Ketamine may be better option than ECT for less severe treatment-resistant depression
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Key takeaways:
- Researchers analyzed data from patients with treatment-resistant depression given ketamine or electroconvulsive therapy.
- Those with less severe depression had better outcomes with ketamine compared with ECT.
Individuals with moderate to less severe treatment-resistant depression may benefit from treatment with ketamine instead of electroconvulsive therapy, according to research from JAMA Network Open.
“Patients with [treatment-resistant depression] have greater illness burden and higher rates of intentional self-harm and all-cause mortality compared with other patients with [major depressive disorder],” Manish Kumar Jha, MBBS, an associate professor of psychiatry at the Center for Depression Research and Clinical Care, in the department of psychiatry, UT Southwestern Medical Center, and colleagues wrote.
“Therefore, they may need interventions such as electroconvulsive therapy, considered one of the most effective approaches.”
Jha and colleagues sought to evaluate whether selected clinical features were associated with differential improvement in treatment-resistant depression (TRD) with ketamine vs electroconvulsive therapy (ECT) in a secondary analysis of data from the ELEKT-D clinical trial.
ELEKT-D was an open-label, randomized, multicenter, noninferiority study conducted at five academic medical centers in the United States between April 2017 and November 2022. The study cohort included 365 participants (mean age, 46 years; 52.3% female), with TRD, who were in a current nonpsychotic depressive episode of at least moderate severity and were referred for ECT by their clinicians. Patients were randomized 1:1 to receive either six infusions of ketamine or nine treatments with ECT over 3 weeks.
The primary outcome was the association between baseline factors (including 16-item Quick Inventory of Depressive Symptomatology Self-Report [QIDS-SR16], Montgomery-Asberg Depression Rating Scale [MADRS], premorbid intelligence, cognitive function, history of attempted suicide, inpatient vs. outpatient status) and treatment response, which were assessed with repeated measures mixed-effects model analyses.
Results showed that participants with a baseline QIDS-SR16 score of 20 or lower, indicating of less severe depression (7.7 vs 5.6 points) and those starting treatment as outpatients (8.4 vs 6.2 points) reported greater reduction in the QIDS-SR16 with ketamine compared with ECT.
Patients with a baseline QIDS-SR16 score of more than 20 (very severe depression) who started treatment as inpatients reported a greater reduction in the QIDS-SR16 score earlier in the course of treatment (8.4 vs 6.7 points) with ECT, but the scores were similar in both groups at the end-of-treatment visit (9 vs 9.9 points), the researchers wrote. In the group that received ECT only, participants with higher scores on measures of premorbid intelligence (14 vs 11.2 points) and with comorbid PTSD (16.6 vs 12 points) reported greater reduction in the MADRS score.
During the second week of treatment, patients with impaired memory recall had greater reduction in MADRS score (13.4 vs 9.6 points), but levels of MADRS were similar to those with unimpaired recall at the end-of-treatment visit (14.3 vs 12.2 points).
“Shared decision-making approaches for selecting between [electroconvulsive therapy] and ketamine may incorporate findings from this study,” Jha and colleagues wrote. “Future studies are needed to replicate and extend these findings to inform selection of optimal therapy by patients with [treatment-resistant depression].”