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Calder CN, Kwan ATH, Teopiz KM, Wong S, Rosenblat JD, Mansur RB, Rhee TG, Ho R, Cao B, McIntyre RS. Number needed to treat (NNT) for ketamine and esketamine in adults with treatment-resistant depression: A systematic review and meta-analysis. J Affect Disord 2024; 356:753-762. [PMID: 38636712 DOI: 10.1016/j.jad.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Ketamine has been established as efficacious in adults living with Treatment-resistant Depression (TRD). Toward providing a quantifiable estimate of the clinical meaningfulness of the therapeutic benefit of ketamine, herein, we conduct a systematic review that aims to report the Number Needed to Treat (NNT) and the Number Needed to Harm (NNH). METHODS This systematic review searched Embase, Medline/Pubmed, PsycINFO and ClinicalTrials.gov from inception up to October 15th 2023, for placebo-controlled, Randomized Controlled Trials (RCTs) assessing racemic ketamine or esketamine therapy for unipolar TRD. We calculated NNT and NNH for ketamine treatments over various time points. RESULTS A total of 21 studies with 2042 participants were included. Racemic ketamine treatments had pooled NNTs for response of 7 at 4 h, 3 from one day to one week and 9 for studies at four weeks. Esketamine treatment was found to have a similar efficacy with an NNT of 2 at one day and 11 at four weeks. NNH values indicated low risk for ketamine treatments. LIMITATIONS Limitations in the data used include the possibility of functional unblinding and selective reporting bias. Moreover, the meta-analysis may have been limited in its precision by including low threshold definitions of treatment resistance (≥ 1 failed antidepressant) and low-dose ketamine treatments. CONCLUSION Herein, we determined that the NNT for ketamine treatment in adults living with TRD across different intervals of observation was <10. We conclude that the NNTs observed herein are highly clinically meaningful in this difficult to treat disorder.
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Affiliation(s)
| | - Angela T H Kwan
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada.
| | - Sabrina Wong
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
| | - Joshua D Rosenblat
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Rodrigo B Mansur
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore.
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing 400715, PR China.
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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Gärde M, Matheson GJ, Varnäs K, Svenningsson P, Hedman-Lagerlöf E, Lundberg J, Farde L, Tiger M. Altered Serotonin 1B Receptor Binding After Escitalopram for Depression Is Correlated With Treatment Effect. Int J Neuropsychopharmacol 2024; 27:pyae021. [PMID: 38695786 PMCID: PMC11119883 DOI: 10.1093/ijnp/pyae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is commonly treated with selective serotonin reuptake inhibitors (SSRIs). SSRIs inhibit the serotonin transporter (5-HTT), but the downstream antidepressant mechanism of action of these drugs is poorly understood. The serotonin 1B (5-HT1B) receptor is functionally linked to 5-HTT and 5-HT1B receptor binding and 5-HT1B receptor mRNA is reduced in the raphe nuclei after SSRI administration in primates and rodents, respectively. The effect of SSRI treatment on 5-HT1B receptor binding in patients with MDD has not been examined previously. This positron emission tomography (PET) study aimed to quantify brain 5-HT1B receptor binding changes in vivo after SSRI treatment for MDD in relation to treatment effect. METHODS Eight unmedicated patients with moderate to severe MDD underwent PET with the 5-HT1B receptor radioligand [11C]AZ10419369 before and after 3 to 4 weeks of treatment with the SSRI escitalopram 10 mg daily. Depression severity was assessed at time of PET and after 6 to 7 weeks of treatment with the Montgomery-Åsberg Depression Rating Scale. RESULTS We observed a significant reduction in [11C]AZ10419369 binding in a dorsal brainstem (DBS) region containing the median and dorsal raphe nuclei after escitalopram treatment (P = .036). Change in DBS [11C]AZ10419369 binding correlated with Montgomery-Åsberg Depression Rating Scale reduction after 3-4 (r = 0.78, P = .021) and 6-7 (r = 0.94, P < .001) weeks' treatment. CONCLUSIONS Our findings align with the previously reported reduction of 5-HT1B receptor binding in the raphe nuclei after SSRI administration and support future studies testing change in DBS 5-HT1B receptor binding as an SSRI treatment response marker.
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Affiliation(s)
- M Gärde
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - G J Matheson
- Department of Psychiatry, Columbia University, New York, USA
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - K Varnäs
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - P Svenningsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - E Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - J Lundberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - L Farde
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - M Tiger
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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3
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Deka A, Joseph E, Sharma N, Berhanu T, Kaplan J. Recurrent Serotonin Syndrome After Ketamine-assisted Electroconvulsive Therapy: A Case Report and Review of the Literature. J Psychiatr Pract 2024; 30:234-241. [PMID: 38819248 DOI: 10.1097/pra.0000000000000787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Serotonin (5-HT) syndrome (SS) consists of changes in mental status as well as autonomic and neuromuscular changes. Though not well understood, serotonergic pathways have been implicated in the mechanism of action of electroconvulsive therapy (ECT). Ketamine has been used as an induction agent in ECT and as therapy for treatment-resistant depression. Utilizing a case report and literature review, we explored the underlying serotonergic mechanisms of ECT and ketamine by which a syndrome of serotonin toxicity may be precipitated. We describe the case of a 72-year-old woman who developed recurrent SS on 2 occasions in similar circumstances involving the administration of ketamine for ECT. In our literature review, we found 5 cases in which SS was associated with ECT and 1 case linking ketamine to SS. There is emerging evidence that the mechanism of ECT involves 5-HT1A and 5-HT2A receptors, the same receptors that are involved in SS. ECT can transiently increase the permeability of the blood-brain barrier, leading to increased levels of antidepressants in the brain. ECT can, therefore, enhance 5-HT transmission and the likelihood of SS in the presence of serotonergic agents. The effect of ketamine on 5-HT transmission is mediated by the glutamate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor. Ketamine increases α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid activity in the medial prefrontal cortex, which leads to downstream 5-HT release through glutamate. Through this mechanism, ketamine can increase 5-HT transmission, leading to SS. To our knowledge, this is the only case report of recurrent SS with concurrent use of ECT and ketamine. As ketamine is frequently used in ECT and many patients undergoing ECT are on serotonergic medications, it is important to recognize ketamine as a potential risk factor for SS. There is no evidence for added efficacy when combining ECT and ketamine. Thus, one should proceed with caution when combining these treatments. The burgeoning use of ketamine in ambulatory settings makes it necessary to elucidate the risks, which we discuss further. More research is needed into the mechanisms of ketamine and ECT, specifically how the combination of these treatments influence 5-HT levels.
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Affiliation(s)
- Aniruddha Deka
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL
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4
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Singh SB, Tiwari A, Katta MR, Kafle R, Ayubcha C, Patel KH, Bhattarai Y, Werner TJ, Alavi A, Revheim ME. The utility of PET imaging in depression. Front Psychiatry 2024; 15:1322118. [PMID: 38711875 PMCID: PMC11070570 DOI: 10.3389/fpsyt.2024.1322118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
This educational review article aims to discuss growing evidence from PET studies in the diagnosis and treatment of depression. PET has been used in depression to explore the neurotransmitters involved, the alterations in neuroreceptors, non-neuroreceptor targets (e.g., microglia and astrocytes), the severity and duration of the disease, the pharmacodynamics of various antidepressants, and neurobiological mechanisms of non-pharmacological therapies like psychotherapy, electroconvulsive therapy, and deep brain stimulation therapy, by showing changes in brain metabolism and receptor and non-receptor targets. Studies have revealed alterations in neurotransmitter systems such as serotonin, dopamine, GABA, and glutamate, which are linked to the pathophysiology of depression. Overall, PET imaging has furthered the neurobiological understanding of depression. Despite these advancements, PET findings have not yet led to significant changes in evidence-based practices. Addressing the reasons behind inconsistencies in PET imaging results, conducting large sample size studies with a more standardized methodological approach, and investigating further the genetic and neurobiological aspects of depression may better leverage PET imaging in future studies.
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Affiliation(s)
- Shashi B. Singh
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Atit Tiwari
- BP Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Riju Kafle
- Rhythm Neuropsychiatry Hospital and Research Center Pvt. Ltd, Lalitpur, Nepal
| | - Cyrus Ayubcha
- Harvard Medical School, Boston, MA, United States
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Krishna H. Patel
- Icahn School of Medicine at Mount Sinai, New York City, NY, United States
| | - Yash Bhattarai
- Case Western Reserve University/The MetroHealth System, Cleveland, OH, United States
| | - Thomas J. Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Mona-Elisabeth Revheim
- The Intervention Center, Division of Technology and Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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5
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Zhou L, Duan J. The role of NMDARs in the anesthetic and antidepressant effects of ketamine. CNS Neurosci Ther 2024; 30:e14464. [PMID: 37680076 PMCID: PMC11017467 DOI: 10.1111/cns.14464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/19/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND As a phencyclidine (PCP) analog, ketamine can generate rapid-onset and substantial anesthetic effects. Contrary to traditional anesthetics, ketamine is a dissociative anesthetic and can induce loss of consciousness in patients. Recently, the subanaesthetic dose of ketamine was found to produce rapid-onset and lasting antidepressant effects. AIM However, how different concentrations of ketamine can induce diverse actions remains unclear. Furthermore, the molecular mechanisms underlying the NMDAR-mediated anesthetic and antidepressant effects of ketamine are not fully understood. METHOD In this review, we have introduced ketamine and its metabolism, summarized recent advances in the molecular mechanisms underlying NMDAR inhibition in the anesthetic and antidepressant effects of ketamine, explored the possible functions of NMDAR subunits in the effects of ketamine, and discussed the future directions of ketamine-based anesthetic and antidepressant drugs. RESULT Both the anesthetic and antidepressant effects of ketamine were thought to be mediated by N-methyl-D-aspartate receptor (NMDAR) inhibition. CONCLUSION The roles of NMDARs have been extensively studied in the anaesthetic effects of ketamine. However, the roles of NMDARs in antidepressant effects of ketamine are complicated and controversial.
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Affiliation(s)
- Liang Zhou
- Department of Pharmacology, College of Pharmaceutical SciencesSoochow UniversitySuzhouChina
| | - Jingjing Duan
- Department of Anatomy and Neurobiology, Zhongshan School of MedicineSunYat‐sen UniversityGuangzhouChina
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6
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Matsingos A, Wilhelm M, Noor L, Yildiz C, Rief W, Hofmann SG, Falkenberg I, Kircher T. Hype or hope? High placebo response in major depression treatment with ketamine and esketamine: a systematic review and meta-analysis. Front Psychiatry 2024; 15:1346697. [PMID: 38525254 PMCID: PMC10957753 DOI: 10.3389/fpsyt.2024.1346697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/13/2024] [Indexed: 03/26/2024] Open
Abstract
Background Ketamine and esketamine offer a novel approach in the pharmacological treatment of major depressive disorder (MDD). This meta-analysis aimed to investigate the placebo response in double-blind, randomized controlled studies (RCTs) on patients with MDD receiving ketamine or esketamine. Methods For this systematic review and meta-analysis Medline (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), PsycInfo and Embase databases were systematically searched for citations published up to March 17, 2023. A total number of 5017 abstracts was identified. Quality of the included trials was assessed with the Cochrane risk-of-bias tool. The meta-analysis was performed using a restricted maximum likelihood model. This study is registered with PROSPERO, number CRD42022377591. Results A total number of 14 studies and 1100 participants (593 in the medication group and 507 in the placebo group) meeting the inclusion criteria were selected. We estimated the pooled effect sizes of the overall placebo (d pl = -1.85 [CI 95%: -2.9 to -0.79] and overall treatment (dtr = -2.57; [CI 95% -3.36 to -1.78]) response. The overall placebo response accounts for up to 72% of the overall treatment response. Furthermore, we performed subgroup analysis of 8 studies for the for the 7 days post-intervention timepoint. Seven days post-intervention the placebo response (d pl 7d = -1.98 [CI 95%: -3.26 to -0.69]) accounts for 66% of the treatment response (d tr 7d = - 3.01 [CI 95%, -4.28 to -1.74]). Conclusion Ketamine and esketamine show large antidepressant effects. However, our findings suggest that the placebo response plays a significant role in the antidepressant response and should be used for the benefit of the patients in clinical practice. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022377591.
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Affiliation(s)
- Alexandros Matsingos
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Marcel Wilhelm
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Laila Noor
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Cüneyt Yildiz
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Stefan G. Hofmann
- Translational Clinical Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Irina Falkenberg
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
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7
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Zhan Q, Kong F, Shao S, Zhang B, Huang S. Pathogenesis of Depression in Alzheimer's Disease. Neurochem Res 2024; 49:548-556. [PMID: 38015411 DOI: 10.1007/s11064-023-04061-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
Depression is a prevalent occurrence among Alzheimer's disease (AD) patients, yet its underlying mechanism remains unclear. Recent investigations have revealed that several pathophysiological changes associated with Alzheimer's disease can lead to mood disorders. These alterations include irregularities in monoamine neurotransmitters, disruptions in glutamatergic synaptic transmission, neuro-inflammation, dysfunction within the hypothalamic-pituitary-adrenocortical (HPA) axis, diminished levels of brain-derived neurotrophic factor (BDNF), and hippocampal atrophy. This review consolidates research findings from pertinent fields to elucidate the mechanisms underlying depression in Alzheimer's disease, aiming to provide valuable insights for the study of its mechanisms and clinical treatment.
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Affiliation(s)
- Qingyang Zhan
- Institute of Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Fanyi Kong
- Institute of Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Shuai Shao
- Institute of Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Bo Zhang
- Institute of Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, 150040, China.
| | - Shuming Huang
- Institute of Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, 150040, China
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Abstract
Major depressive disorder (MDD) is a leading cause of suicide in the world. Monoamine-based antidepressant drugs are a primary line of treatment for this mental disorder, although the delayed response and incomplete efficacy in some patients highlight the need for improved therapeutic approaches. Over the past two decades, ketamine has shown rapid onset with sustained (up to several days) antidepressant effects in patients whose MDD has not responded to conventional antidepressant drugs. Recent preclinical studies have started to elucidate the underlying mechanisms of ketamine's antidepressant properties. Herein, we describe and compare recent clinical and preclinical findings to provide a broad perspective of the relevant mechanisms for the antidepressant action of ketamine.
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Affiliation(s)
- Ji-Woon Kim
- Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA;
- College of Pharmacy, Kyung Hee University, Seoul, Republic of Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul, Republic of Korea
| | - Kanzo Suzuki
- Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA;
- Department of Biological Science and Technology, Faculty of Advanced Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
| | - Ege T Kavalali
- Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA;
| | - Lisa M Monteggia
- Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA;
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9
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Hovda N, Gerrish W, Frizzell W, Shackelford R. A systematic review of the incidence of medical serious adverse events in sub-anesthetic ketamine treatment of psychiatric disorders. J Affect Disord 2024; 345:262-271. [PMID: 37875227 DOI: 10.1016/j.jad.2023.10.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/04/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Limited published data exists that collates serious adverse outcomes involving ketamine as a psychiatric intervention. This systematic review assesses the reported incidence of medical serious adverse events (MSAEs), including but not limited to cardiovascular events, in patients receiving sub-anesthetic doses of ketamine for psychiatric disorders to guide practitioners during treatment planning, risk-benefit analyses, and the informed consent process. METHODS Pubmed database was searched for clinical trials of sub-anesthetic ketamine for psychiatric disorders in non-pregnant adult patients. Of the 2275 articles identified, 93 met inclusion criteria, over half of which were published in 2017 or later. Only studies that reported adverse events were included, and the incidence of MSAEs was calculated. RESULTS Of the 3756 participants who received at least one sub-anesthetic dose of ketamine, four participants experienced a MSAE, resulting in an incidence of approximately 0.1 % of individuals. The four MSAEs resolved without reported sequelae. Eighty-three percent of studies reported screening for medical illness and exclusion of high-risk patients. There were no serious cardiac adverse events or deaths observed in any participants; however, most trials' study designs excluded those with high cardiovascular complication risk. LIMITATIONS Most studies were small, underpowered for detecting rare MSAEs, at potential high-risk of bias of non-report of MSAEs, and limited mostly to intranasal and intravenous routes. CONCLUSIONS Findings suggest that with basic medical screening there is a very low incidence of MSAEs including adverse cardiac or cerebrovascular events in individuals receiving sub-anesthetic ketamine for psychiatric disorders.
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Affiliation(s)
- Nicholas Hovda
- Sojourn Psychotherapy, Boise, United States of America; University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Boise VAMC, Psychiatry & Behavioral Sciences Department, United States of America.
| | - Winslow Gerrish
- University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Family Medicine Residency of Idaho - Boise, Full Circle Health, United States of America.
| | - William Frizzell
- University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Boise VAMC, Psychiatry & Behavioral Sciences Department, United States of America.
| | - Ryan Shackelford
- Sojourn Psychotherapy, Boise, United States of America; University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Family Medicine Residency of Idaho - Boise, Full Circle Health, United States of America.
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10
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Johnston JN, Kadriu B, Kraus C, Henter ID, Zarate CA. Ketamine in neuropsychiatric disorders: an update. Neuropsychopharmacology 2024; 49:23-40. [PMID: 37340091 PMCID: PMC10700638 DOI: 10.1038/s41386-023-01632-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant led to a new era in the development of neuropsychiatric therapeutics, one characterized by an antidepressant response that occurred within hours or days rather than weeks or months. Considerable clinical research supports the use of-or further research with-subanesthetic-dose ketamine and its (S)-enantiomer esketamine in multiple neuropsychiatric disorders including depression, bipolar disorder, anxiety spectrum disorders, substance use disorders, and eating disorders, as well as for the management of chronic pain. In addition, ketamine often effectively targets symptom domains associated with multiple disorders, such as anxiety, anhedonia, and suicidal ideation. This manuscript: 1) reviews the literature on the pharmacology and hypothesized mechanisms of subanesthetic-dose ketamine in clinical research; 2) describes similarities and differences in the mechanism of action and antidepressant efficacy between racemic ketamine, its (S) and (R) enantiomers, and its hydroxynorketamine (HNK) metabolite; 3) discusses the day-to-day use of ketamine in the clinical setting; 4) provides an overview of ketamine use in other psychiatric disorders and depression-related comorbidities (e.g., suicidal ideation); and 5) provides insights into the mechanisms of ketamine and therapeutic response gleaned from the study of other novel therapeutics and neuroimaging modalities.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Translational and Experimental Medicine, Neuroscience at Jazz Pharmaceuticals, San Diego, CA, USA
| | - Christoph Kraus
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Wehrman JJ, Casey C, Tanabe S, Mohanta S, Filbey W, Weber L, Banks MI, Pearce RA, Saalmann Y, Sanders RD. Subanaesthetic doses of ketamine reduce but do not eliminate predictive coding responses: implications for mechanisms of sensory disconnection. Br J Anaesth 2023; 131:705-714. [PMID: 37541951 PMCID: PMC10624770 DOI: 10.1016/j.bja.2023.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/23/2023] [Accepted: 06/03/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Sensory disconnection is a key feature of sleep and anaesthesia. We have proposed that predictive coding offers a framework for understanding the mechanisms of disconnection. Low doses of ketamine that do not induce disconnection should thus diminish predictive coding, but not abolish it. METHODS Ketamine was administered to 14 participants up to a blood concentration of 0.3 μg ml-1 Participants were played a series of tones comprising a roving oddball sequence while electroencephalography evoked response potentials were recorded. We fit a Bayesian observer model to the tone sequence, correlating neural activity with the prediction errors generated by the model using linear mixed effects models and cluster-based statistics. RESULTS Ketamine modulated prediction errors associated with the transition of one tone to the next (transitional probability), but not how often tones changed (environmental volatility), of the system. Transitional probability was reduced when blood concentrations of ketamine were increased to 0.2-0.3 μg ml-1 (96-208 ms, P=0.003); however, correlates of prediction error were still evident in the electroencephalogram (124-168 ms, P=0.003). Prediction errors related to environmental volatility were associated with electroencephalographic activity before ketamine (224-284 ms, P=0.028) and during 0.2-0.3 μg ml-1 ketamine (108-248 ms, P=0.003). At this subanaesthetic dose, ketamine did not exert a dose-dependent modulation of prediction error. CONCLUSIONS Subanaesthetic dosing of ketamine reduced correlates of predictive coding but did not eliminate them. Future studies should evaluate whether states of sensory disconnection, including anaesthetic doses of ketamine, are associated with a complete absence of predictive coding responses. CLINICAL TRIAL REGISTRATION NCT03284307.
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Affiliation(s)
- Jordan J Wehrman
- Central Clinical School, Faculty of Medicine and Health, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Cameron Casey
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean Tanabe
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Sounak Mohanta
- Department of Psychology, University of Wisconsin, Madison, WI, USA
| | - William Filbey
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Lilian Weber
- Wellcome Centre for Integrative Neuroimaging, Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Centre for Human Brain Activity (OHBA) University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Matthew I Banks
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert A Pearce
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Yuri Saalmann
- Department of Psychology, University of Wisconsin, Madison, WI, USA
| | - Robert D Sanders
- Central Clinical School, Faculty of Medicine and Health, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia.
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12
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Medeiros GC, Matheson M, Demo I, Reid MJ, Matheson S, Twose C, Smith GS, Gould TD, Zarate CA, Barrett FS, Goes FS. Brain-based correlates of antidepressant response to ketamine: a comprehensive systematic review of neuroimaging studies. Lancet Psychiatry 2023; 10:790-800. [PMID: 37625426 DOI: 10.1016/s2215-0366(23)00183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 08/27/2023]
Abstract
Ketamine is an effective antidepressant, but there is substantial variability in patient response and the precise mechanism of action is unclear. Neuroimaging can provide predictive and mechanistic insights, but findings are limited by small sample sizes. This systematic review covers neuroimaging studies investigating baseline (pre-treatment) and longitudinal (post-treatment) biomarkers of responses to ketamine. All modalities were included. We performed searches of five electronic databases (from inception to April 26, 2022). 69 studies were included (with 1751 participants). There was substantial methodological heterogeneity and no well replicated biomarker. However, we found convergence across some significant results, particularly in longitudinal biomarkers. Response to ketamine was associated with post-treatment increases in gamma power in frontoparietal regions in electrophysiological studies, post-treatment increases in functional connectivity within the prefrontal cortex, and post-treatment increases in the functional activation of the striatum. Although a well replicated neuroimaging biomarker of ketamine response was not identified, there are biomarkers that warrant further investigation.
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Affiliation(s)
- Gustavo C Medeiros
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Malcolm Matheson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isabella Demo
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Reid
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Claire Twose
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gwenn S Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA; Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, NIMH-NIH, Bethesda, MD, USA
| | - Frederick S Barrett
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neuroscience, Department of Psychological and Brain Sciences, and Center for Psychedelic and Consciousness Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fernando S Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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13
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Wydra K, Witek K, Suder A, Filip M. Esketamine Inhibits Cocaine-Seeking Behaviour Subsequent to Various Abstinence Conditions in Rats. Biomolecules 2023; 13:1411. [PMID: 37759811 PMCID: PMC10527312 DOI: 10.3390/biom13091411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Cocaine use disorder (CUD) is a relapsing brain disease caused by a chronic drug intake that involves neural mechanisms and psychological processes, including depression. Preclinical and clinical studies have demonstrated the promise of pharmacological drugs in controlling the reinstatement of cocaine by targeting the N-methyl-D-aspartate (NMDA) receptor. Recent evidence has revealed that esketamine, a (S) enantiomer of ketamine, shows a high affinity to NMDA receptors and has been used in clinical trials to treat moderate-to-severe depression. METHODS In the present paper, we investigated the effects of esketamine in regulating cocaine-seeking behaviour induced through the use of cocaine (10 mg/kg) or the cocaine-associated conditioned cue after a short (10 days)-lasting period of drug abstinence with extinction training, home cage or enrichment environment conditions in male rats. Furthermore, we investigated the acute effects of esketamine on locomotor activity in drug-naïve animals. RESULTS Esketamine (2.5-10 mg/kg) administered peripherally attenuated the reinstatement induced with cocaine priming or the drug-associated conditioned cue after different conditions of abstinence. CONCLUSIONS These results seem to support esketamine as a candidate for the pharmacological management of cocaine-seeking and relapse prevention; however, further preclinical and clinical research is needed to better clarify esketamine's actions in CUD.
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Affiliation(s)
- Karolina Wydra
- Department of Drug Addiction Pharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smętna Street, PL-31-343 Kraków, Poland; (K.W.); (A.S.)
| | | | | | - Małgorzata Filip
- Department of Drug Addiction Pharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smętna Street, PL-31-343 Kraków, Poland; (K.W.); (A.S.)
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14
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Correia AS, Marques L, Cardoso A, Vale N. Exploring the Role of Drug Repurposing in Bridging the Hypoxia-Depression Connection. MEMBRANES 2023; 13:800. [PMID: 37755222 PMCID: PMC10537732 DOI: 10.3390/membranes13090800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
High levels of oxidative stress are implicated in hypoxia, a physiological response to low levels of oxygen. Evidence supports a connection between this response and depression. Previous studies indicate that tryptophan hydroxylase can be negatively affected in hypoxia, impairing serotonin synthesis and downstream pathways. Some studies also hypothesize that increasing hypoxia-inducible factor-1 (HIF-1) levels may be a new therapeutic modality for depression. Hence, this study delved into the influence of hypoxia on the cellular response to drugs designed to act in depression. By the induction of hypoxia in SH-SY5Y cells through a hypoxia incubator chamber or Cobalt Chloride treatment, the effect of Mirtazapine, an antidepressant, and other drugs that interact with serotonin receptors (TCB-2, Dextromethorphan, Ketamine, Quetiapine, Scopolamine, Celecoxib, and Lamotrigine) on SH-SY5Y cellular viability and morphology was explored. The selection of drugs was initially conducted by literature search, focusing on compounds with established potential for employment in depression therapy. Subsequently, we employed in silico approaches to forecast their ability to traverse the blood-brain barrier (BBB). This step was particularly pertinent as we aimed to assess their viability for inducing potential antidepressant effects. The effect of these drugs in hypoxia under the inhibition of HIF-1 by Echinomycin was also tested. Our results revealed that all the potential repurposed drugs promoted cell viability, especially when hypoxia was chemically induced. When combined with Echinomycin, all drugs decreased cellular viability, possibly by the inability to interact with HIF-1.
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Affiliation(s)
- Ana Salomé Correia
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Rua de Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Lara Marques
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
| | - Armando Cardoso
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- NeuroGen Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
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15
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Marzoughi S, Ripsman D, Ong M. Therapeutic effects of 7- to 14-day subanesthetic ketamine infusions for chronic pain on standardized psychiatric measures. Pain Manag 2023; 13:529-538. [PMID: 37656045 DOI: 10.2217/pmt-2023-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Background: We have previously shown that subanesthetic ketamine infusions effectively reduce refractory pain. However, the effects of ketamine infusions on comorbid conditions of depression and anxiety have not been explored in this patient population. Methods: We investigated the effects of ketamine on mood and anxiety in patients with refractory chronic pain treated with 7-14 days of subanesthetic continuous intravenous ketamine infusions, using well-validated clinical scales. Results: There was a significant 52% reduction in pain severity and 33% reduction in pain interference scores following ketamine treatment. Ketamine treatment also reduced scores on the depression module of the Patient Health Questionnaire (PHQ-9) by 28% and scores on the Generalised Anxiety and Depression Assessment (GAD-7) by 36%. Conclusion: Multiday subanesthetic ketamine infusions effectively reduce pain, anxiety and depression in patients with complex chronic pain.
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Affiliation(s)
- Sina Marzoughi
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, V6T 2B5, Canada
| | - David Ripsman
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, V6T 2B5, Canada
| | - May Ong
- Department of Medicine, Division of Internal Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
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16
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Nikolin S, Rodgers A, Schwaab A, Bahji A, Zarate C, Vazquez G, Loo C. Ketamine for the treatment of major depression: a systematic review and meta-analysis. EClinicalMedicine 2023; 62:102127. [PMID: 37593223 PMCID: PMC10430179 DOI: 10.1016/j.eclinm.2023.102127] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background Intranasal esketamine has received regulatory approvals for the treatment of depression. Recently a large trial of repeated dose racemic ketamine also demonstrated efficacy in severe depression. However, uncertainties remain regarding comparative efficacy, dosage, and the time course of response. Methods In this systematic review and meta-analysis, we searched Embase, Medline, Pubmed, PsycINFO, and CENTRAL up to April 13, 2023, for randomised controlled trials (RCTs) investigating ketamine for depression. Two investigators independently assessed study eligibility and risk of bias and extracted the data on depression severity scores, response and remission rates, and all-cause dropouts. Multivariable mixed-effects meta-regressions incorporated drug formulation (racemic (Rac) or esketamine (Esket)) and dose (Low or High) as covariates. Treatment effects were assessed: immediately following the first dose, during further repeated dosing, and follow-up after the final dose of a treatment course. This study is registered with PROSPERO (CRD42021221157). Findings The systematic review identified 687 articles, of which 49 RCTs were eligible for analysis, comprising 3299 participants. Standardised mean differences (95% confidence intervals) immediately following the first/single treatment were moderate-high for all conditions (Rac-High: -0.73, -0.91 to -0.56; Esket-High: -0.48, -0.75 to -0.20; Rac-Low: -0.33, -0.54 to -0.12; Esket-Low: -0.55, -0.87 to -0.24). Ongoing effects during repeated dosing were significantly greater than the control for Rac-High (-0.61; -1.02 to -0.20) and Rac-Low (-0.55, -1.09 to -0.00), but not Esket-Low (-0.15, -0.49 to 0.19) or Esket-High (-0.22, -0.54 to 0.10). At follow-up effects remained significant for racemic ketamine (-0.65; -1.23 to -0.07) but not esketamine (-0.33; -0.96 to 0.31). All-cause dropout was similar between experiment and control conditions for both formulations combined (Odds Ratio = 1.18, 0.85-1.64). Overall heterogeneity varied from 5.7% to 87.6. Interpretation Our findings suggested that effect sizes for depression severity, as well as response and remission rates, were numerically greater for racemic ketamine than esketamine. Higher doses were more effective than low doses. Differences were evident in initial effects, ongoing treatment, and lasting effects after the final dose. Funding None.
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Affiliation(s)
- Stevan Nikolin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Anees Bahji
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carlos Zarate
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1282, Building 10CRC, Room 7-5342, Bethesda, MD 20892, USA
| | - Gustavo Vazquez
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1282, Building 10CRC, Room 7-5342, Bethesda, MD 20892, USA
| | - Colleen Loo
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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17
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Yang KC, Chou YH. Molecular imaging findings for treatment resistant depression. PROGRESS IN BRAIN RESEARCH 2023; 278:79-116. [PMID: 37414495 DOI: 10.1016/bs.pbr.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Approximately 40% of patients with major depressive disorder (MDD) had limited response to conventional antidepressant treatments, resulting in treatment-resistant depression (TRD), a debilitating subtype that yielded a significant disease burden worldwide. Molecular imaging techniques, such as positron emission tomography (PET) and single photon emission tomography (SPECT), can measure targeted macromolecules or biological processes in vivo. These imaging tools provide a unique possibility to explore the pathophysiology and treatment mechanisms underlying TRD. This work reviewed and summarized prior PET and SPECT studies to examine the neurobiology and treatment-induced changes of TRD. A total of 51 articles were included with supplementary information from studies for MDD and healthy controls (HC). We found that there were altered regional blood flow or metabolic activity in several brain regions, such as the anterior cingulate cortex, prefrontal cortex, insula, hippocampus, amygdala, parahippocampus, and striatum. These regions have been suggested to engage in the pathophysiology or treatment resistance of depression. There was also limited data to demonstrate the changes in the markers of serotonin, dopamine, amyloid, and microglia over some regions in TRD. Moreover, several observed abnormal imaging indices were linked to treatment outcomes, supporting their specificity and clinical relevance. To address the limitations of the included studies, we proposed that future studies needed longitudinal designs, multimodal approaches, and radioligands targeting specific neural substrates for TRD to evaluate their baseline and treatment-related alterations in TRD. Adequate data sharing and reproducible data analysis can facilitate advances in this field.
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Affiliation(s)
- Kai-Chun Yang
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Yuan-Hwa Chou
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Center for Quality Management, Taipei Veterans General Hospital, Taipei, Taiwan
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18
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Gan SL, Long YQ, Wang QY, Feng CD, Lai CX, Liu CT, Ding YY, Liu H, Peng K, Ji FH. Effect of esketamine on postoperative depressive symptoms in patients undergoing thoracoscopic lung cancer surgery: A randomized controlled trial. Front Psychiatry 2023; 14:1128406. [PMID: 37009103 PMCID: PMC10050377 DOI: 10.3389/fpsyt.2023.1128406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/23/2023] [Indexed: 03/17/2023] Open
Abstract
BackgroundDepressive symptoms are common among patients with lung cancer. We aimed to assess the effects of esketamine on postoperative depressive symptoms after thoracoscopic lung cancer surgery.MethodsIn this randomized, double-blind, placebo-controlled trial, 156 patients undergoing thoracoscopic lung cancer surgery were randomly allocated in a 1:1 ratio to receive intravenous esketamine (intraoperatively and in patient-controlled analgesia until 48 h postoperatively) or normal saline placebo. The primary outcome was the proportion of patients with depressive symptoms at 1 month postoperatively, assessed using the Beck Depression Inventory-II (BDI-II). Secondary outcomes included depressive symptoms at 48 h postoperatively, hospital discharge and 3 months postoperatively, BDI-II scores, anxious symptoms, Beck Anxiety Inventory scores, Quality of Recovery-15 (QoR-15) scores, and 1- and 3-month mortality.Main resultsA total of 151 patients (75 in the esketamine group and 76 in the normal saline group) completed the 1-month follow-up. The esketamine group had a significantly lower incidence of depressive symptoms at 1 month compared to the normal saline group (1.3% vs. 11.8%; risk difference = −10.5, 95%CI = −19.6% to −0.49%; p = 0.018). After excluding patients without lung cancer diagnosis, the incidence of depressive symptoms was also lower in the esketamine group (1.4% vs. 12.2%; risk difference = −10.8, 95%CI = −20.2% to −0.52%; p = 0.018). The secondary outcomes were similar between groups, except that the esketamine group had higher QoR-15 scores at 1 month postoperatively (median difference = 2; 95%CI = 0 to 5; p = 0.048). The independent risk factors for depressive symptoms were hypertension (odds ratio = 6.75, 95%CI = 1.13 to 40.31; p = 0.036) and preoperative anxious symptoms (odds ratio = 23.83, 95%CI = 3.41 to 166.33; p = 0.001).ConclusionPerioperative administration of esketamine reduced the incidence of depressive symptoms at 1 month after thoracoscopic lung cancer surgery. History of hypertension and preoperative anxious symptoms were independent risk factors for depressive symptoms.Clinical trial registration: Chinese Clinical Trial Registry http://www.chictr.org.cn, Identifier (ChiCTR2100046194).
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Affiliation(s)
- Shu-lin Gan
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Yu-qin Long
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Qin-yun Wang
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Chang-dong Feng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Chen-xu Lai
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Chun-tong Liu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Yun-ying Ding
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
- *Correspondence: Ke Peng,
| | - Fu-hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
- Fu-hai Ji,
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19
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Johnston JN, Kadriu B, Allen J, Gilbert JR, Henter ID, Zarate CA. Ketamine and serotonergic psychedelics: An update on the mechanisms and biosignatures underlying rapid-acting antidepressant treatment. Neuropharmacology 2023; 226:109422. [PMID: 36646310 PMCID: PMC9983360 DOI: 10.1016/j.neuropharm.2023.109422] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant spurred significant research to understand its underlying mechanisms of action and to identify other novel compounds that may act similarly. Serotonergic psychedelics (SPs) have shown initial promise in treating depression, though the challenge of conducting randomized controlled trials with SPs and the necessity of long-term clinical observation are important limitations. This review summarizes the similarities and differences between the psychoactive effects associated with both ketamine and SPs and the mechanisms of action of these compounds, with a focus on the monoaminergic, glutamatergic, gamma-aminobutyric acid (GABA)-ergic, opioid, and inflammatory systems. Both molecular and neuroimaging aspects are considered. While their main mechanisms of action differ-SPs increase serotonergic signaling while ketamine is a glutamatergic modulator-evidence suggests that the downstream mechanisms of action of both ketamine and SPs include mechanistic target of rapamycin complex 1 (mTORC1) signaling and downstream GABAA receptor activity. The similarities in downstream mechanisms may explain why ketamine, and potentially SPs, exert rapid-acting antidepressant effects. However, research on SPs is still in its infancy compared to the ongoing research that has been conducted with ketamine. For both therapeutics, issues with regulation and proper controls should be addressed before more widespread implementation. This article is part of the Special Issue on "Ketamine and its Metabolites".
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Josh Allen
- The Alfred Centre, Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.
| | - Jessica R Gilbert
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
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20
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Lopresti BJ, Royse SK, Mathis CA, Tollefson SA, Narendran R. Beyond monoamines: I. Novel targets and radiotracers for Positron emission tomography imaging in psychiatric disorders. J Neurochem 2023; 164:364-400. [PMID: 35536762 DOI: 10.1111/jnc.15615] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
With the emergence of positron emission tomography (PET) in the late 1970s, psychiatry had access to a tool capable of non-invasive assessment of human brain function. Early applications in psychiatry focused on identifying characteristic brain blood flow and metabolic derangements using radiotracers such as [15 O]H2 O and [18 F]FDG. Despite the success of these techniques, it became apparent that more specific probes were needed to understand the neurochemical bases of psychiatric disorders. The first neurochemical PET imaging probes targeted sites of action of neuroleptic (dopamine D2 receptors) and psychoactive (serotonin receptors) drugs. Based on the centrality of monoamine dysfunction in psychiatric disorders and the measured success of monoamine-enhancing drugs in treating them, the next 30 years witnessed the development of an armamentarium of PET radiopharmaceuticals and imaging methodologies for studying monoamines. Continued development of monoamine-enhancing drugs over this time however was less successful, realizing only modest gains in efficacy and tolerability. As patent protection for many widely prescribed and profitable psychiatric drugs lapsed, drug development pipelines shifted away from monoamines in search of novel targets with the promises of improved efficacy, or abandoned altogether. Over this period, PET radiopharmaceutical development activities closely paralleled drug development priorities resulting in the development of new PET imaging agents for non-monoamine targets. Part one of this review will briefly survey novel PET imaging targets with relevance to the field of psychiatry, which include the metabotropic glutamate receptor type 5 (mGluR5), purinergic P2 X7 receptor, type 1 cannabinoid receptor (CB1 ), phosphodiesterase 10A (PDE10A), and describe radiotracers developed for these and other targets that have matured to human subject investigations. Current limitations of the targets and techniques will also be discussed.
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Affiliation(s)
- Brian J Lopresti
- Departments of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah K Royse
- Departments of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chester A Mathis
- Departments of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Savannah A Tollefson
- Departments of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rajesh Narendran
- Departments of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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21
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Wehrman JJ, Chung CC, Sanders R. Anaesthetics and time perception: A review. Q J Exp Psychol (Hove) 2023:17470218221144614. [PMID: 36453756 DOI: 10.1177/17470218221144614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Consciousness requires subjective experience in the "now." Establishing "now," however, necessitates temporal processing. In the current article, we review one method of altering consciousness, anaesthetic drug administration, and its effects on perceived duration. We searched PubMed, PsycInfo, and ScienceDirect databases, and article reference sections, for combinations of anaesthetic drugs and time perception tasks, finding a total of 36 articles which met our inclusion criteria. We categorised these articles with regard to whether they altered the felt passage of time, short or long interval timing, or were motor timing tasks. We found that various drugs alter the perceived passage of time; ketamine makes time subjectively slow down while GABAergic drugs make time subjectively speed up. At a short interval there is little established evidence of a shift in time perception, though temporal estimates appear more variable. Similarly, when asked to use time to optimise responses (i.e., in motor timing tasks), various anaesthetic agents make timing more variable. Longer durations are estimated as lasting longer than their objective duration, though there is some variation across articles in this regard. We conclude by proposing further experiments to examine time perception under altered states of consciousness and ask whether it is possible to perceive the passage of time of events which do not necessarily reach the level of conscious perception. The variety of methods used raises the need for more systematic investigations of time perception under anaesthesia. We encourage future investigations into the overlap of consciousness and time perception to advance both fields.
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Affiliation(s)
| | - Clara C Chung
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
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22
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ERK/mTOR signaling may underlying the antidepressant actions of rapastinel in mice. Transl Psychiatry 2022; 12:522. [PMID: 36550125 PMCID: PMC9780240 DOI: 10.1038/s41398-022-02290-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/10/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Rapastinel as the allosteric modulator of N-methyl-D-aspartate receptor (NMDAR) produces rapid antidepressant-like effects dependent on brain-derived neurotrophic factor (BDNF) and VGF (nonacryonimic) release. Herein, we further explore the molecular mechanisms of the antidepressant effects of repeated administration with rapastinel in mice. Our results showed that continuous 3-day rapastinel (5 and 10 mg/kg, i.v.) produced antidepressant-like actions dependent on the increase in extracellular regulated protein kinase (ERK)/mammalian target of rapamycin (mTOR) signaling and downstream substrates p70S6 kinase (p70S6k) and the eukaryotic initiation factor 4E-binding protein 1 (4E-BP1), which may induce the expression of VGF and BDNF in the hippocampus and prefrontal cortex of mice. Furthermore, compared with a single treatment, our data indicated that 3-day repeated rapastinel treatment produced antidepressant-like actions accompanied by potentiation of ERK/mTOR/VGF/BDNF/tropomyosin-related kinase receptor B (TrkB) signaling. Based on previous and our supplementary data that showed the pivotal role of on α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) in the rapid release of VGF and BDNF and activation of TrkB by a single dose of rapastinel, we postulate that the antidepressant-like effects of single or repeated administration of rapastinel may result in the rapid release of VGF and BDNF or ERK/mTOR signaling pathway-mediated VGF/BDNF/TrkB autoregulatory feedback loop respectively. Our current work adds new knowledge to the molecular mechanisms that underlie the antidepressant-like actions of rapastinel in mice.
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Meiering MS, Weigner D, Gärtner M, Schäfer T, Grimm S. Does route of administration affect antidepressant efficacy of ketamine? A meta-analysis of double-blind randomized controlled trials comparing intravenous and intranasal administration. J Psychiatr Res 2022; 156:639-646. [PMID: 36375231 DOI: 10.1016/j.jpsychires.2022.10.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/24/2022] [Accepted: 10/28/2022] [Indexed: 11/11/2022]
Abstract
Intranasal (IN) and intravenous (IV) applications of ketamine have been proven effective for the treatment of depression, but direct comparative trials or meta-analyses on whether both differ in their antidepressant efficacy are lacking. We aimed to meta-analytically compare the short-term efficacy of a single dose of IV and IN ketamine in adult patients with major depressive disorder (MDD) and included double-blind, randomized controlled trials published until February 2022 in our analyses. The main outcome was a response 24 h after the administration of a single dose of ketamine. A random-effects model was used to calculate odds ratios and confidence intervals. Differences in efficacy between intranasal and intravenous application were statistically assessed by calculating a z-test. A total of eleven studies, comprising 1340 patients, were included. Results showed, that while both IN and IV ketamine were associated with increased response rates, efficacy did not differ significantly between these routes. Heterogeneity and funnel plot asymmetry was found in the intranasal sample only. The results of the present meta-analysis corroborate the efficacy of both IN and IV application of ketamine for the treatment of MDD but suggest no difference between both routes of administration. Accordingly, future large-scale trials as well as direct comparative trials are needed to further investigate this question.
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Affiliation(s)
- Marvin S Meiering
- Department of Natural Sciences, MSB Medical School Berlin, Rüdesheimer Straße 50, 14197, Berlin, Germany; Department of Education and Psychology, Freie Universität Berlin, Habelschwerdter Allee 45, 14195, Berlin, Germany.
| | - David Weigner
- Department of Natural Sciences, MSB Medical School Berlin, Rüdesheimer Straße 50, 14197, Berlin, Germany; Department of Education and Psychology, Freie Universität Berlin, Habelschwerdter Allee 45, 14195, Berlin, Germany
| | - Matti Gärtner
- Department of Natural Sciences, MSB Medical School Berlin, Rüdesheimer Straße 50, 14197, Berlin, Germany; Department of Psychiatry and Psychotherapy, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Thomas Schäfer
- Department of Natural Sciences, MSB Medical School Berlin, Rüdesheimer Straße 50, 14197, Berlin, Germany
| | - Simone Grimm
- Department of Natural Sciences, MSB Medical School Berlin, Rüdesheimer Straße 50, 14197, Berlin, Germany; Department of Psychiatry and Psychotherapy, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, CH-8032, Zurich, Switzerland
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24
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International pooled patient-level meta-analysis of ketamine infusion for depression: In search of clinical moderators. Mol Psychiatry 2022; 27:5096-5112. [PMID: 36071111 PMCID: PMC9763119 DOI: 10.1038/s41380-022-01757-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023]
Abstract
Depression is disabling and highly prevalent. Intravenous (IV) ketamine displays rapid-onset antidepressant properties, but little is known regarding which patients are most likely to benefit, limiting personalized prescriptions. We identified randomized controlled trials of IV ketamine that recruited individuals with a relevant psychiatric diagnosis (e.g., unipolar or bipolar depression; post-traumatic stress disorder), included one or more control arms, did not provide any other study-administered treatment in conjunction with ketamine (although clinically prescribed concurrent treatments were allowable), and assessed outcome using either the Montgomery-Åsberg Depression Rating Scale or the Hamilton Rating Scale for Depression (HRSD-17). Individual patient-level data for at least one outcome was obtained from 17 of 25 eligible trials [pooled n = 809]. Rates of participant-level data availability across 33 moderators that were solicited from these 17 studies ranged from 10.8% to 100% (median = 55.6%). After data harmonization, moderators available in at least 40% of the dataset were tested sequentially, as well as with a data-driven, combined moderator approach. Robust main effects of ketamine on acute [~24-hours; β*(95% CI) = 0.58 (0.44, 0.72); p < 0.0001] and post-acute [~7 days; β*(95% CI) = 0.38 (0.23, 0.54); p < 0.0001] depression severity were observed. Two study-level moderators emerged as significant: ketamine effects (relative to placebo) were larger in studies that required a higher degree of previous treatment resistance to federal regulatory agency-approved antidepressant medications (≥2 failed trials) for study entry; and in studies that used a crossover design. A comprehensive data-driven search for combined moderators identified statistically significant, but modest and clinically uninformative, effects (effect size r ≤ 0.29, a small-medium effect). Ketamine robustly reduces depressive symptoms in a heterogeneous range of patients, with benefit relative to placebo even greater in patients more resistant to prior medications. In this largest effort to date to apply precision medicine approaches to ketamine treatment, no clinical or demographic patient-level features were detected that could be used to guide ketamine treatment decisions.Review Registration: PROSPERO Identifier: CRD42021235630.
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Zavaliangos-Petropulu A, Al-Sharif NB, Taraku B, Leaver AM, Sahib AK, Espinoza RT, Narr KL. Neuroimaging-Derived Biomarkers of the Antidepressant Effects of Ketamine. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2022; 8:361-386. [PMID: 36775711 DOI: 10.1016/j.bpsc.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
Major depressive disorder is a highly prevalent psychiatric disorder. Despite an extensive range of treatment options, about a third of patients still struggle to respond to available therapies. In the last 20 years, ketamine has gained considerable attention in the psychiatric field as a promising treatment of depression, particularly in patients who are treatment resistant or at high risk for suicide. At a subanesthetic dose, ketamine produces a rapid and pronounced reduction in depressive symptoms and suicidal ideation, and serial treatment appears to produce a greater and more sustained therapeutic response. However, the mechanism driving ketamine's antidepressant effects is not yet well understood. Biomarker discovery may advance knowledge of ketamine's antidepressant action, which could in turn translate to more personalized and effective treatment strategies. At the brain systems level, neuroimaging can be used to identify functional pathways and networks contributing to ketamine's therapeutic effects by studying how it alters brain structure, function, connectivity, and metabolism. In this review, we summarize and appraise recent work in this area, including 51 articles that use resting-state and task-based functional magnetic resonance imaging, arterial spin labeling, positron emission tomography, structural magnetic resonance imaging, diffusion magnetic resonance imaging, or magnetic resonance spectroscopy to study brain and clinical changes 24 hours or longer after ketamine treatment in populations with unipolar or bipolar depression. Though individual studies have included relatively small samples, used different methodological approaches, and reported disparate regional findings, converging evidence supports that ketamine leads to neuroplasticity in structural and functional brain networks that contribute to or are relevant to its antidepressant effects.
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Affiliation(s)
- Artemis Zavaliangos-Petropulu
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| | - Noor B Al-Sharif
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Brandon Taraku
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Amber M Leaver
- Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ashish K Sahib
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Randall T Espinoza
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Katherine L Narr
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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26
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Targeting NMDA Receptors in Emotional Disorders: Their Role in Neuroprotection. Brain Sci 2022; 12:brainsci12101329. [PMID: 36291261 PMCID: PMC9599159 DOI: 10.3390/brainsci12101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 12/03/2022] Open
Abstract
Excitatory glutamatergic neurotransmission mediated through N-methyl-D-Aspartate (NMDA) receptors (NMDARs) is essential for synaptic plasticity and neuronal survival. While under pathological states, abnormal NMDAR activation is involved in the occurrence and development of psychiatric disorders, which suggests a directional modulation of NMDAR activity that contributes to the remission and treatment of psychiatric disorders. This review thus focuses on the involvement of NMDARs in the pathophysiological processes of psychiatric mood disorders and analyzes the neuroprotective mechanisms of NMDARs. Firstly, we introduce NMDAR-mediated neural signaling pathways in brain function and mood regulation as well as the pathophysiological mechanisms of NMDARs in emotion-related mental disorders such as anxiety and depression. Then, we provide an in-depth summary of current NMDAR modulators that have the potential to be developed into clinical drugs and their pharmacological research achievements in the treatment of anxiety and depression. Based on these findings, drug-targeting for NMDARs might open up novel territory for the development of therapeutic agents for refractory anxiety and depression.
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27
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In vivo correlation of serotonin transporter and 1B receptor availability in the human brain: a PET study. Neuropsychopharmacology 2022; 47:1863-1868. [PMID: 35821068 PMCID: PMC9372190 DOI: 10.1038/s41386-022-01369-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022]
Abstract
Synaptic serotonin levels in the brain are regulated by active transport into the bouton by the serotonin transporter, and by autoreceptors, such as the inhibitory serotonin (5-HT) 1B receptor which, when activated, decreases serotonin release. Animal studies have shown a regulatory link between the two proteins. Evidence of such coupling could translate to an untapped therapeutic potential in augmenting the effect of selective serotonin reuptake inhibitors through pharmacological modulation of 5-HT1B receptors. Here we will for the first time in vivo examine the relationship between 5-HT1B receptors and serotonin transporters in the living human brain. Seventeen healthy individuals were examined with PET twice, using the radioligands [11C]AZ10419369 and [11C]MADAM for quantification of the 5-HT1B receptor and the 5-HT transporter, respectively. The binding potential was calculated for a set of brain regions, and the correlations between the binding estimates of the two radioligands were studied. [11C]AZ10419369 and [11C]MADAM binding was positively correlated in all examined brain regions. In most cortical regions the correlation was strong, e.g., frontal cortex, r(15) = 0.64, p = 0.01 and parietal cortex, r(15) = 0.8, p = 0.0002 while in most subcortical regions, negligible correlations was observed. Though the correlation estimates in cortex should be interpreted with caution due to poor signal to noise ratio of [11C]MADAM binding in these regions, it suggests a link between two key proteins involved in the regulation of synaptic serotonin levels. Our results indicate a need for further studies to address the functional importance of 5-HT1B receptors in treatment with drugs that inhibit serotonin reuptake.
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28
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Patterns of activity correlate with symptom severity in major depressive disorder patients. Transl Psychiatry 2022; 12:226. [PMID: 35654778 PMCID: PMC9163191 DOI: 10.1038/s41398-022-01989-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/19/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objective measures, such as activity monitoring, can potentially complement clinical assessment for psychiatric patients. Alterations in rest-activity patterns are commonly encountered in patients with major depressive disorder. The aim of this study was to investigate whether features of activity patterns correlate with severity of depression symptoms (evaluated by Montgomery-Åsberg Rating Scale (MADRS) for depression). We used actigraphy recordings collected during ongoing major depressive episodes from patients not undergoing any antidepressant treatment. The recordings were acquired from two independent studies using different actigraphy systems. Data was quality-controlled and pre-processed for feature extraction following uniform procedures. We trained multiple regression models to predict MADRS score from features of activity patterns using brute-force and semi-supervised machine learning algorithms. The models were filtered based on the precision and the accuracy of fitting on training dataset before undergoing external validation on an independent dataset. The features enriched in the models surviving external validation point to high depressive symptom severity being associated with less complex activity patterns and stronger coupling to external circadian entrainers. Our results bring proof-of-concept evidence that activity patterns correlate with severity of depressive symptoms and suggest that actigraphy recordings may be a useful tool for individual evaluation of patients with major depressive disorder.
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29
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Gao F, Yang S, Wang J, Zhu G. cAMP-PKA cascade: An outdated topic for depression? Biomed Pharmacother 2022; 150:113030. [PMID: 35486973 DOI: 10.1016/j.biopha.2022.113030] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/02/2022] Open
Abstract
Depression is a common neuropsychiatric disorder characterized by persistent depressed mood and causes serious socioeconomic burden worldwide. Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, deficiency of monoamine transmitters, neuroinflammation and abnormalities of the gut flora are strongly associated with the onset of depression. The cyclic AMP (cAMP)/protein kinase A (PKA) cascade, a major cross-species cellular signaling pathway, is supposed as important player and regulator of depression onset by controlling synaptic plasticity, cytokinesis, transcriptional regulation and HPA axis. In the central nervous system, the cAMP-PKA cascade can dynamically shape neural circuits by enhancing synaptic plasticity, and affect K+ channels by phosphorylating Kir4.1, thereby regulating neuronal excitation. The reduction of cAMP-PKA cascade affects neuronal excitation as well as synaptic plasticity, ultimately leading to pathological outcome of depression, while activation of cAMP-PKA cascade would provide a rapid antidepressant effect. In this review, we proposed to reconsider the function of cAMP-PKA cascade, especially in the rapid antidepressant effect. Local activation or indirect activation of PKA through adjusting anchor proteins would provide new idea for acute treatment of depression.
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Affiliation(s)
- Feng Gao
- Key Laboratory of Xin'an Medicine, the Ministry of Education and Key Laboratory of Molecular Biology (Brain diseases), Anhui University of Chinese Medicine, Hefei 230012, China
| | - Shaojie Yang
- Key Laboratory of Xin'an Medicine, the Ministry of Education and Key Laboratory of Molecular Biology (Brain diseases), Anhui University of Chinese Medicine, Hefei 230012, China
| | - Juan Wang
- Key Laboratory of Xin'an Medicine, the Ministry of Education and Key Laboratory of Molecular Biology (Brain diseases), Anhui University of Chinese Medicine, Hefei 230012, China
| | - Guoqi Zhu
- Key Laboratory of Xin'an Medicine, the Ministry of Education and Key Laboratory of Molecular Biology (Brain diseases), Anhui University of Chinese Medicine, Hefei 230012, China.
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30
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Veldman ER, Varrone A, Varnäs K, Svedberg MM, Cselényi Z, Tiger M, Gulyás B, Halldin C, Lundberg J. Serotonin 1B receptor density mapping of the human brainstem using positron emission tomography and autoradiography. J Cereb Blood Flow Metab 2022; 42:630-641. [PMID: 34644198 PMCID: PMC8943614 DOI: 10.1177/0271678x211049185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The serotonin 1B (5-HT1B) receptor has lately received considerable interest in relation to psychiatric and neurological diseases, partly due to findings based on quantification using Positron Emission Tomography (PET). Although the brainstem is an important structure in this regard, PET radioligand binding quantification in brainstem areas often shows poor reliability. This study aims to improve PET quantification of 5-HT1B receptor binding in the brainstem.Volumes of interest (VOIs) were selected based on a 3D [3H]AZ10419369 Autoradiography brainstem model, which visualized 5-HT1B receptor distribution in high resolution. Two previously developed VOI delineation methods were tested and compared to a conventional manual method. For a method based on template data, a [11C]AZ10419369 PET template was created by averaging parametric binding potential (BPND) images of 52 healthy subjects. VOIs were generated based on a predefined volume and BPND thresholding and subsequently applied to test-retest [11C]AZ10419369 parametric BPND images of 8 healthy subjects. For a method based on individual subject data, VOIs were generated directly on each individual parametric image.Both methods showed improved reliability compared to a conventional manual VOI. The VOIs created with [11C]AZ10419369 template data can be automatically applied to future PET studies measuring 5-HT1B receptor binding in the brainstem.
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Affiliation(s)
- Emma R Veldman
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
| | - Andrea Varrone
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
| | - Katarina Varnäs
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
| | - Marie M Svedberg
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.,Department of Health Promotion Science, Sophiahemmet University, Stockholm, Sweden
| | - Zsolt Cselényi
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.,PET Science Centre, Personalized Medicine and Biosamples, R&D, AstraZeneca, Stockholm, Sweden
| | - Mikael Tiger
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
| | - Balázs Gulyás
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Christer Halldin
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
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31
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Subramanian S, Haroutounian S, Palanca BJA, Lenze EJ. Ketamine as a therapeutic agent for depression and pain: mechanisms and evidence. J Neurol Sci 2022; 434:120152. [PMID: 35092901 DOI: 10.1016/j.jns.2022.120152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 12/14/2022]
Abstract
Ketamine is an anesthetic drug which is now used to treat chronic pain conditions and psychiatric disorders, especially depression. It is an N-methyl-D-aspartate (NMDA) receptor antagonist with additional effects on α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, opioid receptors, and monoaminergic receptors. This article focuses on ketamine's role in treating depression and pain, two commonly comorbid challenging conditions with potentially shared neurobiologic circuitry. Many clinical trials have utilized intravenous or intranasal ketamine for treating depression and pain. Intravenous ketamine is more bioavailable than intranasal ketamine and both are effective for acute depressive episodes. Intravenous ketamine is advantageous for post-operative analgesia and is associated with a reduction in total opioid requirements. Few studies have treated chronic pain or concurrent depression and pain with ketamine. Larger, randomized control trials are needed to examine the safety and efficacy of intravenous vs. intranasal ketamine, ideal target populations, and optimal dosing to treat both depression and pain.
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Affiliation(s)
- Subha Subramanian
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ben Julian A Palanca
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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32
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Hess EM, Riggs LM, Michaelides M, Gould TD. Mechanisms of ketamine and its metabolites as antidepressants. Biochem Pharmacol 2022; 197:114892. [PMID: 34968492 PMCID: PMC8883502 DOI: 10.1016/j.bcp.2021.114892] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 02/06/2023]
Abstract
Treating major depression is a medical need that remains unmet by monoaminergic therapeutic strategies that commonly fail to achieve symptom remission. A breakthrough in the treatment of depression was the discovery that the anesthetic (R,S)-ketamine (ketamine), when administered at sub-anesthetic doses, elicits rapid (sometimes within hours) antidepressant effects in humans that are otherwise resistant to monoaminergic-acting therapies. While this finding was revolutionary and led to the FDA approval of (S)-ketamine (esketamine) for use in adults with treatment-resistant depression and suicidal ideation, the mechanisms underlying how ketamine or esketamine elicit their effects are still under active investigation. An emerging view is that metabolism of ketamine may be a crucial step in its mechanism of action, as several metabolites of ketamine have neuroactive effects of their own and may be leveraged as therapeutics. For example, (2R,6R)-hydroxynorketamine (HNK), is readily observed in humans following ketamine treatment and has shown therapeutic potential in preclinical tests of antidepressant efficacy and synaptic potentiation while being devoid of the negative adverse effects of ketamine, including its dissociative properties and abuse potential. We discuss preclinical and clinical studies pertaining to how ketamine and its metabolites produce antidepressant effects. Specifically, we explore effects on glutamate neurotransmission through N-methyl D-aspartate receptors (NMDARs) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPARs), synaptic structural changes via brain derived neurotrophic factor (BDNF) signaling, interactions with opioid receptors, and the enhancement of serotonin, norepinephrine, and dopamine signaling. Strategic targeting of these mechanisms may result in novel rapid-acting antidepressants with fewer undesirable side effects compared to ketamine.
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Affiliation(s)
- Evan M Hess
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Lace M Riggs
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.,Program in Neuroscience and Training Program in Integrative Membrane Biology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Michael Michaelides
- Biobehavioral Imaging & Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD 21224, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA; Departments of Pharmacology and Anatomy & Neurobiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; Baltimore Veterans Affairs Medical Center, Veterans Affairs Maryland Health Care System, Baltimore, MD 21201, USA.
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Demchenko I, Tassone VK, Kennedy SH, Dunlop K, Bhat V. Intrinsic Connectivity Networks of Glutamate-Mediated Antidepressant Response: A Neuroimaging Review. Front Psychiatry 2022; 13:864902. [PMID: 35722550 PMCID: PMC9199367 DOI: 10.3389/fpsyt.2022.864902] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
Conventional monoamine-based pharmacotherapy, considered the first-line treatment for major depressive disorder (MDD), has several challenges, including high rates of non-response. To address these challenges, preclinical and clinical studies have sought to characterize antidepressant response through monoamine-independent mechanisms. One striking example is glutamate, the brain's foremost excitatory neurotransmitter: since the 1990s, studies have consistently reported altered levels of glutamate in MDD, as well as antidepressant effects following molecular targeting of glutamatergic receptors. Therapeutically, this has led to advances in the discovery, testing, and clinical application of a wide array of glutamatergic agents, particularly ketamine. Notably, ketamine has been demonstrated to rapidly improve mood symptoms, unlike monoamine-based interventions, and the neurobiological basis behind this rapid antidepressant response is under active investigation. Advances in brain imaging techniques, including functional magnetic resonance imaging, magnetic resonance spectroscopy, and positron emission tomography, enable the identification of the brain network-based characteristics distinguishing rapid glutamatergic modulation from the effect of slow-acting conventional monoamine-based pharmacology. Here, we review brain imaging studies that examine brain connectivity features associated with rapid antidepressant response in MDD patients treated with glutamatergic pharmacotherapies in contrast with patients treated with slow-acting monoamine-based treatments. Trends in recent brain imaging literature suggest that the activity of brain regions is organized into coherent functionally distinct networks, termed intrinsic connectivity networks (ICNs). We provide an overview of major ICNs implicated in depression and explore how treatment response following glutamatergic modulation alters functional connectivity of limbic, cognitive, and executive nodes within ICNs, with well-characterized anti-anhedonic effects and the enhancement of "top-down" executive control. Alterations within and between the core ICNs could potentially exert downstream effects on the nodes within other brain networks of relevance to MDD that are structurally and functionally interconnected through glutamatergic synapses. Understanding similarities and differences in brain ICNs features underlying treatment response will positively impact the trajectory and outcomes for adults suffering from MDD and will facilitate the development of biomarkers to enable glutamate-based precision therapeutics.
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Affiliation(s)
- Ilya Demchenko
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Vanessa K Tassone
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Sidney H Kennedy
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katharine Dunlop
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Venkat Bhat
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Tiger M, Gärde M, Tateno A, Matheson GJ, Sakayori T, Nogami T, Moriya H, Varnäs K, Arakawa R, Okubo Y. A positron emission tomography study of the serotonin1B receptor effect of electroconvulsive therapy for severe major depressive episodes. J Affect Disord 2021; 294:645-651. [PMID: 34332365 DOI: 10.1016/j.jad.2021.07.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders, although its molecular mechanism of action is unknown. The serotonin 1B (5-HT1B) receptor is a potential target for treatment of depression and low 5-HT1B receptor binding in limbic regions has been reported in previous positron emission tomography (PET) studies of depression. METHODS The objective of this longitudinal PET study was to examine the effect of ECT for depression on 5-HT1B receptor binding. Fifteen hospitalized patients with major depressive episodes were examined with PET and the 5-HT1B receptor selective radioligand [11C]AZ10419369, before and after ECT. Fifteen controls matched for age and sex were examined. Limbic regions with previously reported low 5-HT1B receptor binding in depression and a dorsal brain stem region were selected. RESULTS Thirteen patients completed the study according to protocol. Eleven out of thirteen patients responded to ECT. 5-HT1B receptor binding in hippocampus increased with 30 % after ECT (p=0.021). Using linear mixed effects modelling, we observed increases in 5-HT1B receptor binding following ECT with a moderate to large effect size, which did not differ significantly between regions. In an exploratory analysis, strong correlations between changes in 5-HT1B receptor binding and agitation scores on the Hamilton Depression Rating Scale after ECT were observed. LIMITATIONS Albeit representative of a PET study, the sample size is still small and there are potential confounding effects of medication. CONCLUSIONS Increased 5-HT1B receptor binding was observed following ECT for depression, corresponding to previous findings of increased 5-HT1B receptor binding in hippocampus after rapid acting ketamine for treatment resistant depression.
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Affiliation(s)
- Mikael Tiger
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Sweden.; Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Martin Gärde
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Amane Tateno
- Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Granville J Matheson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Takeshi Sakayori
- Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Tsuyoshi Nogami
- Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroki Moriya
- Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Katarina Varnäs
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Ryosuke Arakawa
- Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshiro Okubo
- Department of Neuropsychiatry, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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Dean RL, Hurducas C, Hawton K, Spyridi S, Cowen PJ, Hollingsworth S, Marquardt T, Barnes A, Smith R, McShane R, Turner EH, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder. Cochrane Database Syst Rev 2021; 9:CD011612. [PMID: 34510411 PMCID: PMC8434915 DOI: 10.1002/14651858.cd011612.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability and tolerability - of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. DATA COLLECTION AND ANALYSIS Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. MAIN RESULTS Thirty-one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D-cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP-101,606 (1), decoglurant (1), MK-0657 (1), N-acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty-eight studies were placebo-controlled, and 48 were two-arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild-to-moderate depression. Nineteen studies recruited only patients with treatment-resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low-certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) -0.87, 95% CI -1.26 to -0.48; n = 231, studies = 8, very low-certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low-certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low-certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low-certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and placebo (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low-certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate-certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD -0.31, 95% CI -0.45 to -0.17; n = 824, studies = 4, moderate-certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low-certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate-certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. AUTHORS' CONCLUSIONS Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta-analyses for each comparison and the majority of comparisons included only one study. Long term non-inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real-world monitoring are needed to establish comprehensive data on safety and efficacy.
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Affiliation(s)
| | | | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Erick H Turner
- Portland Veterans Affairs Medical Center, P3MHDC, Portland, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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Jiang H, Veldman ER, Tiger M, Ekman CJ, Lundberg J, Svenningsson P. Plasma Levels of Brain-Derived Neurotrophic Factor and S100B in Relation to Antidepressant Response to Ketamine. Front Neurosci 2021; 15:698633. [PMID: 34354565 PMCID: PMC8330598 DOI: 10.3389/fnins.2021.698633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/17/2021] [Indexed: 12/29/2022] Open
Abstract
Background Evidence demonstrates that brain-derived neurotrophic factor (BDNF) and S100 calcium-binding protein B (S100B) have a pivotal role in the pathogenesis of major depressive disorder (MDD) and they are proposed as predictors of antidepressant response. Ketamine produces rapid antidepressant effects in MDD and pre-clinical studies suggest the necessity of increased BDNF levels for the antidepressant action of ketamine. However, studies observing the change of blood BDNF levels after ketamine intervention are inconsistent and studies about the role of plasma S100B in ketamine administration in MDD patients are lacking. Method We evaluated mature BDNF (mBDNF), S100B levels in plasma and their associations with depression severity in 30 Selective Serotonin Reuptake Inhibitor (SSRI)-resistant MDD patients enrolled in a randomized controlled trial of ketamine compared (n = 20) to a placebo (n = 10) control (saline). Severity of depression was assessed using the Montgomery–Åsberg Depression Rating Scale (MADRS). Results Plasma mBDNF and S100B were not significantly changed after 1–2 days of single ketamine compared to placebo. Plasma mBDNF and S100B levels did not significantly differ in responders compared to non-responders of ketamine treatment. The change of plasma mBDNF levels was positively correlated with the improvement of MADRS score after 1–2 weeks of open-label ketamine treatment (rho = 0.495, p = 0.031), though this change did not survive correction for multiple comparisons. Conclusion These findings do not support the hypothesis that ketamine treatment increases BDNF plasma levels in MDD patients. No effect of ketamine treatment on S100B plasma levels was seen.
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Affiliation(s)
- Haitang Jiang
- Department of Psychosomatics and Psychiatry, Zhongda Hospital, Medical School of Southeast University, Nanjing, China.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Emma R Veldman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | - Mikael Tiger
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | - Carl-Johan Ekman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | - Johan Lundberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | - Per Svenningsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Veldman ER, Mamula D, Jiang H, Tiger M, Ekman CJ, Lundberg J, Svenningsson P. P11 (S100A10) as a potential predictor of ketamine response in patients with SSRI-resistant depression. J Affect Disord 2021; 290:240-244. [PMID: 34010748 DOI: 10.1016/j.jad.2021.04.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/02/2021] [Accepted: 04/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ketamine can act as antidepressant in patients with major depressive disorder (MDD) who are treatment-resistant. P11 has been implicated in ketamine's mechanism of action and proposed as biomarker for treatment response to other antidepressants. This study explores the effect of ketamine on peripheral p11 and the potential role for p11 as response marker for ketamine treatment. METHODS Thirty Selective Serotonin Reuptake Inhibitor resistant MDD patients were randomized to either 0.5 mg/kg ketamine or placebo intravenous treatment. Using multicolor Flow Cytometry, peripheral p11 levels were measured before and 1-2 days after treatment. RESULTS P11 levels were decreased within the ketamine group in both cytotoxic T cell and T helper cells populations, although this did not significantly differ from changes seen in the placebo group. Baseline p11 levels in cytotoxic T cells were significantly correlated with antidepressant response to ketamine treatment. LIMITATIONS This study was part of a larger study examining the effect of ketamine on the serotonin system in MDD patients, therefore the number of study subjects was limited to that of the primary study. CONCLUSIONS High baseline p11 levels in cytotoxic T cells were associated with a stronger reduction of depressive symptoms in MDD patients after ketamine treatment. Future studies should confirm if peripheral p11 levels could be used as a predictor of ketamine treatment response.
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Affiliation(s)
- Emma R Veldman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, R5:2, Karolinska Universitetssjukhuset Solna, 171 76 Stockholm, Sweden.
| | - Dejan Mamula
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Haitang Jiang
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Psychosomatics and Psychiatry, ZhongDa Hospital, Medical School of Southeast University, Nanjing, China
| | - Mikael Tiger
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, R5:2, Karolinska Universitetssjukhuset Solna, 171 76 Stockholm, Sweden
| | - Carl-Johan Ekman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, R5:2, Karolinska Universitetssjukhuset Solna, 171 76 Stockholm, Sweden
| | - Johan Lundberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, R5:2, Karolinska Universitetssjukhuset Solna, 171 76 Stockholm, Sweden
| | - Per Svenningsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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