ECT is Superior to TMS for Treatment-Resistant Depression
For patients with treatment-resistant depression, electroconvulsive therapy (ECT) should be the preferred treatment over transcranial magnetic stimulation (TMS) when maximizing clinical response and remission rates is the priority, as ECT demonstrates significantly superior efficacy despite a higher side effect burden. 1, 2
Evidence for ECT Superiority
Clinical Efficacy Data
The most recent and highest quality head-to-head comparison demonstrates clear superiority of ECT:
- In a 2024 register-based crossover study of 138 patients who received both treatments, ECT reduced depression scores (MADRS-S) by 15.0 points compared to only 5.6 points with rTMS (P = 0.0001) 1
- Response rates (≥50% symptom reduction) were 38% for ECT versus 15% for rTMS (P = 0.0001) 1
- ECT was superior across all subgroups regardless of age or baseline depression severity 1
Guideline Recommendations
The 2022 VA/DoD guidelines acknowledge that rTMS improves symptoms in treatment-resistant depression with a number needed to treat of 3.4 to 9 patients for response and 5 to 7 patients for remission 3, 4. However, ECT is consistently positioned as the most effective antidepressant treatment for severe, incapacitating forms of TRD 2.
Critical Nuances in Treatment Selection
When TMS May Be Preferred
Despite inferior efficacy, TMS offers important advantages in specific clinical scenarios:
- Patient tolerability: TMS produces significantly fewer side effects than ECT (P<0.01), particularly avoiding cognitive adverse effects and the need for general anesthesia 5
- Patient preference: TMS scores better in patient preference surveys, with lower stigma and time burden 5, 6
- Maintenance therapy: TMS can successfully substitute for maintenance ECT in patients who cannot tolerate ongoing ECT due to cognitive effects or anesthesia concerns 6
Cost-Effectiveness Considerations
ECT demonstrates superior cost-benefit ratio ($2,075 vs $814 for TMS), though this must be weighed against the requirement for anesthesia, operating room facilities, and recovery time 5.
Clinical Decision Algorithm
For newly diagnosed TRD (≥2 failed adequate antidepressant trials): 3, 7
If severe, incapacitating depression or acute suicidality: Choose ECT as first-line neuromodulation 2
If moderate severity with patient preference for less invasive treatment: Trial rTMS first, with ECT reserved for non-responders 3, 4
If cognitive function is a critical concern (e.g., elderly, professional requirements): Consider rTMS despite lower efficacy 5, 6
If patient has comorbid PTSD or substance use disorder: Note that one recent veteran study found no significant difference between rTMS and sham, suggesting placebo effects may be substantial in this population 3
Important Caveats
Access Barriers
- TMS requires frequent onsite visits (typically 5 sessions per week for 4-6 weeks), which may limit practical access 3, 4
- ECT requires anesthesia capability and operating room facilities 5
Mechanism Differences
Recent neuroimaging reveals distinct mechanisms: ECT produces significant volumetric increases in striatum, pallidum, medial temporal lobe, and subgenual anterior cingulate cortex, while rTMS does not cause structural changes despite comparable clinical outcomes in responders 8. This suggests ECT works through structural neuroplasticity/neuroinflammation, while rTMS operates via neurophysiological plasticity 8.
Theta-Burst Stimulation
The 2022 VA/DoD guidelines state there is insufficient evidence to recommend for or against theta-burst stimulation (TBS), a rapid variant of TMS, despite one study showing non-inferiority to standard 10-Hz rTMS 3, 9.
Practical Implementation
Both treatments should ideally be available in psychiatric facilities to expand the therapeutic toolkit for TRD 5. The choice should prioritize ECT when rapid, robust response is essential for patient safety and functioning, while reserving TMS for patients who refuse ECT, cannot tolerate anesthesia, or have failed ECT but need ongoing neuromodulation maintenance 6, 2.