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Treatment-Resistant Depression

Major depressive disorder is a serious health concern for adults in the United States. According to data from the Centers for Disease Control and Prevention, close to one in five adults have or will have experienced depression at least once in their life. An individual with depression can face severe emotional and physical symptoms, and depression can also lead to suicidal thoughts or suicide attempts.

Furthermore, some estimates point to more than 30 percent of adults currently with depression as having treatment-resistant depression (TRD): depression that does not improve or go away with standard treatment options such as medication. When depression symptoms do not respond to these options, it can be hard for the individual to know where to turn.

Ketamine was found to be a noninferior treatment for TRD compared to ECT. This is an important finding, as Ketamine is currently not in widespread use as a treatment for depression in the United States.

Comparing Two Treatment Options

However, options do exist. One PCORI-funded comparative clinical effectiveness research (CER) study compared two treatment options for patients for whom antidepressant medications had not been effective: electroconvulsive therapy (ECT), and the medication Ketamine. ECT has been shown to be effective in the past, but people may not like the process or side effects—such as memory loss or having to undergo anesthesia first—and ECT can also carry a social stigma. Ketamine, on the other hand, does not require anesthesia and has no effects on memory; however, it can have other side effects, and is not a typical treatment for depression.

The patient-centered CER study sought to determine which might work best for whom and why. In a study designed from the start with input from patients with major depression, patient advocacy groups, healthcare professionals and payers, patients who were originally seeking ECT treatment and agreed to participate in the study were randomized into two groups. Half of the patients received ECT, and half of them received injections of Ketamine.

In results recently published in the New England Journal of Medicine, the study found that both treatment options resulted in similar improvements in quality of life, and Ketamine was found to be a noninferior treatment for TRD compared to ECT. This is an important finding, as Ketamine is currently not in widespread use as a treatment for depression in the U.S. healthcare system, but rather only for pain; furthermore, Ketamine is not covered by most insurance plans. If patients prefer treatment with Ketamine to ECT, results indicating this option can work as well as ECT could have big implications for how TRD is addressed in the future.

Through this PCORI-funded trial, we now have evidence that it may be worth exploring one more treatment option which could help health care be more patient-centered.

Understanding How to Achieve More Patient-Centered Care

Depression is a condition affecting many adults in the United States — many of whom will furthermore face TRD. Even the fact that some cases of depression respond to standard treatment while some do not is testament to how every case of depression is different and may require different treatments. Through this PCORI-funded trial, we now have evidence that it may be worth exploring one more treatment option which could help health care be more patient-centered.

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