ECT and Ketamine- Another Combination

Out on PubMed, from researchers in Germany and Australia, is this LTE case report:

Combination of Electroconvulsive Therapy Alternating With Intravenous Esketamine Can Lead to Rapid Remission of Treatment Resistant Depression.

Kavakbasi E, Hassan A, Baune BT.J ECT. 2020 Dec 17;Publish Ahead of Print. doi: 10.1097/YCT.0000000000000733. Online ahead of print.PMID: 33337652

The text is excerpted below:

To the Editor: We present the case of a 56-year-old female patient with treatment resistant depression and partial response to treatment with electroconvulsive therapy (ECT) and intravenous off-label treatment with esketamine. After partial response to either of these treatment modalities alone, we decided to combine alternating ECT and esketamine during the same episode of depression. By this procedure, we achieved a rapid response and a strong reduction in Montgomery-Asberg Depression Rating Scale (MADRS) score. At the end of therapy, she met remission criteria (MADRS score, 9). 

CASE REPORT The patient was first diagnosed with major depression in 1990. She is married, an unemployed cleaning staff, living with her husband, and mother to 2 adult boys. In 2003, she responded to ECT. In 2013, she got 17 sessions of unilateral ECT, a partial response was documented. The current episode began about 6 months before admission to our inpatient unit after discontinuation of lithium terminated by the patient herself. At admission, severely depressed mood, hopelessness, anhedonia, lack of drive, inner and psychomotor restlessness, generalized anxiety, sleep disorder, and suicidal thoughts were present (MADRS score, 47). After nonresponse to antidepressant medication, we decided to administer ECT. In the first series, we performed a total of 20 ECT sessions (7 unilateral, 13 bilateral). Several key symptoms of depression failed to improve during ECT series. One week after discontinuation of ECT, the symptoms worsened (MADRS score, 46). As a next step in our treatment algorithm, we commenced off-label intravenous esketamine treatment dosed at 0.5 mg/kg, which was increased to 0.75 mg/kg after 3 weeks because of insufficient effectiveness. Initially, 9 esketamine infusions were administered. Only a slight improvement of mood and inner restlessness occurred. At the end of the first esketamine series, the MADRS score was 36. Because only insufficient response with ECT as well as with intravenous esketamine was achieved, a treatment algorithm of a combination of ECT and esketamine infusions on non-ECT days was considered. After a total of 6 bilateral ECT sessions (3 ECTs per week) and 4 esketamine infusions dosed at 1 mg/kg applied on non-ECT days, the patient showed rapid and significant clinical improvement. During the second week of combination treatment, lithium was discontinued because of mild disorientation, which subsided quickly after discontinuation of lithium. Otherwise, the combination treatment of ECT and esketamine was tolerated well without any relevant complications. The combination treatment of ECT and esketamine resulted in a reduction of the MADRS score from 36 to 9 within 18 days. Less than 3 weeks after the beginning of the combination treatment, the patient was discharged from hospital. For relapse prevention, we began lithium maintenance at the previous dose and level and continued with the medication as commenced before the combination treatment of ECT and esketamine.

This case reports adds to the literature on innovative combinations of ECT with some form of ketamine treatment. As a single case, conclusions must be very limited, but this patient's diagnosis and response/remission seem convincing. The authors' review of the relevant literature shows a mix of positive and negative results, and their call for more definitive study is well taken.