Transcranial magnetic stimulation

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Transcranial magnetic stimulation for the treatment of depression

Outcome of the appraisal


The use of repetitive transcranial magnetic stimulation (rTMS) for the treatment of treatment-resistant major depression is partially supported by the evidence.


The use of rTMS is well tolerated, leads to a medium-term (up to three months) reduction in depression score, and improves response and remission rates compared with sham treatment.


De novo economic modelling is subject to considerable uncertainty. Further research is therefore recommended to better determine the case for cost effectiveness, to establish the long-term efficacy of rTMS including potential maintenance therapy, and to determine the appropriate placement of rTMS in the NHS Wales treatment pathway.

Why was this topic appraised?


Major depression can have a debilitating impact on a person’s life and wellbeing. Symptoms vary but commonly include feelings of hopelessness, low interest or pleasure in activities and reduced self-worth. Depression can affect a person’s ability to perform daily tasks or take part in work and social life, as well as impact negatively on relationships with family and friends. Treatment options can include antidepressant medication and talking therapies. However, in some cases antidepressants have limited or no effect on the depression; this is known as treatment-resistant or difficult to treat depression. In some severe cases, electroconvulsive therapy (ECT) is offered, but this is rarely used in Wales. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neurostimulation technique that does not require anaesthesia and can be done in an outpatient setting, with little to no recovery period. It is usually considered for treatment resistant depression, or where antidepressants are unsuitable or poorly tolerated.

Plain language summary


Depression is a mood disorder that causes a persistent feeling of sadness that can last from weeks to months. Depression can result in a loss of interest and can impact a person’s ability to perform everyday tasks. It affects how you feel, think and behave and can lead to a variety of emotional and physical problems. Symptoms of depression include feeling unhappy or hopeless, low self-esteem and finding no pleasure in things you usually enjoy. Many things can cause depression such as stressful events, personality, family history and giving birth. Depression can be managed through medicines, such as antidepressants, talking therapies, lifestyle changes and electroconvulsive therapy (ECT). However, not everyone will respond to treatments in the same way.


Transcranial magnetic stimulation (TMS) involves the placement of an electromagnetic coil against the head. The coil sends repetitive pulses of magnetic energy at fixed frequency to specific areas of the brain. The stimulation can improve symptoms of depression and anxiety. Treatment is usually considered for patients with depression that has not responded to antidepressant medications or patients for whom antidepressant medication is not suitable.


HTW looked for evidence of the effectiveness of TMS as an intervention for depression where traditional treatments, like antidepressants, have failed. The evidence partially supports the use of TMS for the treatment of treatment-resistant major depression and further research is recommended.


Topic Exploration Report

TER247 04.2021

Evidence Appraisal Review

EAR035 11.2021


GUI035 11.2021

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