Ketamine shown to be equivalent to ECT for severe depression

W.If severely depressed patients do not respond to antidepressants, alternatives are limited. A new study found that ketamine was at least as effective as electroconvulsive therapy (ECT), the current gold standard, for such patients, making it a frontline treatment for patients with treatment-resistant depression. As a result, it was suggested that ketamine deserves consideration.

However, while the potential benefits are comparable and ketamine is easier to administer than ECT, the risk of dependence from long-term ketamine treatment is not well established, prompting some physicians to caution. I’m here. “It’s a matter of individual patient risk assessment,” said Boris Heifetz, who studies ketamine at Stanford University but was not involved in the new study. “None of these things are risk-free, nor are they transformational.”

The study, presented Wednesday at a meeting of the American Psychiatric Association and published in the New England Journal of Medicine, showed that intravenous ketamine was “not inferior” to ECT. Patients randomized to take ketamine twice a week for three weeks actually did marginally better, with 55.4% responding to treatment. By comparison, those who received ECT three times a week during the same period had a 41.2% response rate.

The study involved 403 participants and was significantly larger than previous comparative ketamine studies. A meta-analysis of these small studies, published last year and focused on major depression rather than treatment-resistant depression, found better outcomes with ECT. However, the new paper is stronger and arguably more sickly focused, enrolling only major depressive patients without psychosis who did not respond to SSRIs, showing that ketamine is comparable to ECT. provides strong evidence that Ketamine, an anesthetic that has been used for many years, has gained popularity in recent years as a treatment for depression.

Patrick Oliver, medical director of the Mindpiece Ketamine Clinic, which studies the drug as a treatment for depression but was not involved in the study, said the implications of the findings were “huge.” Stated. Although structured to show “non-inferiority,” the data suggest that ketamine is more effective than ECT, he said.

“I affirm that this should change the practice of interventional psychiatry,” said Professor Oliver, moving ketamine use from last-line to first-line for SSRI-nonresponsive patients. That said, neither result is great, he added. “We are on C-minus.”

Others, however, were more cautious about the future use of ketamine, pointing out its addictive potential. ECT performed while patients are under general anesthesia has been shown to cause cognitive impairment, including long-term memory loss, and is not without risks. In contrast, ketamine is known to be addictive, but its exact risks have not been well studied. Without regulation and more data, some worry that ketamine use will become widespread and lead to new addiction epidemics such as the opioid crisis.

“This trial did not have a long follow-up period, nor did it assess future drug-seeking behavior in those who responded or did not respond to ketamine,” said Robert Friedman, professor of psychiatry at the University of Colorado Denver. said. In a NEJM editorial published alongside his research, the MD said: “We have to remember that only a few doctors were responsible for the oxycodone epidemic.”

Amit Anand, lead author of the study and Director of Psychiatric Translational Clinical Trials at Massachusetts General Brigham, said there was potential for dependence, especially at the study’s sub-anesthetic dose of 0.5 milligrams per kilogram of body weight. He said there was minimal evidence of “I don’t think there’s hard data that people are misusing it,” he says. “But we have to keep that in mind.”

However, in this study, 41% of participants assigned to take ketamine continued to take ketamine during the 6-month follow-up period. “This is a warning to me,” said Heifetz, adding that this is not a short-term “fix and forget” cure. “This is a subscription model.”

Both ketamine and ECT have immediate effects in patients in acute distress and are of great value in emergency situations. But Anand agreed that long-term use of ketamine has not been well researched. “The challenge with ECT and ketamine is that you can get an acute response, but how do you actually maintain it?”

Ketamine is a popular “Special K” party drug and can cause bladder damage in some patients when used in high doses.

Friedman called for detailed informed consent, while Heifetz said there should be regulations on how the drug is administered and close monitoring of patients taking ketamine long-term. Both warned of lessons to be learned from the opioid crisis. “Why would you think ketamine would be different? If we ignore the risks and expand access as aggressively as possible, we’ll be in the same situation in 10 years,” Heifetz said. “Ketamine is not oxycodone. But it is responsible for abuse.

That said, these concerns must be balanced with the potential for amnesia from ECT. ECT is associated with long-term cognitive problems, including permanent memory loss, for some patients. Patients in the study had temporary worsening of memory retrieval after ECT treatment that improved during the 6-month follow-up. Also, musculoskeletal adverse events are more likely in patients receiving ketamine, whereas dissociation has been reported as a side effect.

Ketamine is not approved as a treatment for depression, despite evidence of its effectiveness. Because the drug is generic, it means that drug companies have no financial incentive to bear the costs of filing ketamine for approval with the Food and Drug Administration. Instead, esketamine, an improved version of ketamine patented by Johnson & Johnson subsidiary Janssen Pharmaceuticals, was approved for the treatment of depression. This drug is expensive, but unlike ketamine, it is covered by insurance.

Study author Anand agreed with Oliver’s view that ketamine could be tried before ECT. “Ketamine has the same chance of improving symptoms,” he says. The results are strong enough to encourage insurance companies to consider using ketamine, he said, despite the lack of FDA approval.

That would give patients and doctors more options. “It comes down to which side effects you feel more comfortable with,” says Heifetz. “Neither of these treatments are perfect.”

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