Treatment resistant depression (TRD) affecting approximately 10–30% of all depressed patients often remains misdiagnosed and undertreated, leading to a higher risk of relapse and suicide. Electroconvulsive therapy (ECT) and sub-anesthetic ketamine have repeatedly shown to be effective in the TRD population. Administering ketamine as an anesthetic component to augment antidepressant efficacy of ECT has been proven inconclusive, while a combination of alternating ECT and ketamine has not been investigated yet.

We present a severely depressed and chronically suicidal female inpatient who failed multiple antidepressant treatment attempts, requiring frequent psychiatric admissions. Since available conventional as well as non-conventional antidepressant treatment strategies were nearly exhausted, we employed a combination of ECT (bilateral stimulation up to 150%) 2–3 times/week, while intravenous racemic ketamine (up to 75 mg per infusion) was administered on ECT free days 2–3 times/week. Consequently, robust anti-suicidal and antidepressant effects could be observed already during the first treatment week. The temporarily occurring subjective forgetfulness disappeared after the last ECT. Summarizing, we employed 9 ECT treatments and 7 ketamine infusions leading to a stable psychopathological state even after discharge from psychiatric inpatient care. In order to prevent relapse a maintenance-therapy comprising ECT once monthly and 2 ketamine infusions (up to 100 mg per infusion) administered on the day before and after ECT was established.

In our patient alternating ECT and intravenous racemic ketamine were proven safe and long-term effective after numerous failed antidepressant trials including ECT and ketamine alone. We may hence encourage clinicians to widen their therapeutic armamentarium in severe TRD.

The authors have not supplied their declaration of competing interest.