Real‑world implementation of rTMS for depression: a comparative study of Sweden and Japan

Repetitive transcranial magnetic stimulation (rTMS) is an evidence‑based intervention for major depressive disorder (MDD) and treatment‑resistant depression (TRD). This study compared the regulatory, organizational, and clinical implementation of rTMS in Sweden and Japan between 2020 and 2024 and assessed alignment with international consensus recommendations.

A cross‑sectional survey was conducted using publicly available information from rTMS‑providing facilities in both countries. Facilities confirming rTMS provision were included. Two investigators independently extracted facility‑level variables into a harmonized template covering service distribution, registry participation, stimulation protocols, device types, practitioner roles, eligibility criteria, reimbursement arrangements, and reported patient counts. Analyses were descriptive; financial variables were summarized to characterize access and were not part of a formal economic evaluation.

Both countries primarily used rTMS for MDD/TRD, required psychiatric assessment, and applied similar safety exclusions. Sweden delivered rTMS within a tax‑funded regional system, with 29 centres in 2024 and near‑complete participation in a national registry integrated with electronic health records; intermittent theta‑burst stimulation (iTBS) predominated. Japan had a mixed public-private model with 112 facilities and partial registry participation (62/112). Public insurance in Japan covered only a 10‑Hz left dorsolateral prefrontal cortex protocol, whereas private clinics frequently offered iTBS. Workforce roles, device diversity, and patient co‑payments differed, with greater financial barriers reported in Japan.

Differences in health‑system structure and registry completeness likely explain observed variation. Findings may inform policymakers seeking to optimize neuromodulation services, strengthen monitoring systems, and reduce access inequities.