Earlier this month, the Observer reported that a group of leading health experts were calling for our project involving combining electroconvulsive therapy (ECT) and ketamine to be abandoned. The study, called’Ketamine augmentation of electroconvulsive therapy to improve outcomes in depression’ and led by the University of Manchester, is timely and important.
Depression is common and is a major cause of disability, and sometimes death. There are many treatments available, including psychological therapies and antidepressants, but some people do not recover with these approaches. Therefore, there remains the need to find other ways to help them. This is where ECT comes in. ECT is already being used in the NHS and recommended as a treatment option by the National Institute for Health and Care Excellence (NICE) for patients with moderate or severe depression following failure to respond to other treatments. It appears to be the most effective treatment known to alleviate severe depression but remains controversial.
The academics who are calling for our study to be halted question the effectiveness and safety of ECT, and many of them have publicly indicated their opposition to ECT. However ECT has been the subject of careful independent evaluation by NICE, who have concluded from the evidence that it is an effective short-term treatment for depression but at the cost of cognitive side effects, including memory problems. The main objective of our study is to investigate whether these side effects can be reduced or eliminated.
Ketamine is described by the critics of the study as a ‘street drug’. What they neglect to say is that it is primarily an anaesthetic in daily use throughout the NHS, including for children, and is regarded as a safe drug when used in a clinical context. In our study, supported by the Medical Research Council and the National Institute for Health Research, ketamine is being used as part of the anaesthetic that is routinely given for ECT. We are testing the hypothesis, based on work elsewhere, that ketamine will block the disruptive effect of ECT on thinking and memory.
The administration of ketamine with ECT is nothing new. It has been used occasionally as the anaesthetic for ECT for many years and more recently there have been a number of small studies investigating the combination, many with a similar hypothesis to ours. Unfortunately these studies have been too small to provide a definitive answer, which is why a larger study such as ours is crucial in order to clarify whether or not ketamine should be given as part of standard ECT treatment. What the other studies do provide, however, is evidence that ketamine can be can be safely given as the anaesthetic. They also show that when it is used in the way we are doing so in our study, in a low dose together with another anaesthetic, the short-lived psychological effects of ketamine such as confusion and hallucinations are rarely seen. The opinion expressed by the critics, that ketamine and ECT is a particularly risky combination, is simply not borne out by the evidence.
The final misrepresentation made of our study is that inaccuracies or omissions in the information given to participants may influence their decision about treatment. We only approach people after they have already decided to have ECT for their depression and have given informed consent to their clinical team after being informed of the benefits and risks of undergoing ECT. This is a clinical decision completely independent from our study, and therefore the implication that we may somehow entice people to have ECT could not be further from the truth. We are confident that the information given to patients about the use of ketamine (or a placebo) in this study is accurate, and it has been reviewed both by our service user group, and an NHS Research Ethics Committee.
The truth about the study is that it seeks primarily to investigate whether or not it is possible to reduce one of the major problems associated with ECT. If successful, it will be immensely beneficial to those who need to have this treatment to alleviate their depression.
This article first appeared on The Guardian on 01 July, 2014.