SAN FRANCISCO – Electroconvulsive therapy and ketamine both work well for refractory depression, but ketamine had the edge in a small, open label trial at the University of California, Los Angeles.
M. Alexander Otto/MDedge News
Dr. Katherine Narr
“Over the short term,” even a single ketamine infusion may “be as effective as ... ECT for reducing overall depression, apathy, anhedonia, and suicidal ideation,” but ECT may be more durable, said investigator Katherine Narr, PhD, an associate professor of neurology, psychiatry, and biobehavioral sciences at the school.
The study begins to address an issue that’s probably on the minds of many these days: ECT or ketamine for refractory depression? ELEKT-D (Clinicaltrials.gov NCT03113968), a large randomized, trial is underway to answer the question, but results aren’t expected for a couple of years.
In the meantime, although there was no randomization or blinding, Dr. Narr’s results are informative.
Twenty-six adults received one ketamine infusion, 0.5 mg/kg over 40 minutes, while 36 had four over about 2 weeks. Ketamine patients were allowed to stay on antidepressants. Forty-seven subjects, meanwhile, had 11 ECT treatments over 3 weeks, before which all psychiatric medications were stopped. The Hamilton Depression Rating Scale (HDRS) was used to assess outcomes.
Suicidal ideation probability dropped from 86% to 51% in the ECT group, but from 75% to 37% after one ketamine infusion, and to 11% after four (P less than .0001). A single “ketamine infusion showed similar probability of suicidal ideation reduction as a full course of ECT,” Dr. Narr said at the American Psychiatric Association annual meeting.
Improvements in overall HDRS scores were also greater after both single and serial ketamine (P less than .001).
However, HDRS scores – particularly for suicidal ideation – were beginning to creep up in the ketamine arm after just 5 weeks, but remained largely stable in the ECT group even at 3 months. In both groups, “therapeutic benefits for apathy and anhedonia last longer than for suicidal ideation,” Dr. Narr said.
At the moment, “you can’t predict who’s going to respond” better to one option or the other, “but I’m sure” biomarkers for that “are coming,” she said. Patients were 40 years old, on average, with depression first diagnosed in their early 20s. ECT subjects were equally split between the sexes, while there were more men than women in the ketamine arm, and current episodes were longer (average 6.6 years ketamine versus 3.7 years ECT). Baseline apathy scores were slightly higher in the ketamine group.
The work was funded by the National Institutes of Health. Dr. Narr didn’t have any disclosures.
SOURCE: Narr K et al., Presented at APA 2019