Anand et al. show the noninferi-ority of 3 weeks of twice-weekly ketamine treatment to 3 weeks of thrice-weekly ECT in patients with treatment-resistant depression. We question whether this trial gives ECT a "fair shot" in comparison with ketamine. Patients in the ECT group in the trial completed six to nine ECT sessions, but some patients may not have a response until they have received a greater number of ECT sessions. Intravenous ketamine, in contrast, has been shown to be effective after even just one session. As highlighted by the authors, the patients in their trial did not have psychosis, and not all the patients had severe depression. However, these conditions are in fact hallmarks of patients who generally have a good response to ECT. Finally, patients' expectations may play a role when a commonly stigmatized procedure is compared with a new breakthrough drug. Together, these characteristics might have resulted in an underestimation of the efficacy of ECT, allowing for noninferiority of ketamine.
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