Electric Shock Vs. Ketamine: Which Is Best For TRD?

This week three doctors reviewed the test results comparing the two options for treatment-resistant depression (TRD). Electroconvulsive therapy (ECT) is considered the gold standard for TRD but is not widely used in the U.S.

Ketamine infusion has gained more attention in the U.S. as a treatment for TRD as a rapid-acting option, but also one that has the potential for abuse. Electroconvulsive therapy (ECT) is also known as electroshock therapy and is a treatment for severe major depression, bipolar depression, and other mental health conditions.

The article published in the JAMA Psychiatry commented on a study that compared the two different treatments to see if one was better than the other. The authors were Sanjay J. Mathew, MD, Manish K. Jha, MBBS, and Amit Anand, MD. 

The KetECT trial was conducted on 186 inpatients with TRD (with or without psychosis) at six sites in Sweden. It found that ECT  was superior to ketamine infusion following the 12th treatment, with each treatment administered three times weekly (63% vs 46% remission and 71% vs 57% response rates using a clinician-administered depression scale).

However, a different study called the ELEKT-D study showed that a course of intravenous (IV) ketamine was not inferior to ECT. This study took place in the U.S. and was conducted at five sites, enrolled the largest randomized sample (N = 403) to date, and was composed primarily of outpatients (approximately 90%). The article stated, “Following the 3-week treatment period, 55% vs 41% of patients met response criteria for ketamine and ECT, respectively (the noninferiority margin of −10 percentage points was significantly exceeded), whereas only 32% and 20% attained remission, respectively.”

The authors surmised that the Swedish study could have been affected by the patients chosen for the study and inadequate dosing. The authors wrote that despite statistical analyses favoring one treatment or the other, all the described studies have shown that the short-term effectiveness of IV ketamine is close to that of ECT for TRD.

They believe that ketamine should be considered on par with ECT for the short-term management of depressive symptoms in outpatients with TRD.

The doctors wrote,

Individuals with TRD and their clinicians should consider a trial of IV ketamine before initiating ECT, while ensuring that consideration has also been made for older, evidence-based approaches (eg, monoamine oxidase inhibitors) and recognizing when ECT might be preferred (eg, in elderly patients and patients with psychotic features).

The authors also think that more studies need to be conducted and that future studies should observe patients for longer periods following the treatments. They noted that the effectiveness of both types of treatments tends to wear off resulting in patients needing to repeat treatments as their conditions deteriorate.