Intravenous ketamine versus electroconvulsive therapy for major depressive disorder or bipolar depression: A meta-analysis of randomized controlled trials

Nov 16, 2024Journal of affective disorders

Comparing intravenous ketamine and electroconvulsive therapy for major depression and bipolar depression: A combined analysis of clinical trials

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Abstract

Five randomized controlled trials involving 664 patients indicate that IV ketamine leads to greater immediate reductions in depressive symptoms compared to ECT.

At 24 hours post-treatment, IV ketamine showed a statistically significant reduction in depressive symptoms compared to ECT.
No significant differences were found between IV ketamine and ECT regarding the overall response to treatment at 24 hours.
At the end-of-treatment visit, both treatments did not differ notably in terms of depressive symptom improvement, response rates, or remission rates.
IV ketamine was associated with increased instances of dissociation, blurred vision, dizziness, and diplopia, while ECT was linked to a rise in muscle pain.
Discontinuation rates due to any cause were similar between the two treatment groups.

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BACKGROUND: Intravenous (IV) ketamine has been evaluated alongside electroconvulsive therapy (ECT) in addressing major depressive disorder (MDD) or bipolar depression (BD), though the comparative outcomes remain inconclusive. This meta-analysis aimed to provide a systematic assessment of the efficacy, safety, and tolerability of IV ketamine relative to ECT for treating MDD or BD.

METHODS: Randomized controlled trials (RCTs) comparing IV ketamine and ECT in terms of efficacy, safety, and tolerability for MDD or BD were identified and reviewed. Three independent investigators extracted relevant data, which was synthesized using RevMan 5.3 software under a random effects model.

RESULTS: Five RCTs encompassing 664 patients diagnosed with MDD or BD were analyzed. At 24 h post-initial treatment, IV ketamine demonstrated a statistically greater reduction in depressive symptoms compared to ECT (standardized mean difference (SMD) = -0.49, 95 % CI = -0.96 to -0.03, I= 77 %; P = 0.04). However, no significant differences were observed between groups in terms of the study-defined response (risk ratio (RR) = 1.49, 95 % CI = 0.08 to 28.42, I= 0 %; P = 0.79) at 24 h. Similarly, no notable differences were found for depressive symptom improvement (SMD = -0.48, 95 % CI = -2.41 to 1.45, I= 99 %; P = 0.63), the study-defined response (RR = 0.96, 95 % CI: 0.70 to 1.31, I= 75 %; P = 0.79) or remission (RR = 0.91, 95 % CI: 0.45 to 1.82, I= 90 %; P = 0.78) at the end-of-treatment visit. Among the three RCTs (60 %) comparing the neurocognitive outcomes of IV ketamine and ECT through varying test batteries, results were inconsistent. IV ketamine was associated with marked increases in dissociation, blurred vision, dizziness, and diplopia, while ECT led to a significant rise in muscle pain (all Ps < 0.05). Discontinuation rates due to any cause were comparable between both groups (P > 0.05). 2 2 2 2 2

CONCLUSION: IV ketamine demonstrates a faster onset of antidepressant effects compared to ECT, despite both treatments yielding comparable outcomes at the end-of-treatment visit for patients with MDD or BD. However, large-scale RCTs are required to thoroughly evaluate the long-term efficacy and safety of IV ketamine relative to ECT in these populations.

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Intravenous ketamine versus electroconvulsive therapy for major depressive disorder or bipolar depression: A meta-analysis of randomized controlled trials

Abstract

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