Hello, friends! In this episode, I tackle one awesome question from a listener. This person has treatment resistant depression and bipolar. Their mania is well-controlled, but they need a higher level of treatment for the depression. Their psychiatrist suggested either ketamine of electroconvulsive therapy, so in this episode, I break down everything you need to know about these treatments.   As always, you can send me questions to duffthepsych@gmail.com.

Transcript:

Question:

Dear Dr. Duff,

Thank you so much for the incredible work you do to facilitate healing from mental health difficulties on such a large and accessible scale.

I am 25, have bipolar disorder, and have been on numerous medications/ combinations of medications since I was 18. While the mania has been under control for a while, the depression and suicidality have persisted. After a recent inpatient stay, my psychiatrist and I both came to the conclusion that it was time to try a higher-level treatment. He recommended either ketamine or ECT. Ketamine will likely be far more expensive, and I would need to ask my family for a lot of financial assistance, which I’d only want to do if it is likely to work much better than ECT. What does the research suggest about the efficacy of these two different treatments? At this point I will try just about anything.

Perhaps an episode comparing the dominant higher-level treatments like ECT, TMS, Ketamine, Neurofeedback, etc. would be helpful to people in a similar position to me.

Hope you’re well, and I appreciate all you do.

Response:

Thank you for the great question. I know that we’ve talked about bipolar on the show a lot recently, but this is going to be a bit different. If you would like more of a basic primer about bipolar, I’d advise you check out the previous episode or my social media accounts, where I have recently posted detailed information about bipolar disorders.

In this case, we are talking specifically about the depressive symptoms, as you mentioned that the mania is relatively stable and controlled. First, I’m really proud of you for all of the work that you have done. I’m sure it’s seemed like an uphill battle or like plugging holes in a leaky boat at times, but your efforts have led to all of the gains that you have made and your story isn’t over yet.

You mentioned that you’ve recently had an inpatient stay, so I’m glad that you were able to get that kind of help when it was necessary. But that also means that you have been through it recently. So, thanks for reaching out. You and your psychiatrist are talking about higher levels of care for what we call treatment resistant depression, or TRD. TRD simply refers to depression that has not resolved with other treatment. There are different ways of defining it, but most psychiatrists and insurance agencies use the definition of significant depression persisting after trying two different antidepressant medications.

I’m really happy to hear that your psychiatrist is open to the treatments that you mentioned. For one reason or another, a lot of medical providers like psychiatrists are really hesitant to advise about anything other than oral medications for mental health issues. What I’d like to do is compare and contrast the two treatments that you brought up, which are ECT and Ketamine therapy. Let me start with ECT.

ECT stands for electroconvulsive therapy. I wouldn’t call myself an ECT evangelist in that I think everyone should have the treatment, but there are a lot of misconceptions about ECT and fears regarding the procedure that drive me crazy. I think some of this stems from a bit of a problematic history and some of it stems from media portrayals of ECT. When you think of ECT, a lot of people imagine scenes from “One Flew Over the Cuckoo’s Nest” or even “Return to Oz.” These portrayals were intended to scare people, so it’s no wonder that the perception of ECT is as some sort of barbaric treatment.

In its history, ECT has also been used in problematic ways including without anesthesia, against people’s consent or on people that could not provide consent, and also to punish people’s behavior rather than treating mental illness. This is not what ECT looks like now. ECT is considered to be a safe and humane treatment that generally has no lasting undesirable side effects.

Electroconvulsive therapy is basically what you get when you break down the terms. Electro meaning electricity and convulsive meaning causing convulsions or seizures. So, it’s a treatment that uses an electrical current to induce a controlled seizure in the brain. This may sound scary, but the process itself is very safe. It is done under anesthesia, so you aren’t aware that it’s happening, and you are kept from having violent convulsions. The methods have also been refined over time, so that lower electrical doses and shorter seizure durations are possible, which helps to minimize side effects.

Older forms of ECT have carried concerns of memory loss, whereas the current form only features memory loss as a temporary side effect, which resolves over time.

We don’t know exactly why it works, which is the case for many psychiatric treatments, but we do know that it works. Clinical literature suggests that the response rate for people with TRD ranges from 50-80%.

Typically, ECT is only used as a treatment when other treatments have proven insufficient, but there are some cases where it can be used as a first line treatment for severe and emergent issues like psychotic depression or catatonia.

ECT is considered to be one of the most effective treatments for TRD and it is considered safe enough to use for people that are pregnant in most cases.

Of course, there are things to consider with regard to safety when it comes to ECT. For example, if there is any reason that you shouldn’t be under general anesthesia, that could preclude you. As well, if you have a history of stroke, heart attack, or uncontrolled blood pressure, these might make it unwise for you to undergo ECT. These are all things you would discuss with your providers first.

Regarding side effects, you will typically have some amnesia, meaning memory loss, but it is essentially just for the period of time surrounding the treatment. You can also have some confusion, muscle soreness, nausea, or difficulty concentrating. However, these effects are temporary and you will usually see them resolve over time after the treatment is completed.

That’s the gist of ECT. Let’s move on to discussing ketamine treatments.

Ketamine is an anesthetic drug with dissociative properties. It’s not a hallucinogen. That means it’s a medication that reduces pain and causes someone to disconnect from reality.

We know that the medication is safe, as it’s been used in surgeries in both humans and animals for years and years.

However, more recently, we have recognized that ketamine also has a powerful antidepressant effect and it has been shown to be very useful for treatment resistant depression, which is why it’s being asked about here.

I’ve talked about ketamine on other episodes before, so I won’t get into all the details about it, but it can be administered in a variety of ways, such as IV infusion, orally, or through nasal spray. It appears to work on glutamate, which is the primary excitatory neurotransmitter, which creates downstream effects on other brain systems.

One of the major benefits of ketamine treatment is that it is rapid and powerful. You can someone that is imminently suicidal go in for a ketamine treatment and no longer feel suicidal within an hour. That’s amazing.

Ketamine is considered to be safe when administered in a clinical setting. There are very few common side effects. The risk of abuse or addiction is low because you are not using a giant dose in this context. There can be some changes in blood pressure and of course the dissociation that you experience when taking the substance, but that’s really about it.

When it comes to comparing the two treatments head to head, access to treatment is definitely a factor. As ECT has been around for quite a while and is fully FDA approved for this purpose, it is very likely to be covered by insurance. In fact, you can often see it specifically talked about when you go into your insurance plan details on their website.

Ketamine is not always covered. If you are getting IV infusions, you could be looking at several hundred dollars per infusion with the expectation that you will do a series of several infusions over weeks. However, there are other options, such as Spravato, the esketamine nasal spray, which is often covered by insurance since it’s FDA approved. At-home options, such as our recent sponsor Mindbloom, can also be a more affordable method. Always check with your insurance and don’t be afraid to advocate for yourself.

Regarding efficacy, they are both considered to have a high response rate with ECT clocking in at 50-80% and ketamine at 50-70%. There are pluses and minuses here. One benefit of Ketamine is the rapid action that I talked about. However, a detractor is that it may have less of a lasting effect than ECT and be more reliant on maintenance treatments over time. There is also a much larger body of evidence for ECT.

In terms of access and administration, there are a lot of ketamine clinics out there now, so as long as you don’t live too far from a major city, you will likely be able to find IV infusions. Nasal spray is becoming more common, but not everybody has easy access to a provider that uses it. With ECT, it’s typically done in a hospital setting and it does require a lot more planning, as you need to be driven and not expected to fully functional during the duration of treatment. With ketamine, you are there for the treatment and within a matter of hours, you are basically back to full functioning.

For your situation, you have bipolar, not just depression. There is some research to suggest that certain individuals may experience an increase in mania prompted by either ECT or ketamine. However, this is more common in individuals with rapid cycling or recent recurrent episodes of mania.

So those are really the things to consider with those treatments. They are both totally valid options and it’s going to come down to your specific situation and life. I have done other episodes talking about TMS and other approaches, so I won’t dive into those now.

You did mention neurofeedback in your question, so before I wrap up, I do just want to address that. Right now, there is not compelling evidence that neurofeedback is effective for depression and the research is even more limited for bipolar. Please be very wary when interpreting claims made by neurofeedback clinics.

Thanks for the great question and good luck!