Comparative Efficacies of Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rTMS) in Treatment-Resistant Depression: A Randomized Controlled Trial in Nigeria.

BACKGROUND: Treatment-resistant depression (TRD) poses significant challenges globally, particularly in low-resource settings. While electroconvulsive therapy (ECT) remains the standard for TRD, repetitive transcranial magnetic stimulation (rTMS) offers a non-invasive alternative. This study compared short- and long-term efficacy and safety of ECT versus rTMS among Nigerian patients with TRD. METHODOLOGY: In a randomized, rater-blinded trial, 40 adults with TRD received either ECT (n=20; bilateral, twice weekly for 3 weeks) or high-frequency rTMS (n=20; left dorsolateral prefrontal cortex, 3000 pulses/session, 5 sessions/week for 6 weeks). Depression severity (HAM-D) was assessed at baseline, weeks 2, 4, 6, and at 6 and 12 months. RESULTS: Both interventions significantly reduced HAM-D scores (p<0.001). ECT showed faster early improvement (Week 4: ECT=10.30±2.84, rTMS=12.25±2.99; p<0.001), with comparable outcomes at Week 6 (ECT=4.30±2.23, rTMS=4.40±2.35; p=0.89). However, rTMS demonstrated superior long-term control at 6 months (4.05±2.11 vs. 6.60±2.97; p<0.001) and 12 months (5.25±2.89 vs. 10.55±3.45; p<0.001). Remission rates at 12 months were 65% for rTMS versus 20% for ECT. Adverse events, particularly cognitive impairment, were more frequent with ECT (60% vs. 0%; p<0.001). CONCLUSION: While ECT provides faster acute symptom relief, rTMS offers superior sustained benefits with fewer adverse effects, suggesting its potential as a first-line neurostimulation for TRD in resource-constrained settings. Larger studies with cost-effectiveness analyses are warranted.