Journal Article Annotations
2022, 4th Quarter

Interventional Psychiatry

Annotations by Liliya Gershengoren, MD
January, 2023

Efficacy and Safety of Ketamine vs Electroconvulsive Therapy Among Patients with Major Depressive Episode: A Systematic Review and Meta-analysis.

PUBLICATION #1 — Interventional Psychiatry

Efficacy and Safety of Ketamine vs Electroconvulsive Therapy Among Patients with Major Depressive Episode: A Systematic Review and Meta-analysis.

Taeho Greg Rhee, Sung Ryul Shim, Brent P Forester, Andrew A Nierenberg, Roger S McIntyre, George I Papakostas, John H Krystal, Gerard Sanacora, Samuel T Wilkinson

Abstract: JAMA Psychiatry. 2022 Dec 1;79(12):1162-1172. doi: 10.1001/jamapsychiatry.2022.3352.

Abstract:

Importance:
Whether ketamine is as effective as electroconvulsive therapy (ECT) among patients with major depressive episode remains unknown.

Objective:
To systematically review and meta-analyze data about clinical efficacy and safety for ketamine and ECT in patients with major depressive episode.

Data sources:
PubMed, MEDLINE, Cochrane Library, and Embase were systematically searched using Medical Subject Headings (MeSH) terms and text keywords from database inception through April 19, 2022, with no language limits. Two authors also manually and independently searched all relevant studies in US and European clinical trial registries and Google Scholar.

Study selection:
Included were studies that involved (1) a diagnosis of depression using standardized diagnostic criteria, (2) intervention/comparator groups consisting of ECT and ketamine, and (3) depressive symptoms as an efficacy outcome using standardized measures.

Data extraction and synthesis:
Data extraction was completed independently by 2 extractors and cross-checked for errors. Hedges g standardized mean differences (SMDs) were used for improvement in depressive symptoms. SMDs with corresponding 95% CIs were estimated using fixed- or random-effects models. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.

Main outcomes and measures:
Efficacy outcomes included depression severity, cognition, and memory performance. Safety outcomes included serious adverse events (eg, suicide attempts and deaths) and other adverse events.

Results:
Six clinical trials comprising 340 patients (n = 162 for ECT and n = 178 for ketamine) were included in the review. Six of 6 studies enrolled patients who were eligible to receive ECT, 6 studies were conducted in inpatient settings, and 5 studies were randomized clinical trials. The overall pooled SMD for depression symptoms for ECT when compared with ketamine was -0.69 (95% CI, -0.89 to -0.48; Cochran Q, P = .15; I2 = 39%), suggesting an efficacy advantage for ECT compared with ketamine for depression severity. Significant differences were not observed between groups for studies that assessed cognition/memory or serious adverse events. Both ketamine and ECT had unique adverse effect profiles (ie, ketamine: lower risks for headache and muscle pain; ECT: lower risks for blurred vision, vertigo, diplopia/nystagmus, and transient dissociative/depersonalization symptoms). Limitations included low to moderate methodological quality and underpowered study designs.

Conclusions and relevance:
Findings from this systematic review and meta-analysis suggest that ECT may be superior to ketamine for improving depression severity in the acute phase, but treatment options should be individualized and patient-centered.

Annotation

The finding:
This study found that ECT was more efficacious than ketamine in reducing depression severity. The meta-analysis demonstrates that although ECT may be superior in reducing depressive symptoms to ketamine, it is important to consider ketamine’s faster antidepressant effects for patients with a severe MDE. The systematic review found one study which had a 12-month follow up period, which showed that remission rates were not different between groups. Both ketamine and ECT are known to have unique adverse effect profiles (ie, ketamine had lower risks for headache and muscle pain whereas ECT had lower risks for blurred vision, vertigo, diplopia/ nystagmus, and dissociative or depersonalization symptoms). However, there were no studies assessing the relative tolerability or acceptability of these different adverse effect profiles.

Strength and weaknesses:
This is the first meta-analysis to quantify the efficacy and safety of ketamine compared to ECT in patients with MDE. However, most studies included had relatively small sample sizes and lacked long-term follow-up assessments. The lack of long-term follow-up studies limits information provided about long term side effects, such as ketamine related cystitis. There were no studies directly comparing ECT with esketamine.

Relevance:
ECT is known to have robust efficacy and is considered the gold standard treatment for treatment resistant depression. On the other hand, an increasing number of studies have demonstrated that ketamine can have rapid and robust antidepressant effects in treatment resistant depression. When making treatment recommendations, C-L Psychiatrists will need to consider the relative benefits and risks of ECT as compared with ketamine.