ECT vs Ketamine for Treatment Resistant Depression: Which is Right for You?

For individuals who have not found relief with traditional antidepressants, treatment resistant depression (TRD) can feel overwhelming. Fortunately, two evidence based options-Electroconvulsive Therapy (ECT) and Ketamine treatment offer hope when other treatments fall short.

This article explains how each treatment works, their benefits and risks, and how recent research compares them. Whether you’re a patient or caregiver, our goal is to help you make informed decisions in collaboration with your mental health provider. 

What is Electroconvulsive Therapy (ECT)? 

• ECT is a highly effective medical procedure used for severe or treatment resistant depression. It involved applying a small, controlled electrical current to the brain while the patient is under general anesthesia. This induces a brief, therapeutic seizure that can help reset brain chemistry. 

How ECT works:

• Enhances neurotransmitters like serotonin, norepinephrine, and dopamine. 
• Promotes neuroplasticity and functional brain connectivity. 
• “Resets” mood regulating brain circuits

What to Expect: 

• Typically administered 2-3 times per week over several weeks. 
• Performed in a hospital or specialty clinic under anesthesia
• Follow up or maintenance ECT may be recommended.

Pros of ECT:

• Very effective, especially for severe, suicidal, or psychotic depression

• Rapid improvement for many patients
• It can work when other medications and therapies have failed

Cons of ECT

• Short term memory loss is common; in some cases, longer lasting memory effects may occur

• Requires anesthesia and medical supervision

• Social stigma and misunderstanding remain barriers for some patients

What is Ketamine Therapy? 

Originally developed as an anesthetic, ketamine is now a fast-acting option for depression especially when other treatments haven’t worked. It can be administered as: 

• IV infusions (off label, in specialized clinics)
• Intranasal esketamine (Spravato), FDA-approved for TRD

How Ketamine Works: 

• Targets the glutamate system, not the traditional serotonin/mood pathways
• Blocks NMDA receptors, increasing the release of BDNF (a growth factor for brain cells)
• Encourages rapid reconnection in brain circuits affected by depression

What to Expect:

• Outpatient treatments, typically 2 sessions per week for 2-4 weeks 

• Each session lasts about 40-60 minutes

• Maintenance sessions may be needed 

Pros of Ketamine: 

• Effects may be temporary without ongoing treatment
• Dissociation, dizziness, or nausea during or after sessions
• Long term safety data is still emerging
• Not recommended for patients with active psychosis 

Efficacy and Safety: What Does Research Say? 

Several major trials have compared ECT and ketamine head-to-head:

Key Study 1: NEJM (2023)

• 365 patients with non-psychotic TRD were randomized to IV ketamine or ECT
• Ketamine was non- inferior to ECT for depression relief at 3 and 6 months

• Cognitive side effects were significantly lower in the ketamine group
  
  

Key Study 2: JAMA Psychiatry (2023)

• Patients with severe depression had better early outcomes with ECT. 
• Ketamine performed better in moderate TRD and outpatient settings. 

Clinical Summary

Measure	ECT	Ketamine
Response Rate	~60-80% (short term)	~55% (after several sessions)
Onset of Effect	1-2 weeks	1-2 days
Cognitive Effects	Memory issues, confusion	Mild, usually no memory issues
Duration of Effect	Often longer lasting	May need ongoing maintenance
Ideal for	Severe, psychotic, suicidal	Moderate TRD, outpatient relief

Which One Should You Choose? 

There’s no one size that fits all answers. Here’s a practical guide: 

Choose ECT if:

• Depression is severe, psychotic, or suicidal

• Past treatments (including ketamine) have failed
• You are willing to undergo hospital-based treatment 

Choose Ketamine if:

• You need fast symptom relief without hospitalization
• You want to avoid memory related side effects
• You can commit to frequent clinic visits for infusions or nasal sprays. 

Final Thoughts

Both ECT and ketamine have transformed how we approach treatment resistant depression. While ECT remains a gold standard option, ketamine has carved out a vital role as a less invasive, rapidly acting alternative. 

The best decision involves a collaborative discussion between you and your mental health provider, considering your symptoms, preferences, medical history, and life circumstances.