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Ketamine vs. ECT vs. TMS - Game Over

Ketamine wins...some nay sayers want to recount the "hanging chads"....

ECT, Electroconvulsive Therapy, has for decades been a dramatic treatment for severe psychiatric disorders, including depression that is unresponsive to psychotherapy and antidepressant medications. ECT typically consists of a hospitalized patient receiving brief electrical pulses over the scalp while completely under anesthesia, usually every other day for a week or two. If improved, a patient can be transitioned to outpatient hospital-based ECT sessions every other day for a week or so. Patients are then put on antidepressant medication, and followed as a regular patient would be from then on for outpatient medication management. However, most people will eventually relapse into depression at some point, necessitating re-hospitalization and more rounds of ECT treatment as before over the course of several weeks. Obviously, a patient undergoing ECT will be off work for several weeks, staying in the hospital for some time, will be under anesthesia several times a week, and will incur bills for hospitalization, psychiatrist fees, and anesthesiologist fees (these are covered by medical insurance, minus your deductible). Notable potential side effects of ECT treatment include persistent memory loss. However, ECT is the gold-standard at present for severe depression, and remarkably effective for the vast majority of patients.

TMS, Transcutaneous Magnetic Stimulation, is a recently offered, treatment for mild to moderate depression, whose clinical effectiveness is unclear. The FDA, controversially, approved the use of a TMS device in 2011. This device consists of a handheld magnetic coil that is placed on the scalp to induce small amounts of electrical activity in an outpatient office. No anesthesia or specific safety precautions seem necessary. A patient typically undergoes a one hour treatment session daily, 5 days per week, for 4 to 6 weeks (approximately 20 to 30 treatment sessions total). Very few insurance companies pay for TMS because of its controversial effectiveness, and an entire treatment course can therefore cost $10,000 to $20,000 out of pocket over the course of the 4 to 6 weeks of treatment. Most studies suggest that TMS therapy takes several weeks to work (just like typical antidepressant medications), and is ultimately no more effective than simply switching your antidepressant medication. In the end, it is not known at this point whether TMS can be used to treat depression for the long term, or if you may require periodic re-treatment in the future.

Ketamine, in contrast to ECT and TMS, has a very rapid and robust antidepressant (and anti-suicidal) effect. Like ECT, the data supporting Ketamine are solid and unequivocal, and have proven value in very hard-to-treat depression. TMS, in contrast, does not have strong data to support its

effectiveness, even in non-severe depression, and takes several weeks to work. Both ECT and TMS can be quite expensive (costs of hospitalization, days off work, etc.) compared to Ketamine. Like TMS, Ketamine therapy can be done in an outpatient office setting without anesthesia and with minimal hassle and side effects....basically, they can get back to work and lead normal lives without too much disruption.

However, the one thing that Ketamine, ECT, and TMS have in common is that they likely all will require continued use of antidepressant medications for relapse prevention over time. Ketamine on this front still wins...over time the patient requires less to maintain, not more.

Is this treatment for everyone? No. Ketamine treatment currently is for severe depression, anxiety and most PTSD cases that have not responded, in frustration, to several adequate antidepressant medication trials.

What does it involve? Patients receive a series of 6 infusions over 2 weeks to reach and maintain significant improvements in depression.

What should I expect from it? Studies show that many patients report improvements as soon as 40 minutes after an infusion, with benefits lasting 3 to 4 months, depending on the person. Most people will then go on to take standard antidepressant medications afterwards in order to sustain the antidepressant benefit. Patients who know have reported the effects of Ketamine during the infusion to be similar to either that of Nitrous Oxide (“Laughing Gas” at the dentist’s office). Negligible reports of side effects occur beyond the first few hours after treatment.

Thanks to Dr. William T. Goldman for support data (817-329-3300)

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