KET or ECT for treatment-resistant depression?

Modern electroconvulsive therapy (ECT) and ketamine are the most effective treatments for depressed patients who do not respond to two or more antidepressants. Recent large head-to-head comparisons of intravenous ketamine versus ECT for treatment-resistant depression have produced conflicting findings, largely because of major differences in patients' baseline characteristics and treatment procedures across studies. This commentary argues that treatment decisions between ECT and ketamine should rely on predictive clinical response markers and patient preferences, not on direct comparisons that are methodologically limited. It also emphasizes that since ketamine is usually given before ECT, future studies should examine ECT's effectiveness specifically in patients who did not respond to ketamine.

Study at a glance

Abstract

Modern electroconvulsive therapy (ECT) and ketamine currently represent the most effective treatment options in depressed patients showing non-response to two or more trials of antidepressants. Recently, large sample head-to-head comparisons of intravenous ketamine versus ECT for treatment-resistant depression (TRD) have fuelled the debate on which therapy might be more effective. However, the informative value of these studies is limited due to major methodological differences, especially regarding patients' baseline clinical characteristics and treatment procedures. This commentary, in reaction to the recently published article by Jha et al. 'Ketamine vs Electroconvulsive Therapy for Treatment-Resistant Depression: A Secondary Analysis of a Randomized Clinical Trial' in JAMA Network Open, addresses this issue and proposes that treatment decisions of ECT or ketamine should be based on substantiated, predictive clinical response markers and patient's preferences. It is undisputed that both treatments are highly effective in TRD, yet, given that ketamine is usually administered before ECT, efficacy studies of ECT in ketamine non-responders are urgently warranted.KEYPOINTSModern electroconvulsive therapy (ECT) and ketamine currently represent the most effective treatment options in treatment-resistant depressionHead-to-head comparisons of both treatments have yielded incongruent findings due to differing patients' baseline clinical characteristics and treatment proceduresTreatment-decisions of ECT or ketamine should be based on predictive clinical response markers and patient's preferences while considering the specific side effect profiles of both optionsFuture prospective studies should assess the efficacy of ECT in ketamine non-responders.