Treatment Resistant Depression: ECT (Electroconvulsive Therapy) vs TMS (Transcranial Magnetic Stimulation) vs Ketamine

About the author Dr. Steve Levine is a board-certified psychiatrist internationally recognized for his contributions to advancements in mental health care. Though he is a psychiatrist who places great emphasis on the importance of psychotherapy, medication is often a necessary component of treatment, and he was dissatisfied with the relatively ineffective available options with burdensome side effects. Dr. Levine pioneered a protocol for the clinical use of ketamine infusions, has directly supervised many thousands of infusions and has helped establish similar programs across the country and around the world.

What is treatment-resistant depression?

Patients suffering from depression are most often treated with oral antidepressants as a first-line treatment. Typically, selective serotonin reuptake inhibitors (SSRIs) are prescribed first and if there is no improvement, patients are often prescribed second-line agents such as serotonin-norepinephrine reuptake inhibitors (SNRIs).  However, many patients try two or more medications without significant improvement in their symptoms and with many burdensome side effects such as weight gain and sexual dysfunction.  Those patients who have failed two or more medications, are considered to have “treatment resistant” depression. Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS) have been held as the industry standards for care. Now, ketamine infusion therapy is appropriate for any patient who has met the criteria for treatment resistance and this treatment has been proven effective in significantly improving symptoms of depression in over 70% of treatment resistant patients.¹ In addition to treating those who suffer from treatment resistant depression, ketamine infusions are also used to treat patients who are unable to take oral medications because of side effect intolerance.

Electroconvulsive Therapy

ECT was first performed in the 1930s and is the only form of shock therapy currently used in psychiatry.  Electroconvulsive Therapy is a procedure where electric current is passed through the brain (shocking the brain) to induce a controlled seizure while the patient is under general anesthesia.  This is typically done in an inpatient, hospital setting (at least early on in the course of treatment). A typical course of Electroconvulsive Therapy is administered 3 times a week until the patient’s depression improves (usually within 6-12 treatments). After that, maintenance ECT treatments vary from once per week to once every 3-4 months. The most worrisome potential side effect of ECT is persistent memory loss. To some, ECT seems like a barbaric way to treat patients with severe depression, but there is clear evidence to show that ECT works (50-80% improvement in depression symptoms in various studies) and this has been the gold standard for treatment resistant depression for many years. Often times patients think that because ECT is covered by insurance, this is the cheapest option for their treatment. That isn’t really true. A patient undergoing ECT will often be hospitalized, take several weeks off from work, undergo general anesthesia several times per week, and will incur hospital bills and provider bills (psychiatry and anesthesia). Patients will have to pay their out of pocket deductible and often times additional costs even though they have insurance. The cost of the deductible, additional bills, and time off from work can add up quickly to many thousands of dollars per year.

Transcranial Magnetic Therapy

TMS involves the use of a magnetic field generator (or “coil”) placed near the head of the patient. During a TMS session, this electromagnetic coil is placed against the scalp and the painlessly delivers a magnetic impulse that stimulates nerve cells in the region of the brain involved in mood control and depression. Treatment for depression involves delivering repetitive magnetic pulses, so it’s usually called repetitive TMS or rTMS. The typical course of treatment for TMS involves 1 treatment per day, 5 days per week for 4-6 weeks. Each treatment session lasts about 40 minutes. The typical efficacy rates of TMS vary but most studies quote rates of improvement in depression symptoms in 30-50% of patients. The most common side effect from TMS is headaches, but overall TMS appears to be very benign.  Insurance coverage for TMS is highly variable and for patients who cannot get insurance coverage, the cost of TMS can add up quickly because of the high frequency of treatments over the 4-6 week period. TMS is FDA-approved for the treatment of depression. Actify’s Potomac office is now offering TMS for treatment resistant depression.

Ketamine Therapy

Ketamine infusions are performed in an outpatient setting, like TMS, and involve the placement of an intravenous line (IV) in the patient’s arm. Then an infusion of Ketamine is given through the IV. Ketamine is a dissociative anesthetic agent and often times patients describe an out of body sensation or experience but the dosage used to treat depression does not induce general anesthesia. This means that the patient is awake the entire time, like TMS, and the patient does not undergo general anesthesia (completely asleep with loss of the ability to breathe on his own) like with ECT. A typical course of treatment with Ketamine involves a series of 6 infusions over a 2-3 week period. Each infusion lasts about 40 minutes, with patients spending roughly 2 hours total in one of our Actify. Our psychiatrists speak with the patients both before and after each infusion and monitor the patients during the entire infusion process. This allows for optimal patient care and allows close analysis of each patient’s response to Ketamine to adjust the dosage as needed for the next infusion. One of the best things about Ketamine infusions is that there are no side effects in between infusions. During an infusion, patients often note some blurring of vision, feelings of lightness, floating or intoxication, euphoria, heightened perceptions, and rarely, headaches or nausea. These feelings all subside once the infusion is stopped and patients leave with no residual side effects. Overall, infusions are extremely well tolerated in patients of all ages. Success rates from Ketamine infusions vary from 70-80%, comparable to ECT and much higher than TMS.² In addition, patients will know in hours to days if Ketamine infusions are working, much faster than both ECT and/or TMS. At this time, ketamine infusions are not covered by insurance and price ranges vary from $400-$1000 per infusion, depending on the provider.

So for patients who have failed medication therapy for treatment resistant depression, three major options exist: Electroconvulsive Therapy, Transcranial Magnetic Stimulation, and Ketamine.  We feel that ketamine is the best first option because:

  1. Ketamine has an efficacy much greater than TMS and equal to or greater (in at least one study) than ECT.
  2. Ketamine (and TMS) do not require general anesthesia, like ECT.
  3. Ketamine (and TMS) have no side effects in between treatments.  ECT can have many side effects, the most significant being permanent memory loss.
  4. Ketamine shows improvement in symptoms of depression in hours to days, much quicker than either TMS or ECT.

Citations
1. Schwartz J, Murrough JW, Iosifescu DV. Ketamine for treatment-resistant depression: recent developments and clinical applications. Evid Based Ment Health. 2016;19(2):35- 38. doi:10.1136/eb-2016-102355.

2. Anderson IM, Blamire A, Branton T, et al. Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial. Lancet Psychiatry. 2017;4(5):365-377. doi:10.1016/S2215-0366(17)30077-9.