Comparison Of Efficacy And Safety Of Ketamine In Electroconvulsive Therapy For Depression

Background: Electroconvulsive therapy(Electroconvulsive Therapy,ECT) is a effective treatment for severe depressive episode,is considered a gold standard for the treatment of severe or refractory depression.However,there are still a small number of patients who do not respond to ECT or are clinically unable to cause adequate seizures.Objective: To compare the efficacy and safety of ketamine and other anesthetics (such as propofol,thiopental,midazolam,etomidate,and methohexital) as electroconvulsive anesthetics in patients with depression,and to compare the effects of ketamine as anesthetics on the therapeutic parameters and postoperative vital signs of patients with electroconvulsive therapy.Methods: The literature published in pubmed,Cochrane,Embase,China general database of knowledge resources(cnki),China science and technology journal database (wipro database) and wanfang database were searched,and a randomized controlled trial of ketamine as anesthetic in ECT was determined.A total of 234 literatures were retrieved,including191 English literatures and 43 Chinese literatures.Finally,19 literatures were included (including 15 English literatures and 4 Chinese literatures).In the ketamine group,N = 566,and in the control group,N =523,Among them,there were 17 studies on the efficacy of ketamine (N =513 in the ketamine group,N = 468 in the control group).Review manager5.3 software was used for statistical analysis.Results: 1.The antidepressant efficacy of ketamine as an anesthetic for ECT in depressive disorders was significantly higher than that of other anesthetics(SMD=-0.47,95% CI: [-0.82,-0.12 ],P=0.008).2.Further analyses for depressive symptoms after different ECT sessions,Significant differences were observed after 1st ECT(SMD=-0.47,95%CI: [-0.84,-0.11],P=0.01),2nd ECT(SMD=-0.72,95% CI: [-1.12,0.32],P=0.0004),4th ECT(SMD=-0.82,95% CI: [-1.33,-0.31],P=0.002),6th ECT(SMD=-1.16,95% CI: [-1.91,-0.41],P=0.002),8th ECT(SMD=1.57,95%CI: [-2.68,-0.46],P=0.006).But no statistically significant differences were observed after ECT for the 3rd(SMD=-0.56,95%CI: [-1.22,0.09],P = 0.09),and 5th(SMD=-0.01,95%CI: [-0.58,0.56],P=0.97).3.The response rate(RR=1.19,95%ci:[1.02,1.39],P=0.03)and remission rates(RR=1.74,95%ci: [1.22,2.48],P=0.002)of ketamine group and control group after ECT were significantly different,ketamine group was superior to control group.4.The adverse reactions in ketamine group and control group were compared.The results showed that the incidence of postoperative hypertension (RR=1.87,95%CI: [1.09,3.22],P=0.02)and delirium or agitation(RR=2.49,95%CI: [1.39,4.46],P=0.002) in ketamine group was higher than that in control group,and the difference was statisticallysignificant.The risk of nausea and vomiting (RR=1.59,95%CI: [0.65,3.90],P=0.31),headache(RR=1.29,95%CI: [0.83,2.00],P=0.26)and hallucinations (RR=2.64,95%CI:[0.95,7.32],P=0.06) was not statistically significant compared with the control group.5.Comparison of effects of ketamine group and control group on ECT treatment parameters showed that the seizure duration in ketamine group was higher than that in control group(MD=7.64,95% CI:[3.19,12.09],P=0.0008),and the difference was statistically significant.We also analyzed the seizure duration during each ECT,and found that the seizure duration in ketamine group was higher than that in control group at the 1st(MD=8.84,95%CI: [1.41,16.27],P=0.02),4th(MD=8.44,95%CI: [0.48,16.39],P=0.04)and 8th(MD =14.57,95%CI: [0.27,28.87],P=0.05),and the difference was statistically significant..The duration of ECT in the 2nd(MD=8.62,95% CI: [-0.38,17.62],P=0.06),3rd(MD=2.55,95% CI:[-4.40,9.50],P=0.47),5th(MD=4.75,95% CI: [-1.23,10.72],P=0.12)and 6th(MD=6.04,95% CI: [-4.02,16.09],P=0.24)was no statistically significant difference in two groups;There was no statistically significant difference in the electric quantity required for ECT in two group(MD=-22.57,95% CI:[-50.77,5.63],P=0.12).The effects of the two groups on the vital signs after ECT were analyzed,and found that there was no statistical difference between the two groups in postoperative consciousness recovery time(MD=0.27,95% CI:[-0.53,1.06],P=0.51)and respiratory recovery time(SMD=-0.09,95%CI: [-0.30,0.12],P=0.40).6.Considering the antidepressant effect of ketamine may be difference in the different regional,we divided into two subgroups in Asia and Europe and the analysis,the results showed that depression disorders of Asia have significant curative effect of ketamine group(SMD=-0.66,95% CI: [-1.09,-1.09],P=0.003),the difference was statistically significant.There was no statistically significant difference in depression between European and American patients (SMD =-0.01,95% CI:[-0.39,0.38],P=0.97).Conclusion: Ketamine as an anesthetic for electroconvulsive therapy may have an advantage over other anesthetics in patients with depression,providing early relief from depression,and may be more effective in patients with depression in Asia,but may increase the risk of hypertension,delirium or restlessness after surgery.Ketamine increased the duration of seizures treated with electroconvulsive therapy in patients with depression,and there was no difference in the amount of electricity required compared with the control group.There was no difference in postoperative consciousness recovery time and respiratory recovery time between the two groups.