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ECT Shows Small Advantage Over Ketamine in Major Depressive Episode Treatment
Electroconvulsive therapy (ECT) may be superior to ketamine in treating major depressive episode (MDE) in adults, according to a study published in JAMA Psychiatry.
“However, the advantage is small, and therefore, for many patients, especially those who want to be protected against cognitive risks, a trial of ketamine may be worth considering before a trial of ECT,” researchers wrote in the study.
The relative efficacy and safety of ECT and ketamine for MDE in adults have been unclear. This systematic review and meta-analysis of 5 randomized clinical trials was conducted to compare the 2 treatments.
The researchers searched MEDLINE, ScienceDirect, and Google Scholar databases from their inception until May 31, 2022, to identify relevant English-language trials that compared ketamine and ECT in patients with MDE. The primary outcome was the depression rating 1 week after treatment endpoint. Efficacy outcomes included the 1-week post-treatment depression ratings, study-defined response and remission rates, and the number of sessions to treatment response and remission. Safety outcomes were reported adverse effects.
>> READ: ECT Treatment More Effective for MDD Than Ketamine
The meta-analysis included 278 individuals, with 141 patients in the ketamine group and 137 in the ECT group. The pooled standardized mean difference (SMD) for post-treatment depression ratings was -0.39 (95% CI, -0.81 to 0.02; I2=45%; 5 RCTs), indicating a nonsignificant trend for ECT superiority over ketamine. However, in a sensitivity analysis of methodologically stronger trials, ECT was found to be significantly superior to ketamine (SMD, -0.45; 95% CI, -0.75 to -0.14; I2=6%; 2 RCTs) for this efficacy outcome.
Moreover, ECT was found to be superior to ketamine for study-defined response (RR, 1.27; 95% CI, 1.06-1.53; I2=0%; 3 RCTs) and remission (RR, 1.43; 95% CI, 1.12-1.82; I2=0%; 2 RCTs) rates. No significant differences were noted between groups for the number of sessions to response and remission and for cognitive outcomes.
The authors acknowledged the small number and size of existing trials and the high risk of bias in all trials as key limitations of their study. They also noted that cognitive outcomes were poorly reported in the included studies, and the long-term effects of both treatments were not evaluated.
“These findings supplement those presented in the meta-analysis by Rhee et al. but suggest that the advantage for ECT over ketamine may be smaller than shown by them, supporting our recommendation for a trial of ketamine before a trial of ECT for patients with MDE. A caveat is that this recommendation is supported by only a small number of patients in a small number of trials,” the authors concluded.
Researchers urged for future studies to replicate these findings in larger, methodologically rigorous trials, and to examine the long-term outcomes of both treatments.
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