Efficacy and adverse effects of ketamine versus electroconvulsive therapy for major depressive disorder: A systematic review and meta-analysis

Genetic and molecular basis of abnormal BOLD signaling variability in patients with major depressive disorder after electroconvulsive therapy

Electroconvulsive therapy (ECT) is an effective and rapid neuromodulatory intervention for treatment-resistant major depressive disorders (MDD). However, the precise mechanisms underlying their efficacies remain unclear. Resting-state functional magnetic resonance imaging (fMRI) data were collected from 84 individuals with MDD and healthy controls before and after ECT, and coefficient of variation of the BOLD signal (CVBOLD) analysis was combined with region of interest (ROI) functional connectivity (FC) analysis. To assess the reliability of the antidepressant mechanism of ECT, we analyzed the changes in CVBOLD in a separate cohort consisting of 35 patients with MDD who underwent ECT. Moreover, transcriptomic and neurotransmitter receptor data were used to reveal the genetic and molecular bases of the changes in CVBOLD. Patients with MDD who underwent ECT demonstrated increased CVBOLD in the left angular cortex and left precuneus. Following ECT, an increase in FC between the left precuneus and right lingual lobes was associated with improvements in Hamilton Depression Rating Scale (HAMD) scores. validation analysis consistently demonstrated similar changes in CVBOLD in two independent cohorts of patients with MDD. Moreover, these changes in CVBOLD were closely associated with thyroid hormone synthesis, oxidative phosphorylation, endocytosis, and the insulin signaling pathway, and were significantly correlated with the receptor/transporter density of serotonin and dopamine. These findings suggest that ECT modulates abnormal functions in the left angular cortex and left precuneus, leading to widespread changes in functional connectivity and neuroplasticity, especially in the default mode network, and exerts an antidepressant effect.

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

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, I2 = 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, I2 = 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, I2 = 99 %; P = 0.63), the study-defined response (RR = 0.96, 95 % CI: 0.70 to 1.31, I2 = 75 %; P = 0.79) or remission (RR = 0.91, 95 % CI: 0.45 to 1.82, I2 = 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).

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.

Seltorexant for major depressive disorder

INTRODUCTION

Preclinical and clinical pharmacologic evidence indicates that orexin systems are relevant to sleep-wake cycle regulation and dimensions of reward and cognition, providing the basis for hypothesizing that they may be effective as therapeutics in mental disorders. Due to the limited efficacy and tolerability profiles of existing treatments for Major Depressive Disorder (MDD), investigational compounds in novel treatment classes are needed; seltorexant, an orexin receptor antagonist, is a potential new treatment currently under investigation.

AREAS COVERED

Mechanisms implicated in MDD, including reward and sleep, are first overviewed. Then, the safety, tolerability, and efficacy profiles of seltorexant and the wider context of orexin receptor antagonism for depression are discussed in focus. Preclinical and clinical data are also discussed. PubMed, Medline, Cochrane Library, Embase, Scopus, and Web of Science were systematically searched from inception to 10 October 2024, in accordance with PRISMA guidelines.

EXPERT OPINION

Early clinical evidence suggests that seltorexant is effective in treating MDD, both in individuals diagnosed with insomnia and those not, although greater antidepressant effects are observed in individuals with severe sleep disturbance. Results from large phase III clinical trials are needed to confirm efficacy and safety.

Brain structural changes underlying clinical symptom improvement following fast-acting treatments in treatment resistant depression

BACKGROUND

Electroconvulsive therapy (ECT), ketamine infusion (KI), and total sleep deprivation (TSD) are effective and fast in treating patients with treatment-resistant depression (TRD). However, it remains unclear whether the three treatments have the same effect on clinical symptom improvement and have common brain structural mechanisms.

METHODS

The current study included 127 TRD patients and 37 healthy controls, which were obtained from the Perturbation of the Treatment Resistant Depression Connectome Project. We aimed to investigate the shared and distinct brain structural changes underlying clinical symptom improvement among ECT, KI, and TSD treatments.

RESULTS

All of the three treatments significantly reduced the depressive symptoms in TRD patients, but they differently affected other clinical measurements. Neuroimaging results also revealed that all of ECT, KI, and TSD treatments significantly increased gray matter volume of left caudate after treatment in TRD patients. However, the gray matter volume of other brain regions including hippocampus, parahippocampus, amygdala, insula, fusiform gyrus, several occipital and temporal areas was increased only after ECT treatment. Still, the baseline or the change of gray matter volume did not correlate with the depressive symptom improvement for all of the three treatments.

LIMITATIONS

A higher sample size would be required to further validate our findings.

CONCLUSIONS

The results observed in the current study suggested that the ECT, KI, and TSD treatments differently affected clinical measurements and brain structures in TRD patients, though all of them were effective in depressive symptom improvement, which might facilitate the development of personalized treatment protocol for this disease.

KET or ECT for treatment-resistant depression?

Modern electroconvulsive therapy (ECT) and ketamine currently represent the most effective treatment options in depressed patients showing non-response to two or more trials of antidepressants. Recently, large sample head-to-head comparisons of intravenous ketamine versus ECT for treatment-resistant depression (TRD) have fuelled the debate on which therapy might be more effective. However, the informative value of these studies is limited due to major methodological differences, especially regarding patients' baseline clinical characteristics and treatment procedures. This commentary, in reaction to the recently published article by Jha et al. 'Ketamine vs Electroconvulsive Therapy for Treatment-Resistant Depression: A Secondary Analysis of a Randomized Clinical Trial' in JAMA Network Open, addresses this issue and proposes that treatment decisions of ECT or ketamine should be based on substantiated, predictive clinical response markers and patient's preferences. It is undisputed that both treatments are highly effective in TRD, yet, given that ketamine is usually administered before ECT, efficacy studies of ECT in ketamine non-responders are urgently warranted.KEYPOINTSModern electroconvulsive therapy (ECT) and ketamine currently represent the most effective treatment options in treatment-resistant depressionHead-to-head comparisons of both treatments have yielded incongruent findings due to differing patients' baseline clinical characteristics and treatment proceduresTreatment-decisions of ECT or ketamine should be based on predictive clinical response markers and patient's preferences while considering the specific side effect profiles of both optionsFuture prospective studies should assess the efficacy of ECT in ketamine non-responders.

Ketamine and electroconvulsive therapy for severe depression: A network meta-analysis of efficacy and safety

BACKGROUND

Ketamine, electroconvulsive therapy (ECT), and their combination are effective for treating severe depression, but few large-scale studies have compared these.

METHODS

We searched databases for randomized controlled trials (RCTs) using ketamine, ECT, ketamine + ECT, or placebo for severe depression. Standardized measures were efficacy outcomes. Risk of bias was assessed. Stata and ADDIS were used for network meta-analysis (NMA) comparing efficacy and adverse reactions post-treatment. This study was registered on PROSPERO (CRD42023476740).

RESULTS

17 RCTs with 1370 patients were included. NMA showed ECT and ketamine improved Hamilton Depression Rating Scale (HDRS) versus placebo; other comparisons not significant. Rank probabilities showed highest probability for ECT, followed by ketamine + ECT, ketamine, placebo. No differences in Montgomery-Asberg Depression Rating Scale (MADRS); highest rank probability again for ECT, followed by ketamine + ECT, ketamine, placebo.

CONCLUSIONS

Analysis suggests ECT superior to ketamine and their combination for improving depressive severity, but individualized treatment selection warranted. Higher adverse reactions with ketamine + ECT need further study for optimized combined use.

Comparative Efficacy of Intravenous Ketamine and Tramadol in Reducing Postspinal Anesthesia Shivering in Urological Surgeries: A Triple-blind Randomized Clinical Trial

Objective

Shivering is one of the most common complications due to disturbances in the thermoregulatory system after regional anesthesia, leading to adverse outcomes and decreased patient satisfaction. Ketamine and tramadol are considered mild analgesics that affect the thermoregulatory center. This triple-blind, randomized clinical trial aims to explore the comparative efficacy of intravenous ketamine and tramadol in reducing postspinal anesthesia shivering in high-risk urological surgeries.

Methods

A total of 90 patients undergoing urological surgeries under spinal anesthesia at Shahid Hasheminejad Hospital in Tehran in 2024 were randomized into three groups: ketamine (0.5 mg/kg), tramadol (0.5 mg/kg), and placebo (normal saline). Variables, including ambient temperature, patient demographics, surgery duration, and anesthetic techniques, were meticulously controlled. The primary outcome was the incidence of shivering, measured using the Crossley and Mahajan scale. Data were analyzed using the SPSS software Version 19, employing Chi-square tests, analysis of variance, and logistic regression.

Findings

The patients were homogeneous regarding demographic and surgical variables. No significant difference was found in patients' body temperature upon admission. The incidence of shivering was significantly lower in the tramadol group (23.3%) compared to the ketamine group (36.7%) and placebo group (60%) (P = 0.013). Tramadol demonstrated superior efficacy with minimal side effects. Logistic regression analysis confirmed that patients in the tramadol group were significantly less likely to experience shivering (odds ratio = 0.286; 95% confidence interval: 0.098-0.834, P = 0.022). Ketamine, while effective, had a higher incidence of hemodynamic fluctuations and psychotropic effects.

Conclusion

The incidence of shivering was significantly lower in the tramadol group compared to the ketamine and placebo groups. Tramadol demonstrated superior efficacy with minimal side effects. While effective, ketamine had a higher incidence of hemodynamic fluctuations and psychotropic effects.