RESET-TRD; a Randomised trial on oral ESketamine compared to Electroconvulsive Therapy for patients with Treatment Resistant Depression

Prior treatment

• A potential participant who meets any of the following criteria is excluded from participation in this study: • Prior or current bipolar disorder, schizophrenia spectrum, other psychotic disorders, current MDD with psychotic features (previous MDD with psychotic features is allowed if the current episode is non-psychotic). All diagnoses according to DSM-5, assessed with MINI-S interview at screening; • The presence of current moderate or severe dependence of alcohol or drugs 6 months within screening according to the DSM-5, not including tobacco-related and caffeinerelated disorders, ascertained by the MINI-S interview at screening; • Current use of a MAOI in excess of a daily dose of 60 mg
• Recent (within the last four weeks of screening) or current use of cannabis or any other non-prescribed psychoactive compounds, including Saint John’s wort, assessed at screening; • Relevant neurological disorders, such as dementia or epilepsy; • Recent (within the last four weeks of screening) change of treatment with antidepressants; • Planned changes in antidepressant treatment during phase 1 of the study, not being part of the standard practice of ECT treatment like change in lithium or anti-epileptics; • Active suicidal plans, defined by a score higher than 5 (explicit plans for suicide when there is an opportunity or active preparations for suicide) on the MADRS’s item for suicidal ideation; • (Suspected) pregnancy, lactation, or insufficient contraception. In fertile women, a urine pregnancy test will be performed prior to Phase 1 (screening) and prior to Phase 2 (month 1) of the study. • Current use of benzodiazepine and benzodiazepine-like agents (zolpidem, zopiclone) in excess of 3 mg lorazepam or an equivalent per day; • Recent (within the last four weeks of screening) start or change in the use of somatic medication that commonly affects mood, like corticosteroids; • Previous treatment with ECT or esketamine during the current depressive episode

Lab values

• Presence of any absolute contra-indication for esketamine use (according to the Summaries of Product Characteristics) or ECT (according to Dutch ECT guidelines, Appendix A), namely pheochromocytoma, increased intracranial pressure, intracranial surgery (< 6 months), a recent cerebrovascular accident / cerebral trauma, glaucoma, recent myocardial infarction (<6 months), unstable angina pectoris or myocardial disease (New York Heart Association (NYHA) class IV), aneurysmal vascular disease, severe hypertension, severe hyperthyroidism, severe liver problems (Child-Pugh class C), severe kidney problems, acute intermittent porphyria, severe upper airway infection, the use of medication that esketamine interacts with on a major level, such as xanthine derivates (aminophylline, theophylline) or previous hypersensitivity to esketamine or its components; • Presence of any of the following relative contra-indications for esketamine use (according to the Summaries of Product Characteristics) or ECT (according to Dutch ECT guidelines, Appendix A), namely stable angina pectoris, hypertension, myocardial infarction (> 6 months ago), intracranial process, unstable cervical spine, carcinoid, severe COPD, severe obesity, pseudocholinesterase deficiency, malignant hyperthermia and congenital muscle diseases. Cardiovascular relative contra-indications will lead to consultation with a colleague from the cardiology department. This will be performed after screening by the researcher who screened the patient. After cardiological clearance it may still be possible to enrol. Presence of an intracranial process will be discussed after screening with a colleague from neurosurgery department and an anaesthesiologist. Remaining relative contra-indications will lead to discussion with the anaesthesiology department. This will be performed after screening by the researcher who screened the patient. After anaesthesiologic clearance it may still be possible to enrol. • Mental incompetence to fully understand the informed consent of this study, based on the judgment of the general practitioner or treating psychiatrist of the participant; • Inability to understand or comply with study requirements, as judged by the investigator(s); • Use of other investigational drugs within 4 weeks of screening.

• To be eligible to participate in this study, a participant must meet the following criteria: • 18 years or older of age at screening; • Sufficient level of spoken and written Dutch; • Ability to freely provide written informed consent prior to study participation; • Current DSM-5 diagnosis of MDD without psychotic symptoms, ascertained by the Mini International Neuropsychiatry Interview (MINI-S); • At least moderate to severe depression, defined by a MADRS total score ≥ 20; • Indication for ECT treatment for the treatment of the current depressive episode. • TRD, defined as non-response to (or established non-tolerability of) treatment with at least two different antidepressants plus an augmentation step such as lithium, mirtazapine or quetiapine during lifetime, all prescribed in an adequate dose (i.e. defined daily dose) for at least four weeks; • Patients agree with initial clinical admission and subsequent daycare/outpatient treatment.