It's really dissapointingly seeing the comments section do exactly what the article tries to avoid. There seems to be so much lack of understanding for the process of prescribing treatment for depression, and overreliance on endless anecdotes or other singular data points, directly at the antithesis of the study:

> “Every single study directly reports ECT works better than ketamine. But _people are still skeptical of ECT, perhaps because of stigma_,” Rhee says, or negative depictions in films such as “One Flew Over the Cuckoo’s Nest” and shows such as “Stranger Things.” “_We need to improve public awareness of ECT for treatment-resistant depression_.”

If we read the article carefully, we can see that the headline (as all headlines are) is lacking in nuance:

> Most people diagnosed with depression are offered an _oral antidepressant (in combination with psychotherapy) as a first-line treatment option_. But _if oral antidepressants don’t help, or if the person is at imminent risk of hurting themselves_, there are other, more rapid treatment options: ECT, and more recently ketamine or esketamine.

Firstly, oral antidepressants and psychotherapy are still the firstly line of defence, and for the majority of people enough. As it is, ketamine or esketamine is nowhere near close - has nowhere near enough evidence and longitudinal studies - to replace SSRIs and psychotherapy as the first line. Unfortunately modern medicine isn't advanced enough to fully understand what's going on with oral antidepressants (we have theories, but the majority evidence is simply statistics), let alone (es) ketamine and ECT. As a result, if oral antidepressants are not effective it can often be difficult to effectively prescribe treatment. Naturally a consequence of this is increased risk, from procedures that may not have much if any benifits, not even including the very real chances of a misdiagnosis!

If we look at the cited paper's abstract, the message is even more clear

> Question: Is ketamine as effective as electroconvulsive therapy (ECT) in patients with _major depressive episode_?

> Findings: This systematic review and meta-analysis of 6 trials with 340 patients suggests that ECT may be superior to ketamine in improving depression severity. Findings also suggest that ketamine and ECT each have unique adverse effect profiles.

> The overall pooled SMD for depression symptoms for ECT when compared with ketamine was −0.69 (95% CI, −0.89 to −0.48; Cochran Q, P = .15; I2 = 39%), suggesting an efficacy advantage for ECT compared with ketamine for depression severity.

> Both ketamine and ECT had unique adverse effect profiles (ie, ketamine: lower risks for headache and muscle pain; ECT: lower risks for blurred vision, vertigo, diplopia/nystagmus, and transient dissociative/depersonalization symptoms).

> Meaning: Although ECT may be more efficacious than ketamine in the acute phase, _treatment options should be individualized and patient-centered, considering different adverse effect profiles and patient preferences._

Both (Es)Ketamine and ECT are useful and sometimes literally life saving therapies for those with treatment resistant depression. Like any treatment some respond effectively and may never have to undergo future treatment whilst others may require constant support. The stigma around ECT and the uninformed experience and use of anecdotes is dangerous, and ignores the reality that there are no good answers, at least with our current medical knowledge.

I would advise not drawing any conclusions from limited evidence, and if they want to see more personal anecdotes explore both the positive and negative comments at /r/ECT and /r/TherapeuticKetamine