ECT should be considered early, not only as a last resort, when severe major depressive disorder calls for a rapid and substantial response. That is especially true for psychotic depression, catatonia, severe suicidality, inability to maintain nutrition or hydration, medical deterioration, prior strong ECT response, or poor response to multiple adequate antidepressant trials.

Why It Matters To Your Practice

• Urgent depressive illness can worsen faster than standard medication strategies can work.

• ECT has a longer-established role in severe syndromes such as psychotic depression and catatonia, even though benefit usually emerges over several treatments rather than after the first session alone.

Clinical Implications

• Immediate suicide risk or medical compromise still requires observation, safety measures, and appropriate psychiatric or medical care without waiting for ECT to take effect.

• Before ECT, clinicians should review diagnosis, including possible bipolar disorder or catatonia, prior treatments, patient preferences, capacity and consent, anesthesia risk, medical comorbidity, medications, hydration, and baseline cognition. Consent must follow applicable legal requirements when a patient cannot provide informed consent.

Insights

• There is no universally accepted absolute medical contraindication to ECT, but risk rises with symptomatic intracranial mass or raised intracranial pressure, recent stroke or intracranial hemorrhage, unstable aneurysm or vascular malformation, unstable cardiovascular disease, pheochromocytoma or other uncontrolled catecholamine excess, major airway or anesthesia risk, and unstable fractures or spinal injuries.

• Pregnancy, older age, dementia, and implanted cardiac or neurologic devices are not automatic exclusions; they require individualized planning and, when appropriate, specialist input. Cognitive adverse effects can include short-term confusion and impaired new learning, with some patients experiencing longer-lasting autobiographical memory gaps. Electrode placement and treatment settings can be adjusted to balance urgency, efficacy, and cognitive risk.

The Bottom Line

• Ketamine and ECT serve different urgent needs. Intravenous ketamine may improve depressive symptoms and suicidal ideation within hours to a day, while ECT remains the better-established option for psychotic depression, catatonia, and severe medically compromising depression.

• For nonpsychotic treatment-resistant MDD, a large randomized trial published in The New England Journal of Medicine found IV ketamine met noninferiority criteria versus ECT for short-term response, but that does not establish substitution in psychotic or catatonic illness. Either approach requires individualized risk assessment, planning for relapse prevention, and caution that symptom improvement does not by itself prove suicide prevention.