Use of Ketamine to Enhance Electroconvulsive Therapy (ECT) in Depression

Study Overview
=================
Brief Summary
-----------------
The primary objectives of this study are to investigate the potential for ketamine anesthesia to increase the antidepressant efficacy of Electroconvulsive therapy (ECT) and to decrease acute ECT-induced adverse cognitive effects.

Detailed Description
-----------------
Electroconvulsive therapy (ECT) is one of the most robust antidepressant treatments available. However, there is the potential for significant acute and longer term adverse cognitive effects with ECT and the antidepressant response requires multiple treatment sessions, increasing risk of adverse effects. Further, antidepressant response to ECT is often less than maximal and relapse is common. Growing preclinical and clinical evidence of the rapid-acting antidepressant properties of the anesthetic agent ketamine suggests the use of ketamine anesthesia as a strategy to increase rate of response and shorten treatment course in the administration of ECT. In addition, preclinical and clinical evidence suggests the potential of ketamine to decrease the adverse cognitive effects associated with ECT. The investigators propose a pilot study to measure both acute therapeutic efficacy and cognitive side effects of ECT using ketamine compared to methohexital in depressed patients. The investigators will also explore other parameters of ECT such as seizure duration and morphology, as well as hemodynamic and behavioral changes.

Official Title
-----------------
Ketamine Anesthesia to Enhance Efficacy and Tolerability of Electroconvulsive Therapy in Patients With Unipolar or Bipolar Depression

Conditions
-----------------
Major Depression, Bipolar Depression

Intervention / Treatment
-----------------
* Drug: Ketamine
* Drug: Methohexital


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Male or female patients: 18 to 59 years Women of childbearing potential must agree to use a medically accepted means of contraception for the duration of the study DSM IV MINI diagnosis of major depressive episode (MDD), unipolar or bipolar Pretreatment 24-item Hamilton Rating Scale for Depression score > 21 ECT is clinically indicated Patient has the capacity to provide informed consent. Exclusion Criteria: DSM-IV diagnosis of schizophrenia, schizoaffective disorder, or mental retardation Current primary diagnosis of anxiety disorder, obsessive- compulsive disorder, or eating disorder that precedes the onset of the current episode of depression Current diagnosis of delirium, dementia, or amnestic disorder Baseline Mini Mental State Exam (MMSE) score < 24 and a total score falling two standard deviations below the age- and education-adjusted mean Any active general medical condition or CNS disease which can affect cognition or response to treatment Current (within the past three months) diagnosis of active substance dependence, or active substance abuse within the past week Lifetime history of ketamine or PCP abuse or dependence ECT within three months The presence of any known or suspected contraindication to methohexital or ketamine including but not limited to known allergic reactions to these agents, uncontrolled hypertension arrhythmia severe coronary artery disease and porphyria Pregnancy

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

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Ketamine<br>Participants receiving ECT for depression will be randomized 1:1 to either ketamine (experimental condition) or methohexital (standard anesthetic). | Drug: Ketamine<br>* Ketamine 1-2 mg/kg IV as indicated for ECT<br>|
| Active Comparator: Methohexital<br>Participants receiving ECT for depression will be randomized 1:1 to either ketamine (experimental condition) or methohexital (standard anesthetic). | Drug: Methohexital<br>* Methohexital 1 mg/kg IV as indicated for ECT<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hamilton Rating Scale for Depression-24 (HRSD24) | The HDRS-24 is used to rate depressive symptoms. This instrument is considered one of the gold standard clinician-rated instruments for depressive symptoms. We have established procedures for the maintenance of inter-rater reliability. | Change from beginning of ECT treatment to end; on average 3 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Quick Inventory of Depressive Symptomatology, Self Report (QIDS-SR) | The QIDS-SR is a 16-item self-rated instrument designed to assess the severity of depressive symptoms present in the past seven days (Rush et al 2003). The 16 items cover the nine symptom domains of major depression, and are rated on a scale of 0-3. Total score ranges from 0 to 27, with ranges of 0-5 (normal), 6-10 (mild), 11-15 (moderate), 16-20 (moderate to severe), and 21+ (severe). | Change from beginning of ECT treatment to end; on average 3 weeks | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
depression, electroconvulsive therapy, ketamine, antidepressant