new research For some patients, the anesthetic ketamine is a promising alternative to electroconvulsive therapy (ECT), which is currently one of the most rapid and effective treatments for patients with difficult-to-treat depression. suggests that This study is the largest to directly compare the two treatments.
Patients unresponsive to at least two antidepressants — almost one third Patients who are clinically depressed and have what clinicians refer to as ‘treatment-resistant’. Their rescue options are limited. Doctors usually recommend up to 12 ECT sessions for her. Long-established effectivenessbut is tainted by the stigma of historical misuse and scary hollywood picture People who are tied to the table and struggle with suffering. His ECT today is safer and performed under general anesthesia, but the procedure is still underutilized.
The study, published Wednesday in The New England Journal of Medicine, found that intravenous ketamine was at least as effective as ECT in patients with treatment-resistant depression without psychosis. found. (For people with psychosis, even very low doses of ketamine can exacerbate psychosis-like symptoms.)
“The results were quite surprising to us,” said lead author Amit Amit, a professor of psychiatry at Harvard Medical School who studies mood disorders at Massachusetts General Brigham. Dr. Anand said. His team initially hypothesized that ketamine would be nearly as effective as ECT. Instead, ketamine turned out to perform better than that, Dr. Anand said.
This is important in part because some patients are uncomfortable with potential side effects of ECT such as temporary memory loss, muscle pain and weakness. (In rare cases, a permanent gap in memory can occur.)
The study, sponsored by the Cleveland Clinic Foundation, showed that ketamine was easier to administer, had fewer adjustments during treatment, and fewer patients dropped out, Dr. Anand said. “More importantly, we show that, as expected, ECT is associated with memory impairment, whereas ketamine is not.” , is not an unpleasant experience for patients,” said Dr. Anand.
Previous studies have shown that both treatments work for patients with difficult-to-treat depression, but that study mainly looked at the two treatments separately. Dr. Roger S. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, who was not involved in the study, called it “groundbreaking.”
“This kind of rigorous, randomized, real-world actionable data is robust and highly clinically meaningful,” said Dr. McIntyre.
Researchers randomly assigned 365 patients to intravenous ketamine or ECT. Nearly half received ketamine twice weekly and the rest received ECT three times weekly. By the end of three weeks of treatment, 55 percent of patients in the ketamine group and 41 percent of patients in the ECT group reported a 50 percent or greater reduction in symptoms.
After 6 months, both groups had similar quality of life scores.
Dr. Daniel F. Meiksner, ECT program director at the University of Michigan Medical School, said one of the limitations of the study was that the number of ECT treatments may not have been sufficient because the duration of treatment was only three weeks. said. He is in research.
Study subjects started a course of ECT by passing an electric current through one side of the brain, but 10 to 12 sessions may be needed, compared to nine sessions used in the study. he added.
“If you see further improvements, keep going,” says Dr. Meiksner.
Patients starting bilaterallyoften stimulating both sides at the same time. Fewer sessions required. If patients had completed more ECT sessions, more patients might have responded to the treatment, which likely caused more side effects, Dr. Anand said. .
A minority of patients (less than 33%) in both groups achieved remission, meaning only mild depressive symptoms. This suggests that additional treatment may be required to maintain relief of the patient’s symptoms.
However, continuing treatment comes with additional risks. For ketamine, for example, prolonged treatment “increases the likelihood of both drug dependence and adverse cognitive effects, including dissociation, paranoia, and other psychotic symptoms,” said Robert Friedman, Ph.D., professor of psychiatry at the University of Colorado in a paper. says in Editorials published with the study.
previous evidence Although they suggest that remission rates for ECT may be much higher, often at least 60 percent, these studies include psychotic depressive patients for whom ECT appears to be particularly effective. as well as a higher proportion of hospitalized patients.
Researchers and clinicians use intravenous ketamine off-label because, unlike its cognate esketamine, also known as intranasally administered Supravat, it is not approved by the Food and Drug Administration as a treatment for mood disorders. . It is widely believed among clinicians that intravenous ketamine is: effective Alternatively, it works better than esketamine for treatment-resistant depression, Dr. Anand said.
Unfortunately, because intravenous ketamine is a generic drug, “probably no one is going to seek FDA approval to facilitate reimbursement by insurance companies,” he added.
Later this year, Dr. Anand and his colleagues will conduct a large-scale study comparing ECT with intravenous ketamine in 1,500 acutely suicidal depressed patients, most likely hospitalized. We plan to recruit patients for further studies. Dr. Anand said he also plans to investigate how the effects differ by age group.
Michigan Medicine’s Dr Mikesner says intravenous ketamine, which he has also used to treat patients, may have a powerful new effect on hard-to-treat depression, which ‘gives people a choice’. Research suggests it is possible, he said.