The Effect of S-ketamine for Patients Undergoing Electroconvulsive Therapy (ECT)

Study Overview
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Brief Summary
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This study will determine the effectiveness and safety of S-Ketamine in depression patients undergoing electroconvulsive therapy.

Detailed Description
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Nowadays, depression has become one of the serious mental diseases that affect human's life. With the acceleration of life pace and social pressure, the incidence of depression is increasing year-on-year. According to the statistics of the WHO, by 2017, there were more than 300 million people suffering from depression, accounting for 4.4% of the global population. Depression is highly related to suicide, which is an important reason for suicidal intention and attempt. It has been demonstrated that the incidence of suicide associated with major depression was as high as 15%. The main characteristic of depression is significant and lasting depression, which is caused by the decrease of monoamine transmitters (including dopamine, 5-HT, et al.) related to mood. In the past, antidepressants mainly relied on increasing or reducing the metabolism of transmitters, but these drugs usually took weeks or even months to take effect, and although the symptoms of depression were relieved within weeks after the start of treatment, they were still not ideal in the long term. Therefore, the drug treatment of depression is not optimistic. Electroconvulsive therapy (ECT), as the first biological therapy introduced into psychiatry, has been improving with the progress of technology and equipment. More studies show that ECT is a safe and effective treatment, and the treatment of severe depression is the first choice in some cases. However, cognitive dysfunction, relapse tendency and related safety after ECT need further study. Short acting sedatives and muscle relaxants before ECT can minimize the fear and muscle pain caused by ECT induced seizures. Previous sedatives used include propofol, mesaclopidol, thiopental and ketamine. Ketamine can be used for ECT anesthesia in patients with depression because of its good epileptic characteristics and prevention of cognitive dysfunction after ECT. More evidences reveal ketamine has strong antidepressant effect and reduces suicide of patients with treatment-resistant depression or mania. The low dose of ketamine can take effect within one hour, produce rapid antidepressant effect, and can play a role in more than 70% of patients with refractory depression. In addition, even a single intravenous injection of ketamine can effectively reduce the symptoms of depression within 24-72 hours, and may have synergistic antidepressant effect when combined with ECT. Although ketamine is considered to have a significant antidepressant effect in patients with depression, its application in mental disorders remains to be further explored because it may aggravate mental symptoms. However, some studies also found that ketamine did not significantly improve the effect of ECT on depression compared with other anesthetics. Esketamine is the isomer of ketamine, which mainly acts on NMDA receptor of glutamate and its affinity to the receptor is 3-4 times that of ketamine, therefore it has stronger effect. Evidence suggests that esketamine can regulate NMDA receptor, increase the release of various neurotransmitters, improve the depression of patients, and repair the damaged neurons to improve the neuronal connections in the brain. As an anesthetic, the potency of esketamine is two times higher than ketamine, three times higher than R-ketamine, and its drug metabolism time is shorter, and the related side effects are also significantly reduced. Conseuqently, it has been widely used as an anesthetic in some countries. The efficacy and safety of esketamine nasal spray as a rapid and effective antidepressant in the treatment of patients with refractory depression have been confirmed. However the effect of intravenous esketamine as an anesthetic in ECT anesthesia on patients who are depressed remains unknown. The aim of this study is to evaluate the short-term effect and safety of esketamine as a adjunctive anesthetic in routine ECT anesthesia for patients with depression.

Official Title
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Effect of S-ketamine on Depressed Patients Undergoing Electroconvulsive Therapy-a Randomized, Double-blind, Controlled Clinical Study

Conditions
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Depression, Bipolar, Depression, Unipolar, Major Depressive Disorder, Manic-Depressive - Now Depressed

Intervention / Treatment
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* Drug: S-ketamine
* Drug: ketamine
* Drug: saline


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: American Society of Anesthesiologists (ASA) Physical Status I-II diagnose depressive disorders with DSM-IV Without cognitive impairment Without ECT in past 6 months Exclusion Criteria: had other comorbid psychiatric diagnoses, including schizophrenia, mania organic heart diseases, severe hypertension and arrhythmia severe hepatic and renal diseases severe cerebrovascular disorder or malformation, intracranial mass lesions and seizure glaucoma or high intraocular pressure and intra-ocular pathology severe haematological disease, fracture and obesity, pregnancy severe respiratory tract disease or difficult ventilation or incubation had pre-existing neurological disease or cognitive impairment allergy to anesthetics drugs abuse or alcohol addiction family history of malignant hyperthemia refuse to participate in this trial, had taken part in other clinical trial and with less education and couldn't understand the content of questionnaire

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Propofol group<br>patients were treated with propofol 1 mg/kg and saline bolus infusion before ECT | Drug: saline<br>* The depression patients received propofol and saline before ECT<br>|
| Active Comparator: Ketamine group<br>patients were treated with propofol 1 mg/kg and ketamine 0.5 mg/kg bolus infusion before ECT | Drug: ketamine<br>* The depression patients received propofol and ketamine before ECT<br>|
| Experimental: S-ketamine group<br>patients were treated with propofol 1 mg/kg and S-ketamine 0.25 mg/kg bolus infusion before ECT | Drug: S-ketamine<br>* The depression patients received propofol and S-ketamine before ECT<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hamilton Depression Scale-17 scores | the patients' depression were evaluated with Hamilton Depression Scale with 17 questions after ECT. The scores ranged 0-68, and <7 were normal, the higher the score means more serious disease. | the 1 day after the last ECT | 
| Montgomery-Asberg Depression Rating Scale scores | the patients' depression were evaluated with Montgomery-Asberg Depression Rating Scale scores after ECT. The scores ranged 0-60, and <17 were normal, the higher the score means more serious disease. | the 1 day after the last ECT | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hamilton Depression Scale-17 scores | the patients' depression were evaluated with Hamilton Depression Scale with 17 questions before ECT. The scores ranged 0-68, and <7 were normal, the higher the score means more serious disease. | baseline (before first ECT) | 
| Hamilton Depression Scale-17 scores | the patients' depression were evaluated with Hamilton Depression Scale with 17 questions after ECT. The scores ranged 0-68, and <7 were normal, the higher the score means more serious disease. | one week after the first ECT | 
| Hamilton Depression Scale-17 scores | the patients' depression were evaluated with Hamilton Depression Scale with 17 questions after ECT. The scores ranged 0-68, and <7 were normal, the higher the score means more serious disease. | one month after the last ECT | 
| Montgomery-Asberg Depression Rating Scale scores | the patients' depression were evaluated with Montgomery-Asberg Depression Rating Scale scores before ECT. The scores ranged 0-60, and <17 were normal, the higher the score means more serious disease. | baseline (before first ECT) | 
| Montgomery-Asberg Depression Rating Scale scores | the patients' depression were evaluated with Montgomery-Asberg Depression Rating Scale scores after ECT. The scores ranged 0-60, and <17 were normal, the higher the score means more serious disease. | one week after the first ECT | 
| Montgomery-Asberg Depression Rating Scale scores | the patients' depression were evaluated with Montgomery-Asberg Depression Rating Scale scores after ECT. The scores ranged 0-60, and <17 were normal, the higher the score means more serious disease. | one month after the last ECT | 
| Mini-mental State Examination scores | the patients' cognitive function were evaluated with Mini-mental State Examination scores before ECT. The scores ranged 0-30, and 27-30 were normal, the lower the score means more serious disease. | baseline (before first ECT) | 
| Mini-mental State Examination scores | the patients' cognitive function were evaluated with Mini-mental State Examination scores after ECT. The scores ranged 0-30, and 27-30 were normal, the lower the score means more serious disease. | one week after the first ECT | 
| Mini-mental State Examination scores | the patients' cognitive function were evaluated with Mini-mental State Examination scores after ECT. The scores ranged 0-30, and 27-30 were normal, the lower the score means more serious disease. | the 1 day after the last ECT | 
| Mini-mental State Examination scores | the patients' cognitive function were evaluated with Mini-mental State Examination scores after ECT. The scores ranged 0-30, and 27-30 were normal, the lower the score means more serious disease. | one month after the last ECT | 
| suicide | adverse events | times of symptomatic episodes from first ECT up to one month after last ECT | 
| Mean heart rate before ECT | patients' vital sign | 5 minutes before each ECT | 
| Mean heart rate after ECT | patients' vital sign | 5 minutes after patients emergency from each ECT | 
| Mean Arterial Pressure before ECT | patients' vital sign | 5 minutes before each ECT | 
| Mean Arterial Pressure after ECT | patients' vital sign | 5 minutes after patients emergency from each ECT | 
| Mean time for return of spontaneous respiration after ECT | time for return of spontaneous respiration after ECT | from end of ECT to return of spontaneous respiration after each ECT | 
| Mean emergency time after ECT | patients' recovery time after ECT | from end of ECT to eye opening or following commands after each ECT | 
| Mean seizure duration during ECT | patients' seizure duration during ECT | from end of electrical stimulus to clonic movements in the right lower limb during each ECT | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Depression, Electroconvulsive therapy, S-ketamine