Wednesday, April 19, 2023

ECT May Be Superior to Ketamine for Adults Experiencing Major Depressive Episode

Electroconvulsive therapy (ECT) may be more effective than ketamine at reducing symptoms of depression, suggests a meta-analysis in JAMA Psychiatry.

“Importantly, ECT was associated with significantly higher response and remission rates but not with significantly faster onset of either response or remission,” wrote Vikas Menon, M.D., of the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) in India and colleagues.

Menon and colleagues searched MEDLINE, ScienceDirect, and Google Scholar databases from inception until May 31, 2022, for articles describing randomized, controlled trials (RCTs) comparing ketamine and ECT in patients with major depressive episode (MDE). The researchers limited their search to articles written in English. Five RCTs, including a total of 278 patients, were included in the meta-analysis.

The primary outcome for the analysis was depression rating at one week posttreatment. Secondary outcomes were response and remission rates, number of treatment sessions taken to attain response and remission, and adverse effects.

“In the main analysis, posttreatment depression ratings showed a trend for lower scores with ECT compared with ketamine,” Menon and colleagues reported. When the researchers excluded three of the RCTs for what they described as “reasons related to questionable methods and reporting,” they found that “posttreatment depression ratings in the remaining RCTs were significantly lower with ECT than with ketamine.” They calculated that patients were about 43% more likely to achieve remission with ECT relative to ketamine.

There was little difference between ketamine and ECT groups when it came to posttreatment cognition scores. The pooled ketamine versus ECT data showed that those who had received ketamine had a lower risk of headache and musculoskeletal pain whereas those who had received ECT had a lower risk of dissociative symptoms. None of the studies included in the meta-analysis assessed rates of memory loss, which is one of the most problematic side effects of ECT.

The authors acknowledged other limitations of the meta-analysis, including the small number of eligible studies and the small sample sizes of these studies.

“[G]iven the possibility that patients with bipolar depression may not respond as well to ketamine as those with major depressive disorder, we believe that future RCTs of ECT vs. ketamine for patients with MDE should report outcomes separately for bipolar depression and major depressive disorder … so that future meta-analyses can pool outcomes separately for bipolar disorder and major depressive disorder.”

For related information, see the Psychiatric Services article “Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners.”

(Image: iStock/LumiNola)

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