Dataset Information

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

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.

SUBMITTER: Rhee TG

PROVIDER: S-EPMC9582972 | biostudies-literature | 2022 Dec

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

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

Rhee Taeho Greg TG Shim Sung Ryul SR Forester Brent P BP Nierenberg Andrew A AA McIntyre Roger S RS Papakostas George I GI Krystal John H JH Sanacora Gerard G Wilkinson Samuel T ST

JAMA psychiatry 20221201 12

<h4>Importance</h4>Whether ketamine is as effective as electroconvulsive therapy (ECT) among patients with major depressive episode remains unknown.<h4>Objective</h4>To systematically review and meta-analyze data about clinical efficacy and safety for ketamine and ECT in patients with major depressive episode.<h4>Data sources</h4>PubMed, MEDLINE, Cochrane Library, and Embase were systematically searched using Medical Subject Headings (MeSH) terms and text keywords from database inception through ...[more]

PMID: 36260324

Similar Datasets

Project description:ImportanceThe relative efficacy of ketamine and electroconvulsive therapy (ECT) in adults with major depressive episode (MDE) needs clarification.ObjectiveTo compare depression rating outcomes with ketamine vs ECT in adults with MDE and to compare response and remission rates, number of sessions to response and remission, and adverse effects.Data sourcesTwo investigators independently systematically searched MEDLINE, ScienceDirect, and Google Scholar databases using a combination of relevant Medical Subject Headings terms and free-text keywords from database inception through May 15, 2022, to identify relevant English-language trials.Study selectionParallel-group randomized clinical trials (RCTs).Data extraction and synthesisTwo investigators independently extracted data and assessed risk of bias. One-week posttreatment outcomes were pooled as standardized mean difference (SMD; Hedges g) for continuous outcomes and risk ratio (RR) for categorical outcomes in random-effects meta-analyses.Main outcomes and measuresEfficacy outcomes were 1-week (or nearest) posttreatment depression ratings, 1-week (or nearest) study-defined response and remission rates, and number of sessions to treatment response and remission. Safety outcomes were reported adverse effects.ResultsFive trials (ketamine group: n = 141; ECT group: n = 137) were meta-analyzed. The overall pooled SMD for posttreatment depression ratings was -0.39 (95% CI, -0.81 to 0.02; I2 = 45%; 5 RCTs). For this efficacy outcome, in a sensitivity analysis of methodologically stronger trials, ECT was superior to ketamine (SMD, -0.45; 95% CI, -0.75 to -0.14; I2 = 6%; 2 RCTs). ECT was also superior to ketamine for study-defined response (RR, 1.27; 95% CI, 1.06-1.53; I2 = 0%; 3 RCTs) and remission (RR, 1.43; 95% CI, 1.12-1.82; I2 = 0%; 2 RCTs) rates. No significant differences were noted between groups for number of sessions to response and remission and for cognitive outcomes. Key limitations were small number of studies, limited sample size, and high risk of bias in all trials.Conclusion and relevanceThe findings of this systematic review and meta-analysis suggest an efficacy advantage for ECT over ketamine in adults with MDE. These conclusions are tempered by the small number and size of existing trials.

Project description:ImportanceElectroconvulsive therapy (ECT) is highly effective and rapid in treating depression, but it carries a risk of significant cognitive adverse effects. Magnetic seizure therapy (MST), an investigational antidepressant treatment, may maintain the robust antidepressant efficacy of ECT while substantially reducing adverse effects due to its enhanced focality and weaker stimulation strength; however, previous clinical trials of MST were limited by small sample sizes.ObjectiveTo compare the antidepressant efficacy of MST vs ultrabrief pulse right unilateral (RUL) ECT.Design, setting, and participantsA between-participants, double-blinded, randomized clinical trial was conducted at 3 academic hospitals from June 2007 to August 2012. Adults aged 18 to 90 years who were referred for treatment with ECT, had a major depressive episode in the context of major depressive disorder or bipolar disorder, and had a baseline 24-item Hamilton Depression Rating Scale (HDRS-24) total score of 18 or higher were included. Participants were randomly assigned 1:1 to treatment with MST or ultrabrief pulse RUL ECT. After the treatment course, patients were naturalistically followed up for up to 6 months to examine the durability of clinical effects.InterventionsTreatment with MST, applied at 100 Hz at 100% of the maximum device power for 10 seconds, or ultrabrief pulse RUL ECT, applied at 6 times seizure threshold.Main outcomes and measuresThe primary outcome was change from baseline in HDRS-24 total score, with patients followed up for up to 6 months. A reduction of at least 50% in the HDRS-24 score indicated response, and at least a 60% decrease in the HDRS-24 score and a total score of 8 or less indicated remission.ResultsOf the 73 participants (41 [56.2%] female; mean [SD] age, 48 [14.1] years), 35 were randomized to MST and 38 to ECT. Among them, 53 (72.6%) were classified as completers (29 in the MST group and 24 in the ECT group). Both MST and ECT demonstrated clinically meaningful antidepressant effects. In the intent-to-treat sample, 18 participants (51.4%) in the MST group and 16 (42.1%) in the ECT group met response criteria; 13 (37.1%) in the MST group and 10 (26.3%) in the ECT group met remission criteria. Among completers, 17 of 29 (58.6%) in the MST group and 15 of 24 (62.5%) in the ECT group met response criteria; 13 of 29 (44.8%) in the MST group and 10 of 24 (41.7%) in the ECT group met remission criteria. There was no significant difference between MST and ECT for either response or remission rates. However, the mean (SD) number of treatments needed to achieve remission was 9.0 (3.1) with MST and 6.7 (3.3) with ECT, a difference of 2.3 treatments (t71.0 = 3.1; P = .003). Both MST and ECT showed a sustained benefit over a 6-month follow-up period, again with no significant difference between them. Compared with MST, ECT had significantly longer time to orientation after treatment (threshold level: F1,56 = 10.0; P = .003) and greater severity of subjective adverse effects, particularly in the physical and cognitive domains.Conclusions and relevanceThis randomized clinical trial found that the efficacy of MST was indistinguishable from that of ultrabrief pulse RUL ECT, the safest form of ECT currently available. These results support the continued development of MST and provide evidence for advantages relative to state-of-the-art ECT.Trial registrationClinicalTrials.gov Identifier: NCT00488748.

Project description:Although large genome-wide association studies (GWAS) of major depressive disorder (MDD) have identified many significant loci, the SNP-based heritability remains notably low, which might be due to etiological heterogeneity in existing samples. Here, we test the utility of targeting the severe end of the MDD spectrum through genome-wide SNP genotyping of 2725 cases who received electroconvulsive therapy (ECT) for a major depressive episode (MDE) and 4035 controls. A subset of cases (n = 1796) met a narrow case definition (MDE occurring in the context of MDD). Standard GWAS quality control procedures and imputation were conducted. SNP heritability and genetic correlations with other traits were estimated using linkage disequilibrium score regression. Results were compared with MDD cases of mild-moderate severity receiving internet-based cognitive behavioral therapy (iCBT) and summary results from the Psychiatric Genomics Consortium (PGC). The SNP-based heritability was estimated at 29-34% (SE: 6%) for the narrow case definition, considerably higher than the 6.5-8.0% estimate in the most recent PGC MDD study. Our severe MDE cases had smaller genetic correlations with neurodevelopmental disorders and neuroticism than PGC MDD cases but higher genetic risk scores for bipolar disorder than iCBT MDD cases. One genome-wide significant locus was identified (rs114583506, P = 5e-8) in an intron of HLA-B in the major histocompatibility locus on chr6. These results indicate that individuals receiving ECT for an MDE have higher burden of common variant risk loci than individuals with mild-moderate MDD. Furthermore, severe MDE shows stronger relations with other severe adult-onset psychiatric disorders but weaker relations with personality and stress-related traits than mild-moderate MDD. These findings suggest a different genetic architecture at the severest end of the spectrum, and support further study of the severest MDD cases as an extreme phenotype approach to understand the etiology of MDD.

Dataset Information

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

Importance

Objective

Data sources

Study selection

Data extraction and synthesis

Main outcomes and measures

Results

Conclusions and relevance

Publications

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

Similar Datasets

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