT 120000000

Annual energy costs 2920000Medication costs: This drug is injected as an anesthetic and a

muscle relaxant. Cost of Thiopental sodium 5.2mg/kg 5300 Cost ofEsculin1-1.5mg/kg 800

Total cost of Medication 6100Costs of anesthesia: These costs include purchase of equip-

ment, depreciation, energy and annualmaintenance.

Costs related to the respiratory devices 60000000 Cost of monitoring devices 20000000 costs related to anesthesia Supplies 51600

Total cost of anesthesia: 8051600Total costs of hospitalization: 5168000 Costs are related to hospitalization in a

private hospital in 1392.Total cost of treatment with ECT 360529300Cost of one session of ECT 123500 This cost is calculated by dividing the

costs of treatment with ECT in 8 interven-tion sessions on 2920hospital beds.

Cost of eight sessions of ECT 988000Costs for Maintenance period (6 months follow-up) The costs of 6-month follow-up period,

including 6 sessions of psychiatric exami-nation, daily use of Asentra and Loraze-

pam once every two days.

Cost of referring to a psychiatrist for 6 monthsafter treatment

151800

Cost of Asentra 50mg 30600 Cost of Lorazepam 1mg 3870

Costs for Maintenance period (6 months follow-up) 186270Total cost of treatment and maintenance phase by ECT. 1174270

Economic evaluation of resistant major depressive disorder ...

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