Effects of ketamine and esketamine on preventing postpartum depression after cesarean delivery: A meta-analysis

Impact of esketamine intravenous analgesic pump on pain and depression post-cesarean

BACKGROUND

Postoperative pain and psychological well-being in postpartum women following cesarean section are critical for optimal maternal recovery. Traditional analgesics often have limitations and side effects, prompting the need for alternative solutions. This study evaluates the impact of an esketamine intravenous analgesic pump on postoperative pain and psychological status in postpartum women following cesarean section.

METHODS

A comprehensive retrospective evaluation was conducted at our institution from October 2021 to July 2023, including 168 patients who underwent cesarean delivery. The observation group (n = 82) received esketamine via an intravenous analgesic pump, while the control group (n = 86) received traditional analgesic therapy. Data collected included demographic information, surgical details, postoperative pain (assessed using the Visual Analog Scale, VAS), psychological status (assessed using the Edinburgh Postnatal Depression Scale, EPDS), recovery metrics, and adverse reactions.

RESULTS

The observation group demonstrated consistently lower VAS scores at all postoperative time points compared to the control group, indicating superior pain control. EPDS scores were significantly lower in the observation group at 3, 5, and 14 days postoperatively, suggesting better psychological outcomes. The incidence of postpartum depression was also lower in the observation group at 3, 5, and 14 days. Recovery metrics such as time to first ambulation, first flatus, and initiation of lactation were significantly improved in the observation group. There were no significant differences in the incidence of adverse reactions between the groups.

CONCLUSIONS

The use of the Esketamine Intravenous Analgesic Pump significantly reduces postoperative pain and the incidence of postpartum depression within the first 14 days. It promotes early recovery and breastfeeding in postpartum women without significant adverse reactions, making it a valuable addition to postoperative care.

Esketamine reduces the risk of postpartum depression in women undergoing cesarean section: A systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is a prevalent and debilitating disorder that occurs in 14% of women after giving birth.

OBJECTIVES

We aimed to assess the efficacy and safety of perioperative esketamine for preventing PPD in women undergoing cesarean section.

SEARCH STRATEGY

We performed a systematic literature search in five medical databases - MEDLINE, Cochrane Library, Embase, Scopus, and Web of Science on the 12th of January 2025.

SELECTION CRITERIA

We searched for trials on the efficacy and safety of esketamine for preventing PPD.

DATA COLLECTION AND ANALYSIS

We collected data on rates of PPD, Edinburgh Postnatal Depression Scale (EPDS) scores, and adverse effects. Pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using a random-effects model.

RESULTS

Our systematic search provided 2681 records; we screened 1336 duplicate-free records. A total of 17 eligible studies were identified after title, abstract, and full-text selection. Esketamine administration was associated with a lower rate of PPD at postpartum days 3-7 and 28-42 (OR = 0.43; 95% CI: 0.31-0.59 and OR = 0.59; 95% CI: 0.39-0.87, respectively). Esketamine administration was associated with significantly lower EPDS scores at postpartum days 3-7 (MD = -1.32; 95% CI: 1.84 to -0.80).

CONCLUSIONS

Our findings suggest that perioperative administration of esketamine was associated with lower PPD rates and lower scores on the EPDS questionnaire and was considered safe compared to placebo/standard care.

Efficacy and safety of ketamine and esketamine in reducing the incidence of postpartum depression: an updated systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is categorized by the Disorders-Fifth Edition as depression that begins during pregnancy or within the first month after giving birth. Ketamine and esketamine have shown promising results in the treatment of several depressive disorders, which suggests that they may have a role in the prevention of PPD. This systematic review and meta-analysis aim to update evidence about the efficacy and safety of using ketamine and esketamine to reduce PPD incidence.

METHODS

We searched four databases, PubMed, Scopus, Web of Science, and Cochrane, to collect relevant studies. We included studies which investigated the preventive effect of ketamine or esketamine on PPD among women after giving birth through caesarean or vaginal delivery. We extracted PPD occurrence rate, PPD score, pain score and side effects. Finally, a meta-analysis was conducted using RevMan software.

RESULTS

Twenty-one eligible studies were incorporated in the current systematic review and meta-analysis involving 4,389 pregnant women. Esketamine was the intervention in 14 studies, and ketamine was used in 7 studies. In subgroup analysis, both ketamine and esketamine were significantly effective in reducing the incidence of short-term PPD (ketamine: RR = 0.72, 95% CI [0.56, 0.93], P = 0.01; esketamine: RR = 0.43, P < 0.0001). Esketamine only significantly reduced the incidence of long-term PPD (RR = 0.44, P < 0.00001). Low doses and high doses were effective in reducing the incidence of both short-term (high dose: RR = 0.48, P = 0.0005; low dose: RR = 0.46, P = 0.002) and long-term PPD (high dose: RR = 0.54, P < 0.0001; low dose: RR = 0.61, P = 0.009). Regarding the risk of side effects, patients in the Ketamine/esketamine group showed statistically significant higher rates of developing dizziness (P = 0.0007), blurred vision (P = 0.02), vomiting (P = 0.004) and hallucinations (P = 0,002) than women in the control group.

CONCLUSION

Both ketamine and esketamine are effective in lowering the incidence of short-term PPD. On the other hand, only esketamine is effective in reducing the incidence of long-term PPD. It is recommended to use smaller doses for a more tolerable treatment period since doses less than 0.5 mg are significantly effective. Temporary side effects such as dizziness, blurred vision, vomiting and hallucinations were reported.

Intraoperative Esketamine and Postpartum Depression Among Women With Cesarean Delivery: A Randomized Clinical Trial

Importance

Esketamine has been found to reduce the incidence of postpartum depression (PPD) in randomized clinical trials. However, current evidence from randomized clinical trials does not reflect esketamine's efficacy in clinical settings.

Objective

To assess the clinical efficacy of intraoperative esketamine administration for preventing PPD among women who underwent cesarean delivery.

Design, Setting, and Participants

This randomized clinical trial was conducted at The First Affiliated Hospital of Chongqing Medical University in Chongqing, China, from March 2023 to February 2024. Pregnant patients admitted for cesarean delivery were included, while those with intellectual dysfunction or contraindications to esketamine were excluded. All participants were assigned randomly to either the esketamine group or control group in a 1:1 ratio. Data analysis was based on the intention-to-treat principle.

Interventions

Patients in the esketamine group received an infusion of 0.25 mg/kg esketamine in 20 mL of saline over 20 minutes, whereas patients in the control group received 20 mL saline over 20 minutes.

Main Outcomes and Measures

The primary outcome was the incidence of PPD at 6 weeks post partum. PPD was assessed using the Edinburgh Postnatal Depression Scale.

Results

A total of 308 pregnant women were randomly assigned to 1 of 2 groups: esketamine (n = 154; mean [SD] patient age, 31.57 [4.26] years) and control (n = 154; mean [SD] patient age, 32.53 [7.74] years). Incidence of PPD was significantly lower in the esketamine group compared with the control group at 6 weeks post partum (10.4% [16] vs 19.5% [30]; relative risk, 0.53; 95% CI, 0.30-0.93; P = .02).

Conclusions and Relevance

This randomized clinical trial demonstrated esketamine's advantage in reducing the incidence of PPD at 6 weeks post partum in patients who underwent cesarean delivery. The efficacy and safety of esketamine in preventing PPD warrant further investigation in clinical practice.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2200065494.

Perioperative administration of sub-anesthetic ketamine/esketamine for preventing postpartum depression symptoms: A trial sequential meta-analysis

OBJECTIVE

Postpartum depression (PPD) is a major mental health issue affecting 10%-15% of women globally. This meta-analysis synthesized updated evidence on sub-anesthetic ketamine/esketamine's efficacy in preventing PPD.

METHODS

Randomized controlled trials (RCTs) comparing ketamine/esketamine to a placebo for PPD prevention were searched without language restriction. Primary outcomes were PPD risk at 1- and 4-6-week postpartum. Secondary outcomes included the difference in depression scores and risk of adverse events. Trial sequential analysis (TSA) was conducted to validate the reliability.

RESULTS

A meta-analysis of 22 RCTs (n = 3,463) showed that ketamine/esketamine significantly decreased PPD risk at 1- (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.3-0.57) and 4-6-week (RR, 0.47; 95%CI, 0.35-0.63) follow-ups. Consistently, participants receiving ketamine/esketamine had lower depression-related scores at 1- (standardized mean difference [SMD], -0.94; 95%CI, -1.26 to -0.62) and 4-6-week (SMD, -0.89; 95%CI, -1.25 to -0.53) follow-ups. Despite potential publication bias, TSA confirmed the evidence's reliability. Subgroup analysis showed that ketamine/esketamine's preventive effect on 1-week PPD was consistent, regardless of administration timing, type of agents, or total dosage (<0.5 vs. ≥0.5 mg/kg). For the 4-6-week period, PPD risk was favorably reduced only with postoperative administration or the use of esketamine, with the total dosage having no observed influence. Participants on ketamine/esketamine experienced more frequency of hallucinations (RR, 4.77; 95%CI, 1.39-16.44) and dizziness (RR, 1.36; 95%CI, 1.02-1.81).

CONCLUSION

Our findings advocate for the postoperative administration of low-dose ketamine/esketamine to avert PPD, which needed additional research for confirmation.

The effect of a subclinical dose of esketamine on depression and pain after cesarean section: A prospective, randomized, double-blinded controlled trial

BACKGROUND

The aim of this randomized, double-blind placebo-controlled clinical trial was to study the effects of subclinical doses of esketamine on postpartum depression and pain following elective cesarean sections.

METHODS

This randomized, double-blind placebo-controlled trial included 150 pregnant women undergoing elective cesarean sections. After umbilical cord clamping, participants received either subclinical doses of esketamine (0.25 mg/kg, diluted in 10 mL of 0.9% saline) or a placebo (10 mL of 0.9% saline). The primary outcome measures were the incidence of postpartum depression (PPD) and postoperative pain. The Edinburgh Postnatal Depression Scale was used to evaluate PPD on days 3, 7, and 14 postpartum, with an Edinburgh Postnatal Depression Scale score ≥ 10 indicating PPD. Postoperative pain was assessed using the Visual Analog Scale (VAS) at 4, 24, and 48 hours post-surgery. Secondary outcomes included adverse reactions and Ramsay sedation scores at 5 and 15 minutes post-administration.

RESULTS

There were no significant differences in the incidence of PPD between the 2 groups on days 3, 7, and 14 postpartum (P > .05). The VAS scores showed significant differences between the 2 groups at 4 and 24 hours postoperatively (P < .05), but not at 48 hours (P > .05). The experimental group had significantly higher adverse reactions and Ramsay sedation scores 5 minutes post-administration compared to the control group (P < .05), but no significant differences were observed upon leaving the operating room (P > .05).

CONCLUSION

Subclinical doses of esketamine did not reduce the incidence of PPD at 14 days postpartum but did significantly lower VAS scores at 24 hours post-surgery. The experimental group experienced temporary increases in adverse reactions and Ramsay sedation scores shortly after administration.

Esketamine Nasal Spray: Rapid Relief for TRD and Suicide Prevention-Mechanisms and Pharmacodynamics

Esketamine nasal spray has emerged as a promising rapid-relief therapy for treatment-resistant depression (TRD) and suicide prevention. This review examines the chemical structure and pharmacodynamics of esketamine, highlighting its primary action on NMDA receptors and additional effects on AMPA receptors, opioid receptors, monoaminergic receptors, and inflammatory pathways. Despite the synergistic mechanisms contributing to its clinical benefits not being fully understood, future studies are essential to refine our understanding and optimize clinical use. Clinical research indicates that esketamine effectively alleviates depressive symptoms and prevents suicidal behavior in TRD patients, demonstrating good safety and efficacy over extended periods. Specifically, multiple randomized controlled trials have shown that esketamine reduces depressive symptoms within hours and maintains these benefits over several weeks, with a favorable safety profile and minimal side effects observed in long-term use. The approval of esketamine for TRD has significant implications for healthcare practices and policies, offering a new therapeutic option that addresses the urgent needs of patients with severe depression.

Neuronal excitation-inhibition imbalance in the basolateral amygdala is involved in propofol-mediated enhancement of fear memory

Posttraumatic stress disorder (PTSD) is associated with glutamatergic neuron hyperactivation in the basolateral amygdala (BLA) brain area, while GABAergic interneurons in the BLA modulate glutamatergic neuron excitability. Studies have shown that propofol exerts its effects through potentiation of the inhibitory neurotransmitter γ-aminobutyric acid. The neuronal mechanism by which propofol anesthesia modulates fear memory is currently unknown. Here, we used optogenetics and chemogenetics to suppress glutamatergic neurons or activate GABAergic interneurons in the BLA to assess alterations in neuronal excitation-inhibition balance and investigate fear memory. The excitability of glutamatergic neurons in the BLA was significantly reduced by the suppression of glutamatergic neurons or activation of GABAergic interneurons, while propofol-mediated enhancement of fear memory was attenuated. We suggest that propofol anesthesia could reduce the excitability of GABAergic neurons through activation of GABAA receptors, subsequently increasing the excitability of glutamatergic neurons in the mice BLA; the effect of propofol on enhancing mice fear memory might be mediated by strengthening glutamatergic neuronal excitability and decreasing the excitability of GABAergic neurons in the BLA; neuronal excitation-inhibition imbalance in the BLA might be important in mediating the enhancement of fear memory induced by propofol.

Innovative Ketamine Formulations: Enhancing Therapeutic Efficacy and Safety

Ketamine, originally developed as an anesthetic, has shown significant potential for treating depression, chronic pain, and other conditions. However, its conventional formulations often result in side effects such as hallucinations and dizziness due to rapid spikes in blood concentration. This article explores recent patents that optimize ketamine delivery and efficacy: subcutaneous injectable compositions, ketamine conjugates with various molecules, and dual-release formulations combining ketamine with aspirin. These innovations promise to improve ketamine-based treatments' pharmacokinetic profiles, therapeutic outcomes, and safety.

Efficacy and safety of peri-partum Esketamine for prevention of post-partum depression in women undergoing caesarian section: A meta-analysis and systematic review of randomized controlled trials

Postpartum depression (PPD) is a psychiatric condition affecting women post-childbirth. Medication combined with psychotherapy, is the current protocol for its treatment. A meta-analysis was conducted using RevMan 5.4 to explore the efficacy and safety of peri-partum administration of esketamine for preventing PPD. After searching several databases to retrieve the relevant RCTs, seven were included in this analysis, with dichotomous data presented as risk ratio and continuous data as mean difference. The study found a lower incidence of PPD in the esketamine group compared to the control group (RR= 0.37), with significant difference in EPDS scores between the two groups (MD= -1.23) in the first week postpartum. The esketamine group reported a lower prevalence of PPD 4-6 weeks postpartum (RR= 0.48), and no significant difference in EPDS scores after 4 weeks postpartum (MD = -0.10). The esketamine group had a significantly higher incidence of hallucination (RR= 13.85). Other adverse effects, such as dizziness (RR= 4.09), nausea (RR= 0.88), vomiting (RR=0.74), headache (RR=1.52), nightmares (RR=1.22), pruritus (RR=0.29), and drowsiness (RR=1.57) did not show significant differences between the two groups. The study found that esketamine, with manageable side effects, reduces the prevalence of post-partum depression (PPD) after one week as well as after four to six weeks. However, the findings are limited by the limited number of available RCTs, and future research should determine the ideal dosage, the most effective method of administration and the long-term safety profile of esketamine so that it may be considered as an adjunct therapy or a potential sole treatment option.