Ketamine as augmentation for the treatment of major depression and suicidal risk in advanced cancer: Case report

Ketamine and Ketamine-Assisted Psychotherapy for Psychiatric and Existential Distress in Patients with Serious Medical Illness: A Narrative Review

Context: Psychiatric and existential distress are common and difficult-to-treat symptoms that are frequently encountered in the palliative care setting; current treatment options are limited in efficacy and tolerability. Psychedelic-assisted therapies (PAT) have gained public and scientific interest in their potential to induce rapid and effective reductions in psychiatric and existential distress in patients with serious medical illness, but remain available only in the research setting. Ketamine as a pharmacologic agent has a large body of evidence in the treatment of refractory depression. Objectives: To review the evidence that exists for use of ketamine or ketamine-assisted psychotherapy (KAP) for psychiatric and existential distress in patients with serious medical illness, aiming to identify therapeutic signals and gaps in research. Methods: A literature search identified publications of (1) ketamine or KAP, (2) psychiatric or existential distress, and (3) palliative care or patients with serious medical illness. Identified reports were carefully reviewed with attention to population and treatment-related factors, which were described in a narrative and aggregate format. Results: Nine studies and 12 case reports were identified that reported positive results and a good safety profile. There was significant variation in patient population, setting, route of administration, dosing schedule, and concurrent treatments. Most reports were of ketamine as a pharmacologic agent for symptoms of psychiatric distress. Conclusion: Evidence suggests that ketamine may induce rapid and transient improvements in psychiatric symptoms in patients with serious medical illness. A large gap in research exists for KAP and symptoms of existential distress. There is a signal that suggests ketamine could be used in a psychedelic therapy model with potential benefits over classical psychedelics.

Efficacy of ketamine for comorbid depression and acute or chronic pain: A systematic review

Pain and depression frequently co-occur. Due to its antidepressant and analgesic properties, ketamine has been used for the management of treatment-resistant depression and pain. This systematic review examined the literature on the efficacy of sub-anesthetic doses of ketamine in individuals experiencing comorbid depression and chronic pain (CDCP), as well as comorbid depression and acute pain (CDAP). A secondary objective was to provide an assessment of dosage, route, and adverse effects of ketamine treatment for CDCP and CDAP. A literature search was conducted on MEDLINE, PsycINFO, and Embase databases, coupled with a manual screening of the bibliography sections of included articles. In addition, registered ongoing and planned trials were searched on Clinicaltrials.gov. The end date of the search was April 9th, 2022. Included studies assessed changes in depression and pain in patients receiving at least one sub-anesthetic dose of ketamine. Assessment of quality was conducted using the GRADE checklist. Of the 7 CDCP clinical trials, 3 reported a reduction in depression and pain, 3 reported a reduction in depression or pain only, and 1 reported no improvement in either comorbidity. Among the 7 CDAP clinical trials, 4 studies found improvements in depression and pain while the remaining 3 reported improvements in only one parameter. Ten of the 12 case studies and 2 of the 3 observational studies assessing CDCP and CDAP found improvements in pain and depression scores post-treatment with effects of variable duration. The planned methodologies of the registered clinical trials are in line with those of the published research. Preliminary evidence supports the efficacy of ketamine in treating CDCP and CDAP. However, the current review identified a small number of heterogeneous studies with mixed results, preventing comprehensive conclusions. More longitudinal placebo-controlled studies are needed to identify the effects of ketamine for patients with CDCP and CDAP.

Low-dose ketamine infusion in treatment-resistant double depression: Revisiting the adjunctive ketamine study of Taiwanese patients with treatment-resistant depression

BACKGROUND

Whether a single low-dose ketamine infusion may have rapid antidepressant and antisuicidal effects in patients with treatment-resistant double depression remains unclear.

METHODS

This study enrolled 35 patients with treatment-resistant double depression, 12 of whom received 0.5 mg/kg ketamine, 11 received 0.2 mg/kg ketamine, and 12 received normal saline as a placebo. The patients were assessed using the 17-item Hamilton Rating Scale for Depression (HDRS) prior to the initiation of infusions, at 40 and 240 min post-infusion, and sequentially on Days 2-7 and on Day 14 after ketamine or placebo infusions.

RESULTS

A single 0.5 mg/kg ketamine infusion had rapid antidepressant (p = 0.031, measured by the HDRS) and antisuicidal (p = 0.033, measured by the HDRS item 3 scores) effects in patients with treatment-resistant double depression. However, 0.2 mg/kg ketamine was insufficient to exert rapid antidepressant and antisuicidal effects in this patient population with severe and chronic illness.

DISCUSSION

In this patient population, the commonly used dose of 0.5 mg/kg was sufficient. Additional studies are required to investigate whether repeated infusions of low-dose ketamine may also maintain antidepressant and antisuicidal effects in patients with treatment-resistant double depression.

Psychedelics for the treatment of depression, anxiety, and existential distress in patients with a terminal illness: a systematic review

BACKGROUND

Terminally ill patients may experience existential distress, depression, or anxiety, limiting quality of life in the final stage. Existing psychotherapeutic or pharmacological interventions have (time) limited efficacy. Psychedelic treatment may be a safe and effective alternative treatment option.

AIM

Systematically review studies on psychedelic treatment with and without psychotherapy for existential distress, depression, and anxiety in terminally ill patients.

METHODS

Medline, PsycINFO, and Embase were searched for original-data studies on the treatment of depression, anxiety, and existential distress with classical or a-typical psychedelics in patients with a terminal illness, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 1850 records were screened, and 33 articles were included in this review: 14 studies on classical psychedelics (DPT, LSD, and psilocybin) and 19 studies on atypical psychedelics (MDMA and ketamine). Results of early pre-post studies are promising but have serious methodological flaws. Recent (controlled) trials with LSD, psilocybin, ketamine, and MDMA are of higher methodological quality and indicate positive effects on existential and spiritual well-being, quality of life, acceptance, and reduction of anxiety and depression with few adverse and no serious adverse effects.

CONCLUSIONS

Both classical and a-typical psychedelics are promising treatment options in patients with terminal illness. To draw final conclusions on effectiveness and safety of psychedelics, we need larger high-quality studies for classical psychedelics and MDMA. Ketamine studies should pay more attention to existential dimensions of well-being and the psychotherapeutic context of the treatment.

Study protocol for SKIPMDD: subcutaneous ketamine infusion in palliative care patients with advanced life limiting illnesses for major depressive disorder (phase II pilot feasibility study)

INTRODUCTION

Major depressive disorder (MDD) in people with advanced life-limiting illnesses can have significant impact on the quality-of-life of those affected. The management of MDD in the palliative care setting can be challenging as typical antidepressants may not work in time nor be tolerated due to coexisting organ dysfunctions, symptom burden and frailty. Parenteral ketamine was found to exhibit effective and rapid-onset antidepressant effect even against treatment-resistant depression in the psychiatric population. However, there is currently neither feasibility study nor available prospective study available to inform of the safety, tolerability and efficacy of such for MDD in the palliative setting.

METHODS AND ANALYSIS

This is an open-labelled, single arm, phase II pilot feasibility study involving adult patients with advanced life-limiting illnesses and MDD across four palliative care services in Australia. It has an individual dose-titration design (0.1-0.4 mg/kg) with weekly treatments of subcutaneous ketamine infusion over 2 hours. The primary outcome is feasibility. The secondary outcomes are related to the safety, tolerability and antidepressant efficacy of ketamine, participants' satisfaction in relation to the trial process and the reasons for not completing the study at various stages. The feasibility data will be reported using descriptive statistics. Meanwhile, side effects, tolerability and efficacy data will be analysed using change of assessment scores from baseline.

ETHICS AND DISSEMINATION

Ethics approval was acquired (South Western Sydney Local Health District: HREC/18/LPOOL/466). The results of this study will be submitted for publication in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry Number: ACTRN12618001586202; Pre-results.

Effective Therapy Against Severe Anxiety Caused by Cancer: A Case Report and Review of the Literature

Anxiety can make it difficult for patients to manage their illness. Therefore, it is important to reduce their anxiety if possible. However, few studies have examined the efficacy of drugs in the treatment of anxiety in patients with cancer. Our case had failed to respond to benzodiazepines, and it was difficult to use a selective serotonin reuptake inhibitor (SSRI) as the next drug. This case report describes the effective use of quetiapine to treat anxiety. We report this rare case along with a literature review. Few studies have assessed the treatment of anxiety in patients with rare cancers. In our case, quetiapine effectively alleviated anxiety associated with cystic adenoid carcinoma. However, in clinical practice, it is possible that anxiety is treated without differentiating the effects of cancer status, e.g. life prognosis, treatment progress. In our patient, benzodiazepines had no effect on anxiety. Thus, different drugs may be required to treat anxiety associated with cancer. The present study demonstrated that quetiapine is a useful modality for the palliative care of patients with rare cancer and intractable anxiety. Quetiapine may be an effective alternative to benzodiazepines (BZ) and SSRIs for treating anxiety in patients with cancer. However, further investigation is needed to clarify the efficacy of treatments for anxiety associated with rare cancers.