Electroconvulsive Therapy vs. Ketamine: A Scoping Review and Meta-Analysis of Rapid-Acting Interventions for Acute Suicidality in Adults
V. Sharma, S. Ather, A. Sič, A. Asressahegn, A. Haryal, S. Prasad, T. Kainth, S. GunturuIntroduction
Suicide is a leading cause of death in the psychiatric population. The existing modes of treatment (pharmacological and psychotherapeutic) for suicidality are effective but have longer onset, this delay causing a dangerous therapeutic gap in an acute crisis. We compare the two fast-acting treatments, the newer psychopharmacological agent Ketamine and well-established neuro-modulatory electroconvulsive therapy (ECT), for acute suicidality.
Objectives
Comparing efficacy, safety and side effect profiles of Ketamine and electroconvulsive therapy through a scoping review and meta-analysis.
Methods
PubMed was searched on 15 January 2025 without temporal and geographical restrictions, using keywords ‘Ketamine’, ‘Electroconvulsive therapy’ and ‘Suicidality’ yielding 916 records. After duplicate removal, 895 remaining records were screened and 52 relevant original research or meta-analysis were included as primary records. Non-original, non-English, non-human and not relevant were excluded (843 records). Additional 50 secondary sources were retrieved from 1) references of primary sources and 2) targeted open-source Google search while drafting the manuscript. The final 102 articles were subdivided into 3 subsections (30- ketamine + 57- ECT+ 15- comparison of modalities) for analysis. PRISMA-ScR guidelines were followed (Figure 1) and 5 different meta-analyses were conducted using RevMan 5.4.1.
Results
Ketamine demonstrated high potential as an anti-suicidal agent. Clinical trials with suicidality as primary outcome showed significant improvement in scores on clinical suicidal scales with ketamine, with standard mean difference (SMD) of -1.24 (95% CI [-1.79, -.068], Z = 4.34, p < 0.0001), but the heterogeneity was high (I
2
= 92%). Trials with suicidality as secondary outcome also showed significant improvement with SMD -0.79 ([-1.00, -0.57], Z= 7.28, p< 0.00001; I
2
= 0%) (Figure 2). The research in last 10 years demonstrate that the risk of suicide was significantly decreased by 22% with ECT (overall hazard ratio: 0.78, 95% CI [0.68, 0.90], Z = 3.52, p = 0.0004; I
2=
0) (Figure 3). In psychopharmacological era, suicide and suicide attempt rates improved with ECT, with significant peto-odds ratio (OR) of 0.80 (95% CI [0.73, 0.88], Z = 4.85, p < 0.00001), but the heterogeneity was high (I
2
= 65%). Research from the shock therapy era was inconclusive with fallacious methodology. Ketamine has a rapid but short-lived effect with the side effects of dissociation, increased blood pressure, and nausea. In contrast, ECT requires multiple sessions, but a long-lasting impact, with cognitive side effects.
Image 1: Long description.