Efficacy and safety of ketamine-assisted electroconvulsive therapy in major depressive episode: a systematic review and network meta-analysis

Taeho Greg Rhee, Sung Ryul Shim, Jonah H. Popp, Thomas A. Trikalinos, Robert A. Rosenheck, Charles H. Kellner, Stephen J. Seiner, Randall T. Espinoza, Brent P. Forester, Roger S. McIntyre

Research output: Contribution to journalArticlepeer-review

1 Scopus citations

Abstract

Objective: To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive episode (MDE). Methods: PubMed/MEDLINE, Cochrane Library, Embase, GoogleScholar, and US and European trial registries were searched from inception through May 23, 2023, with no language limits. We included RCTs with (1) a diagnosis of MDE; (2) ECT intervention with ketamine and/or other anesthetic agents; and (3) measures included: depressive symptoms, cognitive performance, remission or response rates, and serious adverse events. Network meta-analysis (NMA) was performed to compare ketamine and 7 other anesthetic agents. Hedges’ g standardized mean differences (SMDs) were used for continuous measures, and relative risks (RRs) were used for other binary outcomes using random-effects models. Results: Twenty-two studies were included in the systematic review. A total of 2322 patients from 17 RCTs were included in the NMA. The overall pooled SMD of ketamine, as compared with propofol as a reference group, was –2.21 (95% confidence interval [CI], –3.79 to –0.64) in depressive symptoms, indicating that ketamine had better antidepressant efficacy than propofol. In a sensitivity analysis, however, ketamine-treated patients had a worse outcome in cognitive performance than propofol-treated patients (SMD, –0.18; 95% CI, –0.28 to –0.09). No other statistically significant differences were found. Conclusions: Ketamine-assisted ECT is tolerable and may be efficacious in improving depressive symptoms, but a relative adverse impact on cognition may be an important clinical consideration. Anesthetic agents should be considered based on patient profiles and/or preferences to improve effectiveness and safety of ECT use.

Original languageEnglish
Pages (from-to)750-759
Number of pages10
JournalMolecular Psychiatry
Volume29
Issue number3
DOIs
StatePublished - Mar 2024
Externally publishedYes

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