At a Glance: Ketamine therapy and electroconvulsive therapy (ECT) are both evidence-based options for treatment-resistant depression, but they differ substantially in how they are administered, their side effects, recovery, and the patients for whom they may be most appropriate. Research suggests IV ketamine can be an effective alternative to ECT for some patients with nonpsychotic treatment-resistant depression, while ECT remains particularly important for severe depression, psychotic depression, and catatonia.
When standard antidepressants stop working or never worked to begin with, two important treatment options for treatment-resistant depression (TRD) are ketamine therapy and electroconvulsive therapy (ECT). Both have substantial clinical evidence. Both can produce meaningful improvement in patients who have not responded to previous treatments. And both carry misconceptions that can make treatment decisions more difficult.
This article provides a clinical comparison of ketamine therapy and ECT, including how they work, what treatment is like, their potential benefits and risks, and situations in which each may be considered.
Electroconvulsive therapy is a psychiatric procedure in which brief electrical stimulation is applied to the brain while the patient is under general anesthesia, producing a controlled seizure. ECT is performed in a medically supervised setting with general anesthesia and muscle relaxation.
ECT has been used since the 1930s and has a much longer and more extensive evidence base than ketamine therapy. ECT is one of the most established treatments for severe and treatment-resistant depression and has a particularly important role in conditions such as psychotic depression and catatonia.
The modern version of ECT bears no resemblance to its historical depiction. Patients are fully anesthetized with muscle relaxants, there is no visible convulsion, and the procedure itself lasts only minutes. Patients typically wake up in a recovery room feeling drowsy and disoriented, and most can go home the same day.
Ketamine therapy uses subanesthetic doses of ketamine to produce rapid antidepressant effects, primarily through modulation of the brain’s glutamate system. For depression, IV ketamine has been studied more extensively than other routes of ketamine administration.
Unlike ECT, ketamine therapy does not require general anesthesia or induction of a seizure. At Seaside Ketamine, treatment is provided in a medically monitored outpatient setting, with the route, dose, and treatment schedule individualized to the patient.
Many treatment protocols begin with a series of treatments over several weeks, followed by reassessment rather than assuming that every patient will require ongoing treatment.
Both ketamine and ECT can work substantially faster than conventional antidepressant medications.
Ketamine’s antidepressant effects can emerge within hours to days in some patients. ECT generally produces improvement over a series of treatments, although the timing of response varies considerably between patients.
Speed is only one factor in choosing between these treatments. Severity of illness, psychotic symptoms, catatonia, previous treatment response, medical history, cognitive concerns, and patient preference all matter.
Both ketamine and ECT can be effective for treatment-resistant depression, but the answer depends heavily on the type and severity of depression being treated.
In the large ELEKT-D randomized trial, IV ketamine was found to be noninferior to ECT for patients with nonpsychotic treatment-resistant depression who had been referred for ECT. However, these findings should not be generalized to every patient with severe depression.
ECT has a longer and broader evidence base and remains particularly important for severe psychotic depression, catatonia, and other presentations where rapid, intensive treatment may be necessary.
Rather than asking which treatment is universally “better,” the more useful question is which treatment best fits the individual patient’s clinical situation.
Cognitive effects are one of the most important differences patients consider when comparing ECT and ketamine.
ECT can cause temporary confusion and memory difficulties, particularly around the period of treatment. The severity and duration vary according to factors including electrode placement, treatment parameters, number of treatments, and individual susceptibility.
Ketamine can temporarily affect attention, perception, memory, and thinking during and shortly after treatment. Available comparative research generally suggests a more favorable short-term cognitive profile for ketamine than ECT, but it would be inaccurate to say that ketamine has no cognitive effects.
Patients concerned about memory should discuss the risks and benefits of both treatments with their treating clinicians.
ECT: General anesthesia is required, so the patient is unconscious during the procedure. Common short-term effects after treatment can include confusion, headache, muscle aches, nausea, and memory difficulties.
Ketamine: General anesthesia is not required for standard ketamine treatment. Patients remain conscious in a medically monitored setting and may experience temporary changes in perception, thought, emotion, or sense of self. Some patients find the experience personally meaningful, but the intensity of the subjective experience does not by itself determine whether treatment will be effective.
ECT requires specialized medical facilities and an anesthesia team. Availability varies considerably by region and health system. Because general anesthesia is used, patients also need transportation home after outpatient treatment.
Ketamine therapy can be administered in an appropriately equipped outpatient medical clinic such as Seaside Ketamine. General anesthesia is not required, but patients still need monitoring during treatment and transportation home afterward.
The cost of ketamine and ECT can differ substantially depending on insurance coverage, treatment setting, and the number of treatments needed.
Insurance coverage is often available when ECT is medically necessary, although authorization requirements and out-of-pocket costs vary by health plan. Access can also be limited by the availability of facilities that provide ECT.
IV and IM ketamine therapy for depression are generally self-pay because ketamine use for depression is off-label. Spravato® (esketamine) follows a separate insurance pathway and may be covered for eligible patients.
ECT may be particularly important when depression is severe, urgent, or accompanied by certain clinical features. Situations in which clinicians may consider ECT include:
ECT may also be considered during pregnancy when severe psychiatric illness requires treatment, but this decision requires individualized evaluation and coordination among psychiatry, obstetrics, and anesthesia.
Ketamine therapy may be considered for patients with treatment-resistant depression who have not responded adequately to conventional treatments or who are looking for another evidence-based treatment option.
Factors that may make ketamine therapy worth considering include:
Ketamine is not appropriate for everyone. Medical history, psychiatric diagnosis, medications, cardiovascular health, substance-use history, and other factors should be reviewed before treatment.
Yes. Receiving one treatment does not necessarily prevent someone from receiving the other at a different point in their care.
A patient who does not respond adequately to ketamine may later be referred for ECT. Similarly, someone who previously received ECT may later be evaluated for ketamine therapy. The appropriate sequence depends on the diagnosis, severity of illness, previous response, side effects, medical history, and treatment goals.
Research is still evolving on the best ways to sequence or combine ketamine and ECT, so these decisions should be individualized rather than based on a standard protocol.
At Seaside Ketamine, our goal is not to convince every patient that ketamine is the right treatment. If another treatment, including ECT, appears more appropriate for your clinical situation, we will discuss that with you and recommend appropriate follow-up.
Both ketamine therapy and ECT can be administered safely when patients are appropriately selected, screened, and monitored, but they have different risks.
ECT requires general anesthesia and can cause temporary confusion and memory problems. Ketamine does not require general anesthesia, but it can temporarily increase blood pressure and heart rate and cause changes in perception, attention, or thinking.
The safest option depends on the patient’s medical history, psychiatric diagnosis, medications, and individual risk factors.
Both ketamine and ECT can be effective for treatment-resistant depression, but neither treatment is best for every patient.
In the ELEKT-D randomized trial, IV ketamine was noninferior to ECT for patients with nonpsychotic treatment-resistant depression who had been referred for ECT. These findings should not be generalized to all forms of severe depression.
ECT has a longer evidence base and remains particularly important for conditions such as severe psychotic depression and catatonia.
Yes. Previous ECT treatment does not necessarily prevent someone from receiving ketamine therapy.
A patient who did not respond adequately to ECT, experienced difficult side effects, or is considering another treatment approach may be evaluated for ketamine therapy. Likewise, someone who does not respond adequately to ketamine may later be referred for ECT.
The decision should be based on diagnosis, symptom severity, previous treatment response, medical history, and individual treatment goals.
Neither ketamine nor ECT is universally better. The appropriate treatment depends on the type and severity of depression, previous treatment response, medical history, cognitive concerns, access to treatment, and patient preference.
IV ketamine has strong evidence for nonpsychotic treatment-resistant depression, while ECT has a longer evidence base and an important role in severe psychotic depression and catatonia. A clinical evaluation can help determine which option is more appropriate for an individual patient.
1. Anand A, Mathew SJ, Sanacora G, et al. Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression. New England Journal of Medicine.2023.
2. Petrucci ABC, Fernandes JVA, Reis IA, et al. Ketamine versus electroconvulsive therapy for major depressive episode: An updated systematic review and non-inferiority meta-analysis. Psychiatry Research. 2024.
3. Rhee TG, Shim SR, Forester BP, et al. Efficacy and Safety of Ketamine vs Electroconvulsive Therapy Among Patients With Major Depressive Episode: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022.
4. Leroy A, Naudet F, Vaiva G, Francis A, Thomas P, Amad A. Is electroconvulsive therapy an evidence-based treatment for catatonia? A systematic review and meta-analysis. European Archives of Psychiatry and Clinical Neuroscience. 2018.
5. Kang MJY, Hawken E, Vazquez GH. The Mechanisms Behind Rapid Antidepressant Effects of Ketamine: A Systematic Review With a Focus on Molecular Neuroplasticity. Frontiers in Psychiatry. 2022.
6. Rose S, Dotters-Katz SK, Kuller JA. Electroconvulsive Therapy in Pregnancy: Safety, Best Practices, and Barriers to Care. Obstetrical & Gynecological Survey. 2020.
Medically Reviewed by Scott Gillin, MD
Scott Gillin, MD, is a board-certified anesthesiologist and pediatric anesthesiologist and the Founder and Medical Director of Seaside Ketamine. He oversees Seaside Ketamine’s physician-led approach to ketamine therapy and Spravato® treatment.
Last medically reviewed: September 2026
Choosing between ketamine therapy, ECT, TMS, medication, and other treatments depends on your diagnosis, treatment history, medical history, and individual goals. At Seaside Ketamine, we can review your history and help determine whether ketamine therapy is an appropriate option.
Have more questions? Read our Ketamine Therapy FAQ
Best Place for Ketamine vs ECT for Treatment-Resistant Depression
