Is SMTr cost-effective for our health care system? What the INESSS says
Depression is a condition that affects the family, loved ones, and society as a whole. It has a massive collective cost, often invisible to those who do not live with it up close. Before asking whether SMTr costs too much, perhaps we should ask the question differently: how much does inaction cost? According to the […]
Depression is a condition that affects the family, loved ones, and society as a whole. It has a massive collective cost, often invisible to those who do not live with it up close. Before asking whether SMTr costs too much, perhaps we should ask the question differently: how much does inaction cost?
According to the Mental Health Commission of Canada a few years ago, the economic burden of mental health problems amounts to at least $50 billion per year, including $6 billion attributable solely to productivity loss related to absenteeism and presenteeism. In Quebec, about 30 people out of 1,000 are absent from work each week for psychological health reasons, or nearly 132,000 weekly absences. These figures tell a fiscal story, but not only that: behind every absence there is a person who is struggling, a manager who is reorganizing a team, a family absorbing the fallout.
In this context, one question deserves to be asked plainly: if another approach could bring some of these people back to functional life sooner, how much would that be worth to society?
What does treatment-resistant depression really cost?
Treatment-resistant depression, which does not respond to standard antidepressants, is a particularly heavy burden, both human and economic. Mental health problems account for 30 to 40% of short-term disability cases in Canada, and companies pay nearly twice as much in disability benefits for mental illness as for physical disability.
Treatment-refractory depression affects people who have already tried, without success, at least two different antidepressant treatments, often after months, sometimes years of unsuccessful attempts (INESSS, 2026). This situation represents a path marked by waiting, relapses, and dashed hopes, often accompanied by a prolonged distancing from the labor market and growing exhaustion among the loved ones who support the person on a daily basis.
And this trajectory comes at a price that keeps rising. According to projections by Deloitte Insights, mental health problems could cost the Canadian economy a cumulative $2.5 trillion by 2041 and account for up to 70% of all disability costs – a situation that makes the question of where to invest now to avoid these costs later even more relevant.
What does the INESSS say about the efficiency of SMTr?
In January 2026, the Institut national d'excellence en santé et en services sociaux (INESSS) was tasked by the Ministry of Health and Social Services with assessing not only the clinical effectiveness and safety of SMTr, but also its efficiency in the Quebec context, that is, its real economic value for the health care system.
In this framework, the INESSS concluded that SMTr is clinically appropriate as an option for adults with treatment-refractory depression who have not responded to first-line treatments. This conclusion also aligns with the data grouped under the CANMAT framework (Canadian Network for Mood and Anxiety Treatments or Réseau canadien pour le traitement de l'humeur et de l'anxiété), recognized across Canada for treatment indications in mental health. Notably, the INESSS recommends adding 27 additional devices to the 17 currently operating in Quebec, a recommendation based in part on an efficiency logic: expand access today to reduce the costs associated with untreated depression tomorrow.
What does international research show?
These Quebec findings are not isolated. A cost-utility analysis conducted in Ontario compared SMTr with electroconvulsive therapy (ECT) as a first-line approach for treatment-resistant depression: SMTr proved to be both less costly and more effective, generating 0.96 additional healthy life years and estimated savings of $46,098 per patient compared with ECT.
In the United Kingdom, an economic evaluation published in 2026 in the British Medical Journal calculated an SMTr cost-effectiveness ratio of about £12,000 per quality-adjusted life year, a result well below the acceptability thresholds typically used by public health systems to determine whether a treatment deserves funding. From the perspective of society as a whole, SMTr also reduced the hours of informal care provided by loved ones, generating additional net savings that are not usually counted in strictly hospital-based analyses.
These results are consistent with the INESSS work and suggest that the real question may no longer be whether SMTr is cost-effective, but why it remains underused in several health care systems, including ours.
The Quebec paradox: a covered solution, but inaccessible
Quebec is one of the provinces to offer this option free of charge in the public network : SMTr is covered by the RAMQ there since 2013, and the number of covered sessions has increased thirteenfold between 2013 and 2022, a sign of growing adoption. Yet, with only 17 devices distributed across seven health regions, wait times vary considerably depending on the patient's place of residence, ranging from one week to six months.
Each week of waiting for a person living with treatment-resistant depression potentially represents an additional week off work, prolonged suffering, and direct and indirect costs for the community. It is precisely this paradox that motivates the INESSS recommendation to add devices: an option whose efficiency has been demonstrated, but whose access remains hindered by material constraints rather than by a lack of clinical or economic relevance.
For people seeking a faster assessment or additional support, private clinics such as Neuroperforma offer deep TMS, always under the supervision of a psychiatrist who is a member of the Collège des médecins du Québec (CMQ), who determines each patient's eligibility following an individual assessment – an essential step, whether this solution is received in the public network or in a private clinic. This private offering does not replace the public network or its funding by the RAMQ; it is rather an additional option for people whose situation cannot wait for the current delays.
An investment that benefits everyone
Expanding access to SMTr allows people with treatment-resistant depression to return to active life sooner, reduces pressure on psychiatric emergency departments, avoids the use of heavier treatments like ECT when SMTr may be sufficient, and eases the daily burden on family caregivers who often support, often alone, a person in distress for a long time.
Seen this way, SMTr no longer appears as a marginal expense reserved for exceptional cases, but as a structured response to a problem that already costs society billions every year, whether we choose to act or not.
Conclusion
The question may no longer be whether Quebec has the means to invest more in SMTr, but whether it has the means to continue not doing so. The INESSS data, supported by international research, invite us to see this approach no longer as an exceptional option reserved for the most extreme cases, but as an avenue that deserves to be considered earlier in the care pathway – and supported collectively. As with any decision, outcomes vary from person to person and an individual assessment by a psychiatrist remains always necessary. To learn more about transcranial magnetic stimulation and the options available, Neuroperforma remains a resource for people who want to explore this avenue.
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