Effect of Ketamine, Thiopental and Ketamine–Thiopental Combination during Electroconvulsive Therapy for Depression

Abstract

Objective: We aimed to evaluate the effect of anaesthesia with thiopental (4 mg kg ) and ketamine− thiopental (1 mg kg −1 and 4 mg kg −1 , respectively) combination during electroconvulsive therapy (ECT) on the Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HAM-A) and haemodynamic variables in patients with resistant major depression. Methods:Patients with HDRS scores above 17 were included. The patients were randomly divided into three groups according to the anaesthesia used. Group 1 was given thiopental (4 mg kg ) was administered in all patients for muscle relaxation. HDRS and HAM-A scores were evaluated before ECT, after 3, 6. ECT and after the final ECT. Systolic and diastolic blood pressures, heart rates and oxygen saturations were recorded before and after anaesthesia induction and after the ECT procedure. Seizure duration was recorded.Results: Fifty-eight patients were included in the study. Thirty (52%) patients were male and 28 (48%) were female. The mean age was 42.7±15.8 years in Group 1, 44.8±11 years in Group 2 and 38.6±6.8 years in Group 3. In all groups, HDRS scores were reduced compared with the baseline values. There was no statistical significant difference between the groups regarding HDRS scores. HAM-A scores were higher in Group 2 and Group 3. Systolic and diastolic blood pressures and heart rate values were lower in Group 1 and the difference was statistically significant. Conclusion:In this study, anaesthesia induced with thiopental, ketamine and thiopental-ketamine combination was observed to not result in a difference in ECT for patients with treatment-resistant depression. Ketamine at a dose of 1 mg kg −1 given just before ECT did not enhance the antidepressant effect of ECT; however, anxiety scores were increased with ketamine application.Keywords: Depression, anxiety, thiopental, ketamine, electroconvulsive therapy Amaç: İlaç tedavisine dirençli major depresyon vakalarında elektrokonvülsif tedavide (EKT) anestezi indüksiyonunda tiyopental, ketamin ve ketamin-tiyopental kombinasyonunun Hamilton Depresyon Değerlendirme Ölçeği (HDDÖ), Hamilton Anksiyete Değerlendirme Ölçeği (HADÖ) ve hemodinami üzerine etkilerini değerlendirmeyi amaçladık.

Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial

“…We found a further six randomised trials not included in these meta-analyses. Four found no greater efficacy with ketamine,31, 33, 35, 36 and two reported greater efficacy in the ketamine-treated group,29, 37 although of these two studies, there is uncertainty about the statistical robustness in one 37 and the plausibility of the clinical responses seen in the other 29 . The study reported here found a small numerical advantage in the saline-treated group with the 95% confidence interval excluding more than small-to-moderate advantage with ketamine treatment.…”

Ketamine and Beyond: Investigations into the Potential of Glutamatergic Agents to Treat Depression

“…In addition, a randomized, controlled trial of MDD patients who received pre-ECT ketamine (1–1.5 mg/kg at ECT sessions 2 and 3 or 1–1.5 mg/kg at ECT sessions 2, 4, 6, 8, 10) or thiopental (2–3 mg/kg for all ECT sessions) found that depressive symptom severity was lower after the last ECT session in the group that received ketamine prior to the five ECT sessions than in the group that received only thiopental for all ECT sessions [96], suggesting that a greater frequency of paired ketamine and ECT may offer more clinical benefit than a single pre-ECT ketamine infusion. In contrast, another study series compared pre-ECT infusions of ketamine (1 mg/kg), thiopental (4 mg/kg), or both agents; the investigators found that depression symptom scores improved for all groups (as assessed by the HAM-D) and no statistically significant differences were observed between groups [97]. In another study of 90 patients with TRD randomly assigned to receive either ketamine (0.8mg/kg), subanesthetic ketamine (0.5mg/kg) plus propofol (0.5mg/kg), or propofol (0.8mg/kg) prior to eight ECT sessions, those in the ketamine group had an earlier reduction in depressive symptoms; compared to the other two groups, this effect was most pronounced after completion of the second treatment and lasted until the last treatment [98].…”

A review of ketamine’s role in ECT and non-ECT settings

“…Safety concerns in the setting of ECT include higher rates of hypertension, QTc interval prolongation, transient arrhythmias, confusion, or fear, with hallucinations upon awakening from anesthesia. 7 – 9 , 12 , 16 , 23 , 25 The rates of these effects appear to have a positive correlation with an increasing dose of ketamine, notably in the 0.8–2.0 mg/kg dosing range. 8 , 9 , 12 , 16 , 23 , 25 Ketamine use in patients with cardiovascular disease should be considered with caution, especially when used in an ECT setting.…”

“… 9 When combined with barbiturates such as thiopental, ketamine has not been shown to be effective in reducing depressive symptoms, likely due to the effects of barbiturates in attenuating seizures as a result of their anticonvulsant properties. 7 , 11 , 15 , 16 Ketamine may have a role as an adjunctive agent to a non-barbiturate anesthetic, or as a sole anesthetic to accelerate response in the severely ill and those at risk of suicide. While iv ketamine remains the main route of administration, a few studies have demonstrated promising results in non-ECT settings when using alternate routes, notably intranasal.…”