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Zhou Y, Lan X, Wang C, Zhang F, Liu H, Fu L, Li W, Ye Y, Hu Z, Chao Z, Ning Y. Effect of Repeated Intravenous Esketamine on Adolescents With Major Depressive Disorder and Suicidal Ideation: A Randomized Active-Placebo-Controlled Trial. J Am Acad Child Adolesc Psychiatry 2024; 63:507-518. [PMID: 37414272 DOI: 10.1016/j.jaac.2023.05.031] [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: 01/05/2023] [Revised: 05/05/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Suicide is a major cause of death in adolescents with limited treatment options. Ketamine and its enantiomers have shown rapid anti-suicidal effects in adults with major depressive disorder (MDD), but their efficacy in adolescents is unknown. We conducted an active, placebo-controlled trial to determine the safety and efficacy of intravenous esketamine in this population. METHOD A total of 54 adolescents (aged 13-18 years) with MDD and suicidal ideation were included from an inpatient setting and randomly assigned (1:1) to receive 3 infusions of esketamine (0.25 mg/kg) or midazolam (0.02mg/kg) over 5 days, with routine inpatient care and treatment. Changes from baseline to 24 hours after the final infusion (day 6) in the scores of the Columbia Suicide Severity Rating Scale (C-SSRS) Ideation and Intensity (primary outcome) and the Montgomery-Åsberg Depression Rating Scale (MADRS, key secondary outcome) were analyzed using linear mixed models. In addition, the 4-week clinical treatment response was a key secondary outcome. RESULTS The mean changes in C-SSRS Ideation and Intensity scores from baseline to day 6 were significantly greater in the esketamine group than in the midazolam group (Ideation, -2.6 [SD = 2.0] vs -1.7 [SD = 2.2], p = .007; Intensity, -10.6 [SD = 8.4] vs -5.0 [SD = 7.4], p = .002), and the changes in MADRS scores from baseline to day 6 were significantly greater in the esketamine group than in the midazolam group (-15.3 [SD = 11.2] vs -8.8 [SD = 9.4], p = .004). The rates of antisuicidal and antidepressant responses at 4 weeks posttreatment were 69.2% and 61.5% after esketamine, and were 52.5% and 52.5% after midazolam, respectively. The most common adverse events in the esketamine group were nausea, dissociation, dry mouth, sedation, headache, and dizziness. CONCLUSION These preliminary findings indicate that 3-dose intravenous esketamine, added to routine inpatient care and treatment, was an effective and well-tolerated therapy for treating adolescents with MDD and suicidal ideation. CLINICAL TRIAL REGISTRATION INFORMATION A study to evaluate the efficacy and safety of Esketamine combined with oral antidepressants in the treatment of major depressive disorder with suicidal ideation; http://www.chictr.org.cn; ChiCTR2000041232. DIVERSITY & INCLUSION STATEMENT We worked to ensure that the study questionnaires were prepared in an inclusive way. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. We actively worked to promote sex and gender balance in our author group.
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Affiliation(s)
- Yanling Zhou
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaofeng Lan
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chengyu Wang
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Fan Zhang
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haiyan Liu
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ling Fu
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weicheng Li
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yanxiang Ye
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhibo Hu
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ziyuan Chao
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuping Ning
- Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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Hashimoto K. Are "mystical experiences" essential for antidepressant actions of ketamine and the classic psychedelics? Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01770-7. [PMID: 38411629 DOI: 10.1007/s00406-024-01770-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/22/2024] [Indexed: 02/28/2024]
Abstract
The growing interest in the rapid and sustained antidepressant effects of the dissociative anesthetic ketamine and classic psychedelics, such as psilocybin, is remarkable. However, both ketamine and psychedelics are known to induce acute mystical experiences; ketamine can cause dissociative symptoms such as out-of-body experience, while psychedelics typically bring about hallucinogenic experiences, like a profound sense of unity with the universe or nature. The role of these mystical experiences in enhancing the antidepressant outcomes for patients with depression is currently an area of ongoing investigation and debate. Clinical studies have shown that the dissociative symptoms following the administration of ketamine or (S)-ketamine (esketamine) are not directly linked to their antidepressant properties. In contrast, the antidepressant potential of (R)-ketamine (arketamine), thought to lack dissociative side effects, has yet to be conclusively proven in large-scale clinical trials. Moreover, although the activation of the serotonin 5-HT2A receptor is crucial for the hallucinogenic effects of psychedelics in humans, its precise role in their antidepressant action is still under discussion. This article explores the importance of mystical experiences in enhancing the antidepressant efficacy of both ketamine and classic psychedelics.
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Affiliation(s)
- Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, 1-8-1 Inohana, Chiba, 260-8670, Japan.
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Juby VM, Paruk S, Tomita M, Chiliza B. Ketamine for depressive symptoms: A retrospective chart review of a private ketamine clinic. S Afr J Psychiatr 2024; 30:2176. [PMID: 38444407 PMCID: PMC10913177 DOI: 10.4102/sajpsychiatry.v30i0.2176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/30/2023] [Indexed: 03/07/2024] Open
Abstract
Background There is currently no published evidence demonstrating the effectiveness and safety of subanaesthetic doses of ketamine, when administered intravenously as an adjunct treatment for depressive symptoms, in a real world setting in South Africa. Aim This retrospective chart review reports the clinical response (change in Patient Health Questionnaire - 7 score) to an initial infusion series of ketamine added to usual treatment, and the pattern of its subsequent maintenance use, for depressive symptoms. Setting A private ketamine clinic in Hilton, KwaZulu-Natal. Methods The medical records of all patients who attended a private ketamine clinic between August 2019 and 31 May 2021 were retrospectively analysed. Depression symptoms were evaluated using the Patient Health Questionaire-9 (PHQ-9) administered immediately before and 24 h after each treatment. Response was defined as a score decrease of more than 50%. Results Among the 154 patients who received ketamine infusions for depression, 67 completed a six infusion initial series, with a response rate of 60.6% and remission rate of 32.4%. Of the 154, 50% no longer experienced any suicidal ideation after treatment and adverse events were uncommon, with 6.2% of infusions requiring intervention for adverse events, mostly nausea. In addition, 48.5% of those who completed the initial series continued to receive maintenance infusions, with no evidence of escalating use or abuse. Conclusion Incorporating intravenous ketamine into the existing treatment regimens at a private clinic was associated with reduced acuteness of depression severity and suicidal ideation. This approach appeared safe and tolerable, showing no signs of abuse or dependence. Contribution This is the first known naturalistic study reporting on ketamine use for depressive symptoms in South Africa.
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Affiliation(s)
- Vidette M Juby
- Discipline of Psychiatry, College of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Saaeda Paruk
- Discipline of Psychiatry, College of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Mitsuaki Tomita
- Discipline of Psychiatry, College of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Bonga Chiliza
- Discipline of Psychiatry, College of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Schatzberg AF, Mathew SJ. The why, when, where, how, and so what of so-called rapidly acting antidepressants. Neuropsychopharmacology 2024; 49:189-196. [PMID: 37460770 PMCID: PMC10700639 DOI: 10.1038/s41386-023-01647-8] [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: 04/10/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 12/08/2023]
Abstract
Developing antidepressants that are not only more effective but are rapidly acting is the Holy Grail for psychiatry. We review multiple issues that arise in determining rapid responses in antidepressant trials. The current status of purportedly rapid acting agents is first reviewed. Then, a number of key questions/issues are addressed: Is there a unifying definition for rapid response across studies? Should rapid response criteria be based on required measurable effects on overall improvement? On specific symptoms such as psychomotor retardation, depressed mood, or anhedonia? In associated symptoms such as anxiety or insomnia? When should onset be considered rapid-by Day 3? Day7? Day 14? If there is a rapid response, for how long should the effects be maintained? Is maintenance of effect dependent on continuing the medication? Is rapid response associated with specific mechanisms of action? Do the mechanisms of action suggest possible risk for drug abuse? How important is rapid response really in an often chronic or recurrent depressive disorder? In which types of patients could rapid response be particularly important? What are the study design issues that need to be considered for assessing rapid response, including: selection of specific types of depressed patients, multiple doses of drug studied, designation of primary and secondary outcome measures, specific time points at which to determine efficacy, requirements for demonstrating durability, etc. A framework for approaching this complex area is developed for both researchers and clinicians.
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Affiliation(s)
- Alan F Schatzberg
- Kenneth T. Norris, Jr., Professor of Psychiatry and Behavioral Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
| | - Sanjay J Mathew
- Marjorie Bintliff Johnson and Raleigh White Johnson, Jr. Chair for Research in Psychiatry, Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Houston, TX, USA
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Yonezawa K, Uchida H, Yatomi T, Ohtani Y, Nomoto-Takahashi K, Nakajima S, Mimura M, Tani H. Factors Associated with Antidepressant Effects of Ketamine: A Reanalysis of Double-Blind Randomized Placebo-Controlled Trial of Intravenous Ketamine for Treatment-Resistant Depression. PHARMACOPSYCHIATRY 2024; 57:35-40. [PMID: 37846462 DOI: 10.1055/a-2179-8884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Predictors of treatment response to intravenous ketamine remain unclear in patients with treatment-resistant depression (TRD); therefore, this study aimed to clarify these predictors using the US National Institutes of Health database of clinical trials. METHODS Data from a placebo-controlled, double-blind, randomized controlled trial were used to assess the efficacy of intravenous ketamine in adult patients with TRD (NCT01920555). For the analysis, data were used from the participants who had received therapeutic doses of intravenous ketamine (i. e., 0.5 and 1.0 mg/kg). Logistic and multivariable regression analyses were conducted to explore the demographic and clinical factors associated with response to treatment or changes in the Hamilton Depression Rating Scale 6 items (HAM-D-6) total score. RESULTS This study included 31 patients with TRD (13 women; mean±standard deviation age, 48.4±10.9 years). Logistic regression analysis showed that the age of onset was positively correlated with treatment response after three days of ketamine administration (β=0.08, p=0.037); however, no association was observed between treatment response and age, sex, baseline HAM-D-6 total score, or dissociative score assessed with the Clinician-Administered Dissociative States Scale 40 min after ketamine infusion. Multiple regression analysis showed that no factors were correlated significantly with the percentage change in the HAM-D-6 total score three days after ketamine administration. DISCUSSION Later disease onset correlates with a better treatment response three days after ketamine infusion in patients with TRD. Glutamatergic signal transmission may be impaired in patients with an earlier onset of depression, resulting in decreased neuroplasticity, which diminishes ketamine response.
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Affiliation(s)
- Kengo Yonezawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Taisuke Yatomi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Ohtani
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | | | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Tani
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Garcia-Carachure I, Lira O, Themann A, Rodriguez M, Flores-Ramirez FJ, Lobo MK, Iñiguez SD. Sex-Specific Alterations in Spatial Memory and Hippocampal AKT-mTOR Signaling in Adult Mice Pre-exposed to Ketamine and/or Psychological Stress During Adolescence. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2024; 4:240-251. [PMID: 38298791 PMCID: PMC10829642 DOI: 10.1016/j.bpsgos.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 02/02/2024] Open
Abstract
Background Ketamine (KET) is administered to manage major depression in adolescent patients. However, the long-term effects of juvenile KET exposure on memory-related tasks have not been thoroughly assessed. We examined whether exposure to KET, psychological stress, or both results in long-lasting alterations in spatial memory in C57BL/6 mice. Furthermore, we evaluated how KET and/or psychological stress history influenced hippocampal protein kinase B-mechanistic target of rapamycin (AKT-mTOR)-related signaling. Methods On postnatal day 35, male and female mice underwent vicarious defeat stress (VDS), a form of psychological stress that reduces sociability in both sexes, with or without KET exposure (20 mg/kg/day, postnatal days 35-44). In adulthood (postnatal day 70), mice were assessed for spatial memory performance on a water maze task or euthanized for hippocampal tissue collection. Results Juvenile pre-exposure to KET or VDS individually increased the latency (seconds) to locate the escape platform in adult male, but not female, mice. However, juvenile history of concomitant KET and VDS prevented memory impairment. Furthermore, individual KET or VDS pre-exposure, unlike their combined history, decreased hippocampal AKT-mTOR signaling in adult male mice. Conversely, KET pre-exposure alone increased AKT-mTOR in the hippocampus of adult female mice. Lastly, rapamycin-induced decreases of mTOR in naïve adult female mice induced spatial memory retrieval deficits, mimicking adult male mice with a history of exposure to VDS or KET. Conclusions Our preclinical model shows how KET treatment for the management of adolescent psychological stress-induced sequelae does not impair spatial memory later in life. However, juvenile recreational KET misuse, like psychological stress history, results in long-term spatial memory deficits and hippocampal AKT-mTOR signaling changes in a sex-specific manner.
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Affiliation(s)
| | - Omar Lira
- Department of Psychology, The University of Texas at El Paso, El Paso, Texas
| | - Anapaula Themann
- Department of Psychology, The University of Texas at El Paso, El Paso, Texas
| | - Minerva Rodriguez
- Department of Psychology, The University of Texas at El Paso, El Paso, Texas
| | | | - Mary Kay Lobo
- Department of Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sergio D. Iñiguez
- Department of Psychology, The University of Texas at El Paso, El Paso, Texas
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Krystal JH, Kavalali ET, Monteggia LM. Ketamine and rapid antidepressant action: new treatments and novel synaptic signaling mechanisms. Neuropsychopharmacology 2024; 49:41-50. [PMID: 37488280 PMCID: PMC10700627 DOI: 10.1038/s41386-023-01629-w] [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: 04/06/2023] [Revised: 05/29/2023] [Accepted: 06/04/2023] [Indexed: 07/26/2023]
Abstract
Ketamine is an open channel blocker of ionotropic glutamatergic N-Methyl-D-Aspartate (NMDA) receptors. The discovery of its rapid antidepressant effects in patients with depression and treatment-resistant depression fostered novel effective treatments for mood disorders. This discovery not only provided new insight into the neurobiology of mood disorders but also uncovered fundamental synaptic plasticity mechanisms that underlie its treatment. In this review, we discuss key clinical aspects of ketamine's effect as a rapidly acting antidepressant, synaptic and circuit mechanisms underlying its action, as well as how these novel perspectives in clinical practice and synapse biology form a road map for future studies aimed at more effective treatments for neuropsychiatric disorders.
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Affiliation(s)
- John H Krystal
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Ege T Kavalali
- Department of Pharmacology and the Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA
| | - Lisa M Monteggia
- Department of Pharmacology and the Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA.
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Garel N, Drury J, Thibault Lévesque J, Goyette N, Lehmann A, Looper K, Erritzoe D, Dames S, Turecki G, Rej S, Richard-Devantoy S, Greenway KT. The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression. Front Psychiatry 2023; 14:1268832. [PMID: 37795512 PMCID: PMC10546328 DOI: 10.3389/fpsyt.2023.1268832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
Background Subanesthetic ketamine has accumulated meta-analytic evidence for rapid antidepressant effects in treatment-resistant depression (TRD), resulting in both excitement and debate. Many unanswered questions surround ketamine's mechanisms of action and its integration into real-world psychiatric care, resulting in diverse utilizations that variously resemble electroconvulsive therapy, conventional antidepressants, or serotonergic psychedelics. There is thus an unmet need for clinical approaches to ketamine that are tailored to its unique therapeutic properties. Methods This article presents the Montreal model, a comprehensive biopsychosocial approach to ketamine for severe TRD refined over 6 years in public healthcare settings. To contextualize its development, we review the evidence for ketamine as a biomedical and as a psychedelic treatment of depression, emphasizing each perspectives' strengths, weaknesses, and distinct methods of utilization. We then describe the key clinical experiences and research findings that shaped the model's various components, which are presented in detail. Results The Montreal model, as implemented in a recent randomized clinical trial, aims to synergistically pair ketamine infusions with conventional and psychedelic biopsychosocial care. Ketamine is broadly conceptualized as a brief intervention that can produce windows of opportunity for enhanced psychiatric care, as well as powerful occasions for psychological growth. The model combines structured psychiatric care and concomitant psychotherapy with six ketamine infusions, administered with psychedelic-inspired nonpharmacological adjuncts including rolling preparative and integrative psychological support. Discussion Our integrative model aims to bridge the biomedical-psychedelic divide to offer a feasible, flexible, and standardized approach to ketamine for TRD. Our learnings from developing and implementing this psychedelic-inspired model for severe, real-world patients in two academic hospitals may offer valuable insights for the ongoing roll-out of a range of psychedelic therapies. Further research is needed to assess the Montreal model's effectiveness and hypothesized psychological mechanisms.
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Affiliation(s)
- Nicolas Garel
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Jessica Drury
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
| | | | - Nathalie Goyette
- McGill Group for Suicide Studies, Douglas Mental Health Research Institute, Montreal, QC, Canada
| | - Alexandre Lehmann
- International Laboratory for Brain, Music and Sound Research, Montreal, QC, Canada
- Department of Otolaryngology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Karl Looper
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - David Erritzoe
- Division of Psychiatry, Department of Brain Sciences, Centres for Neuropsychopharmacology and Psychedelic Research, Imperial College London, London, United Kingdom
| | - Shannon Dames
- Health Sciences and Human Services, Vancouver Island University, Nanaimo, BC, Canada
| | - Gustavo Turecki
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- McGill Group for Suicide Studies, Douglas Mental Health Research Institute, Montreal, QC, Canada
| | - Soham Rej
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
- Geri-PARTy Research Group, Jewish General Hospital, Montreal, QC, Canada
| | - Stephane Richard-Devantoy
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- McGill Group for Suicide Studies, Douglas Mental Health Research Institute, Montreal, QC, Canada
| | - Kyle T. Greenway
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
- Division of Psychiatry, Department of Brain Sciences, Centres for Neuropsychopharmacology and Psychedelic Research, Imperial College London, London, United Kingdom
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Pan Y, Gorenflo MP, Davis PB, Kaelber DC, De Luca S, Xu R. Suicidal ideation and suicide attempt following ketamine prescription in patients with treatment-resistant depression: a nation-wide cohort study. RESEARCH SQUARE 2023:rs.3.rs-3207199. [PMID: 37609161 PMCID: PMC10441476 DOI: 10.21203/rs.3.rs-3207199/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Ketamine, including esketamine, is an effective treatment for patients with treatment-resistant depression (TRD); however, its long-term efficacy in real-world populations remains poorly characterized. This is a retrospective cohort study using TriNetX US Collaborative Network, a platform aggregating electronic health records (EHRs) data from 93 million patients from 56 health care organizations in the US, and the study population includes 321,367 patients with a diagnosis of TRD who were prescribed relevant treatment in their EHRs. The prescription of ketamine (including esketamine) was associated with significant decreased risk of suicidal ideation compared to prescription of other common antidepressants: HR = 0.65 (95% CI: 0.53 - 0.81) at 1 day - 7 days, 0.78 (95% CI: 0.66 - 0.92) at 1 day - 30 days, 0.81 (95% CI: 0.70 - 0.92) at 1 day - 90 days, 0.82 (95% CI: 0.72 - 0.92) at 1 day - 180 days, and 0.83 (95% CI: 0.74 - 0.93) at 1 day - 270 days. This trend was especially robust among adults over 24 years of age, males, and White patients with TRD. No significant difference was observed for suicide attempts, except significantly increased risk for adolescents (aged 10-24) at 1 day - 30 days with HR = 2.22 (95% CI: 1.01-4.87). This study provides real-world evidence that ketamine has long-term benefits in mitigating suicidal ideation in patients with treatment-resistant depression. Future work should focus on optimizing dosage regimens for ketamine, understanding the mechanism, and the difference in various demographic subpopulations.
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Affiliation(s)
- Yiheng Pan
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Computer and Data Science, Case Western Reserve University, Cleveland, OH, USA
| | - Maria P. Gorenflo
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pamela B. Davis
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - David C. Kaelber
- The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
| | - Susan De Luca
- Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Rong Xu
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Salari M, Eftekhar-Vaghefi SH, Asadi-Shekaari M, Esmaeilpour K, Solhjou S, Amiri M, Ahmadi-Zeidabadi M. Impact of ketamine administration on chronic unpredictable stress-induced rat model of depression during extremely low-frequency electromagnetic field exposure: Behavioral, histological and molecular study. Brain Behav 2023; 13:e2986. [PMID: 37032465 PMCID: PMC10176018 DOI: 10.1002/brb3.2986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 04/11/2023] Open
Abstract
OBJECTIVES In the study, we examined the effects of ketamine and extremely low-frequency electromagnetic fields (ELF-EMF) on depression-like behavior, learning and memory, expression of GFAP, caspase-3, p53, BDNF, and NMDA receptor in animals subjected to chronic unpredictable stress (CUS). METHODS After applying 21 days of chronic unpredictable stress, male rats received intraperitoneal (IP) of ketamine (5 mg/kg) and then were exposed to ELF-EMF (10-Hz, 10-mT exposure conditions) for 3 days (3 h per day) and behavioral assessments were performed 24 h after the treatments. Instantly after the last behavioral test, the brain was extracted for Nissl staining, immunohistochemistry, and real-time PCR analyses. Immunohistochemistry (IHC) was conducted to assess the effect of ketamine and ELF-EMF on the expression of astrocyte marker (glial fibrillary acidic protein, GFAP) in the CA1 area of the hippocampus and medial prefrontal cortex (mPFC). Also, real-time PCR analyses were used to investigate the impacts of the combination of ketamine and ELF-EMF on the expression of caspase3, p53, BDNF, and NMDA receptors in the hippocampus in rats submitted to the CUS procedure. Results were considered statistically significant when p < .05. RESULTS Our results revealed that the combination of ketamine and ELF-EMF increased depression-like behavior, increased degenerated neurons and decreased the number of GFAP (+) cells in the CA1 area and mPFC, incremented the expression of caspase-3, and reduced the expression of BDNF in the hippocampus but showed no effect on the expression of p53 and NMDA-R. CONCLUSIONS These results reveal that combining ketamine and ELF-EMF has adverse effects on animals under chronic unpredictable stress (CUS).
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Affiliation(s)
- Moein Salari
- Department of Anatomy, Afzalipour School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Seyed Hassan Eftekhar-Vaghefi
- Department of Anatomy, Afzalipour School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Majid Asadi-Shekaari
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Khadijeh Esmaeilpour
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Somayeh Solhjou
- Department of Anatomy, Afzalipour School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Amiri
- Department of Anatomy, Afzalipour School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Meysam Ahmadi-Zeidabadi
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
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Kang MJY, Vazquez GH. Association between peripheral biomarkers and clinical response to IV ketamine for unipolar treatment-resistant depression: An open label study. J Affect Disord 2022; 318:331-337. [PMID: 36070831 DOI: 10.1016/j.jad.2022.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Major Depression is the leading cause of disability worldwide. A cohort of patients do not respond adequately to available antidepressants, leading to treatment-resistant depression (TRD). We evaluated the antidepressant efficacy of an acute intravenous ketamine treatment (0.5 mg/kg) for patients with unipolar TRD, and measured peripheral blood-based biomarkers associated with response to treatment. METHODS Fifteen adults diagnosed with TRD completed an open label study of ten infusions of subanesthetic ketamine over four weeks. Out of fifteen patients, blood was collected from eleven patients at three timepoints to analyze peripheral biomarkers in isolated plasma, including IL-6, IL-10, TNF-α, BDNF, and irisin. Irisin analysis was completed using an ELISA assay, and the remaining biomarkers were analyzed together simultaneously using a multiplex immunoassay. RESULTS Repeated ketamine infusions produced a significant decrease in total average depressive symptoms (MADRS) at all timepoints. Improvements in depressive symptoms were significant at one week, and continued to significantly decrease until two weeks, where it was maintained. Ketamine was generally well tolerated, and we observed improvements in functional impairment, anhedonia, and psychiatric symptoms, with no increases in manic symptoms. Levels of BDNF throughout treatment inversely correlated to decreases in MADRS scores, and higher levels of baseline BDNF predicted mood responses at one- and four weeks. LIMITATIONS The study was observational and uncontrolled, with a sample size of 15. Outpatients remained on their course of medications, unless they were pharmacological agents that have previously been identified to block ketamine's effects. CONCLUSIONS Ketamine may be an efficacious and safe pharmacological option for the acute treatment of patients suffering from severe TRD. BDNF has the potential to function as a prognostic biomarker for predicting response to ketamine treatments.
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Affiliation(s)
- Melody J Y Kang
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada; Neuroscience Graduate Program, University of Southern California, Los Angeles, CA, USA
| | - Gustavo H Vazquez
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada; Department of Psychiatry, Queen's University Medical School, Kingston, Ontario, Canada; International Consortium for Research on Mood & Psychotic Disorders, McLean Hospital, Belmont, MA, USA.
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12
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Kawazoe K, McGlynn R, Felix W, Sevilla R, Liao S, Kulkarni P, Ferris CF. Dose-dependent effects of esketamine on brain activity in awake mice: A BOLD phMRI study. Pharmacol Res Perspect 2022; 10:e01035. [PMID: 36504448 PMCID: PMC9743060 DOI: 10.1002/prp2.1035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
Pharmacological magnetic resonance imaging (phMRI) is a noninvasive method used to evaluate neural circuitry involved in the behavioral effects of drugs like ketamine, independent of their specific biochemical mechanism. The study was designed to evaluate the immediate effect of esketamine, the S-isomer of (±) ketamine on brain activity in awake mice using blood oxygenation level dependent (BOLD) imaging. It was hypothesized the prefrontal cortex, hippocampus, and brain areas associated with reward and motivation would show a dose-dependent increase in brain activity. Mice were given vehicle, 1.0, 3.3, or 10 mg/kg esketamine I.P. and imaged for 10 min post-treatment. Data for each treatment were registered to a 3D MRI mouse brain atlas providing site-specific information on 134 different brain areas. There was a global change in brain activity for both positive and negative BOLD signal affecting over 50 brain areas. Many areas showed a dose-dependent decrease in positive BOLD signal, for example, cortex, hippocampus, and thalamus. The most common profile when comparing the three doses was a U-shape with the 3.3 dose having the lowest change in signal. At 1.0 mg/kg there was a significant increase in positive BOLD in forebrain areas and hippocampus. The anticipated dose-dependent increase in BOLD was not realized; instead, the lowest dose of 1.0 mg/kg had the greatest effect on brain activity. The prefrontal cortex and hippocampus were significantly activated corroborating previous imaging studies in humans and animals. The unexpected sensitivity to the 1.0 mg/kg dose of esketamine could be explained by imaging in fully awake mice without the confound of anesthesia and/or its greater affinity for the N-methyl-d-aspartate receptor (NMDAR) receptor than (±) ketamine.
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Affiliation(s)
- Kyrsten Kawazoe
- Department of Pharmaceutical SciencesNortheastern UniversityBostonMassachusettsUSA
| | - Ryan McGlynn
- Department of Pharmaceutical SciencesNortheastern UniversityBostonMassachusettsUSA
| | - Wilder Felix
- Department of Pharmaceutical SciencesNortheastern UniversityBostonMassachusettsUSA
| | - Raquel Sevilla
- Department of Pharmaceutical SciencesNortheastern UniversityBostonMassachusettsUSA
| | - Siyang Liao
- Department of Pharmaceutical SciencesNortheastern UniversityBostonMassachusettsUSA
| | - Praveen Kulkarni
- Center for Translational NeuroimagingNortheastern UniversityMassachusettsBostonUSA
| | - Craig F. Ferris
- Department of Pharmaceutical SciencesNortheastern UniversityBostonMassachusettsUSA
- Center for Translational NeuroimagingNortheastern UniversityMassachusettsBostonUSA
- Department of PsychologyNortheastern UniversityBostonMassachusettsUSA
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13
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Smith-Apeldoorn SY, Veraart JK, Spijker J, Kamphuis J, Schoevers RA. Maintenance ketamine treatment for depression: a systematic review of efficacy, safety, and tolerability. Lancet Psychiatry 2022; 9:907-921. [PMID: 36244360 DOI: 10.1016/s2215-0366(22)00317-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022]
Abstract
Ketamine has rapid yet often transient antidepressant effects in patients with treatment-resistant depression. Different strategies have been proposed to prolong these effects. Maintenance ketamine treatment appears promising, but little is known about its efficacy, safety, and tolerability in depression. We searched Pubmed, Embase, and the Cochrane Library and identified three randomised controlled trials, eight open-label trials, and 30 case series and reports on maintenance ketamine treatment. We found intravenous, intranasal, oral, and possibly intramuscular and subcutaneous maintenance ketamine treatment to be effective in sustaining antidepressant effect in treatment-resistant depression. Tachyphylaxis, cognitive impairment, addiction, and serious renal and urinary problems seem uncommon. Despite the methodological limitations, we conclude that from a clinical view, maintenance ketamine treatment seems to be of therapeutic potential. We recommend both controlled and naturalistic studies with long-term follow-up and sufficient power to determine the position of maintenance ketamine treatment within routine clinical practice.
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Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Jolien Ke Veraart
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; Department of Mood Disorders, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, Netherlands
| | - Jan Spijker
- Pro Persona Mental Health Care, Depression Expertise Center, Nijmegen, Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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14
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Alnefeesi Y, Chen-Li D, Krane E, Jawad MY, Rodrigues NB, Ceban F, Di Vincenzo JD, Meshkat S, Ho RCM, Gill H, Teopiz KM, Cao B, Lee Y, McIntyre RS, Rosenblat JD. Real-world effectiveness of ketamine in treatment-resistant depression: A systematic review & meta-analysis. J Psychiatr Res 2022; 151:693-709. [PMID: 35688035 DOI: 10.1016/j.jpsychires.2022.04.037] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/10/2022] [Accepted: 04/26/2022] [Indexed: 12/29/2022]
Abstract
Ketamine is a promising therapeutic option in treatment-resistant depression (TRD). The acute efficacy of ketamine in TRD has been demonstrated in replicated randomised-controlled trials (RCTs), but the generalizability of RCT data to real-world practice is limited. To this end, we conducted a systematic review (Search date: 25/12/2021; 1482 records identified) and meta-analysis of studies evaluating the real-world clinical effectiveness of ketamine in TRD patients. Four overlapping syntheses (Total n = 2665 patients; k = 79 studies) and 32 meta-regressions (Total n = 2050; k = 37) were conducted. All results suggest that the mean antidepressant effect is substantial (mean ± 95% CI, % responded = 45 ± 10%; p< 0.0001, % remitted = 30 ± 5.9%; p< 0.0001, Hedges g of symptomatological improvement = 1.44 ± 0.609; p < 0.0001), but the effect varies considerably among patients. The more treatment-resistant cases were found to remit less often (p < 0.01), but no such effect on response was evident (p > 0.05). Meta-regressions also confirmed that the therapeutic effect does not significantly decline with repeated treatments (p > 0.05). These results demonstrate that even the most treatment-resistant patients may benefit from ketamine, and that mid-to-long term treatment is effective in many patients.
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Affiliation(s)
- Yazen Alnefeesi
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - David Chen-Li
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Ella Krane
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | | | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger C M Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Kayla M Teopiz
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Bing Cao
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, 400715, PR China
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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15
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Orsolini L, Salvi V, Volpe U. Craving and addictive potential of esketamine as side effects? Expert Opin Drug Saf 2022; 21:803-812. [PMID: 35509224 DOI: 10.1080/14740338.2022.2071422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Esketamine was approved for adults with treatment-resistant depression (TRD) in conjunction with an oral antidepressant, and for treating depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior. However, evidence of great efficacy and safety of esketamine is accompanied by a widespread concern regarding its addictive potential. AREAS COVERED A comprehensive review on the craving and addictive potential of ketamine and esketamine was carried out. In addition, a clinical case of a 34-year-old TRD woman treated with esketamine who experienced drug-seeking behaviors and craving symptomatology was described and critically discussed, with a particular focus on treatment strategies to manage craving in the short- and long term. EXPERT OPINION Esketamine showed great efficacy and safety in treating TRD and MDD with acute suicidal ideation or behavior. Our clinical experience demonstrated the presence of an additive potential, which has been favorably managed with slow esketamine de-titration and combination with bupropion. However, literature so far published is scant and shows contradictory findings. Therefore, it is crucial to promptly detect and manage craving symptomatology in esketamine-treated TRD patients. In our experience, the use of bupropion to counteract craving and addictive symptoms was proven to be effective and safe.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Virginio Salvi
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
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16
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de la Salle S, Phillips JL, Blier P, Knott V. Electrophysiological correlates and predictors of the antidepressant response to repeated ketamine infusions in treatment-resistant depression. Prog Neuropsychopharmacol Biol Psychiatry 2022; 115:110507. [PMID: 34971723 DOI: 10.1016/j.pnpbp.2021.110507] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/03/2021] [Accepted: 12/23/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Sub-anesthetic ketamine doses rapidly reduce depressive symptoms, although additional investigations of the underlying neural mechanisms and the prediction of response outcomes are needed. Electroencephalographic (EEG)-derived measures have shown promise in predicting antidepressant response to a variety of treatments, and are sensitive to ketamine administration. This study examined their utility in characterizing changes in depressive symptoms following single and repeated ketamine infusions. METHODS Recordings were obtained from patients with treatment-resistant major depressive disorder (MDD) (N = 24) enrolled in a multi-phase clinical ketamine trial. During the randomized, double-blind, crossover phase (Phase 1), patients received intravenous ketamine (0.5 mg/kg) and midazolam (30 μg/kg), at least 1 week apart. For each medication, three resting, eyes-closed recordings were obtained per session (pre-infusion, immediately post-infusion, 2 h post-infusion), and changes in power (delta, theta1/2/total, alpha1/2/total, beta, gamma), alpha asymmetry, theta cordance, and theta source-localized anterior cingulate cortex activity were quantified. The relationships between ketamine-induced changes with early (Phase 1) and sustained (Phases 2,3: open-label repeated infusions) decreases in depressive symptoms (Montgomery-Åsberg Depression Rating Score, MADRS) and suicidal ideation (MADRS item 10) were examined. RESULTS Both medications decreased alpha and theta immediately post-infusion, however, only midazolam increased delta (post-infusion), and only ketamine increased gamma (immediately post- and 2 h post-infusion). Regional- and frequency-specific ketamine-induced EEG changes were related to and predictive of decreases in depressive symptoms (theta, gamma) and suicidal ideation (alpha). Early and sustained treatment responders differed at baseline in surface-level and source-localized theta. CONCLUSIONS Ketamine exerts frequency-specific changes on EEG-derived measures, which are related to depressive symptom decreases in treatment-resistant MDD and provide information regarding early and sustained individual response to ketamine. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: Action of Ketamine in Treatment-Resistant Depression, NCT01945047.
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Affiliation(s)
- Sara de la Salle
- University of Ottawa Institute of Mental Health Research at the Royal, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada; School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Ottawa, ON K1N6N5, Canada.
| | - Jennifer L Phillips
- University of Ottawa Institute of Mental Health Research at the Royal, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada; Department of Psychiatry, University of Ottawa, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada; Department of Biochemistry, Microbiology and Immunology, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada
| | - Pierre Blier
- University of Ottawa Institute of Mental Health Research at the Royal, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada; Department of Psychiatry, University of Ottawa, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada
| | - Verner Knott
- University of Ottawa Institute of Mental Health Research at the Royal, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada; School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Ottawa, ON K1N6N5, Canada
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17
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Nikayin S, Murphy E, Krystal JH, Wilkinson ST. Long-term safety of ketamine and esketamine in treatment of depression. Expert Opin Drug Saf 2022; 21:777-787. [PMID: 35416105 DOI: 10.1080/14740338.2022.2066651] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Ketamine is an NMDA receptor antagonist that can produce rapid-acting antidepressant effects. Esketamine (Spravato), the S-enantiomer of racemic ketamine, was approved by the FDA for treatment-resistant depression in 2019. Here we review what is known about the long-term safety of both racemic ketamine and esketamine as therapies for psychiatric disorders. AREAS COVERED In this article, we conducted a safety review of ketamine and esketamine. In looking at ketamine and esketamine long-term safety effects, we considered data available from experimental studies and several phase-three clinical trials. EXPERT OPINION Based on available data, the most common side effects of ketamine/esketamine are generally transient, mild, and self-limited. These include dissociation, nausea, headache, elevated heart rate, and blood pressure. Treatment with esketamine may lead to an increased risk of lower urinary tract symptoms, such as dysuria or urgency. However, severe bladder pathology has not been reported among patients receiving doses of esketamine/ketamine in line with prescribing guidelines for depression. There is considerable data that ketamine at high doses can lead to long-term impairments in cognition. However, the esketamine clinical trials found that cognition generally remains stable or improves over time, suggesting that when used appropriately, there is no increased risk of cognitive impairment.
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Affiliation(s)
- Sina Nikayin
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
| | - Eva Murphy
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
| | - John H Krystal
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
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18
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McInnes LA, Qian JJ, Gargeya RS, DeBattista C, Heifets BD. A retrospective analysis of ketamine intravenous therapy for depression in real-world care settings. J Affect Disord 2022; 301:486-495. [PMID: 35027209 DOI: 10.1016/j.jad.2021.12.097] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/12/2021] [Accepted: 12/20/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Outcomes of ketamine intravenous therapy (KIT) for depression in real-world care settings have been minimally evaluated. We set out to quantify treatment response to KIT in a large sample of patients from community-based practices. METHODS We retrospectively analyzed 9016 depression patients who received KIT between 2016 and 2020 at one of 178 community practices across the United States. Depression symptoms were evaluated using the Patient Health Questionnaire-9 (PHQ-9). The induction phase of KIT was defined to be a series of 4-8 infusions administered over 7 to 28 days. RESULTS Among the 537 patients who underwent induction and had sufficient data, 53.6% of patients showed a response (≥ 50% reduction in PHQ-9 score) at 14-31 days post-induction and 28.9% remitted (PHQ-9 score drop to < 5). The effect size was d = 1.5. Among patients with baseline suicidal ideation (SI), 73.0% exhibited a reduction in SI. A subset (8.4%) of patients experienced an increase in depressive symptoms after induction while 6.0% of patients reported increased SI. The response rate was uniform across 4 levels of baseline depression severity. However, more severe illness was weakly correlated with a greater drop in scores while remission status was weakly inversely correlated with depression severity. Kaplan-Meier analyses showed that a patient who responds to KIT induction has approximately 80% probability of sustaining response at 4 weeks and approximately 60% probability at 8 weeks, even without maintenance infusions. CONCLUSION KIT can elicit a robust antidepressant response in community clinics; however, a small percentage of patients worsened.
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Affiliation(s)
| | - Jimmy J Qian
- Osmind, San Francisco, CA, United States; Stanford University School of Medicine, Stanford, CA, United States
| | | | - Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Boris D Heifets
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
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Swainson J, Klassen LJ, Brennan S, Chokka P, Katzman MA, Tanguay RL, Khullar A. Non-parenteral Ketamine for Depression: A Practical Discussion on Addiction Potential and Recommendations for Judicious Prescribing. CNS Drugs 2022; 36:239-251. [PMID: 35165841 PMCID: PMC8853036 DOI: 10.1007/s40263-022-00897-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada. .,Misericordia Community Hospital, Edmonton, AB, Canada.
| | | | - Stefan Brennan
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK Canada
| | - Pratap Chokka
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Chokka Center for Integrative Health, Edmonton, AB Canada
| | - Martin A. Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, ON Canada ,Department of Psychiatry, Northern Ontario School of Medicine, Thunder Bay, ON Canada ,Department of Psychology, Lakehead University, Thunder Bay, ON Canada ,Department of Psychology, Adler Graduate Professional School, Toronto, ON Canada
| | - Robert L. Tanguay
- Department of Psychiatry and Department of Surgery, University of Calgary, Calgary, AB Canada ,The Newly Institute, Calgary, AB Canada ,Hotchkiss Brain Institute and Mathison Centre for Mental Health, Calgary, AB Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Northern Alberta Sleep Clinic, Edmonton, AB Canada
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20
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Chen ST, Hsieh CP, Lee MY, Chen LC, Huang CM, Chen HH, Chan MH. Betaine prevents and reverses the behavioral deficits and synaptic dysfunction induced by repeated ketamine exposure in mice. Biomed Pharmacother 2021; 144:112369. [PMID: 34715446 DOI: 10.1016/j.biopha.2021.112369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/16/2022] Open
Abstract
As an N-methyl-D-aspartate (NMDA) receptor inhibitor, ketamine has become a popular recreational substance and currently is used to address treatment-resistant depression. Since heavy ketamine use is associated with persisting psychosis, cognitive impairments, and neuronal damage, the safety of ketamine treatment for depression should be concerned. The nutrient supplement betaine has been shown to counteract the acute ketamine-induced psychotomimetic effects and cognitive dysfunction through modulating NMDA receptors. This study aimed to determine whether the adjunctive or subsequent betaine treatment would improve the enduring behavioral disturbances and hippocampal synaptic abnormality induced by repeated ketamine exposure. Mice received ketamine twice daily for 14 days, either combined with betaine co-treatment or subsequent betaine post-treatment for 7 days. Thereafter, three-chamber social approach test, reciprocal social interaction, novel location/object recognition test, forced swimming test, and head-twitch response induced by serotonergic hallucinogen were monitored. Data showed that the enduring behavioral abnormalities after repeated ketamine exposure, including disrupted social behaviors, recognition memory impairments, and increased depression-like and hallucinogen-induced head-twitch responses, were remarkably improved by betaine co-treatment or post-treatment. Consistently, betaine protected and reversed the reduced hippocampal synaptic activity, such as decreases in field excitatory post-synaptic potentiation (fEPSP), long-term potentiation (LTP), and PSD-95 levels, after repeated ketamine treatment. These results demonstrated that both co-treatment and post-treatment with betaine could effectively prevent and reverse the adverse behavioral manifestations and hippocampal synaptic plasticity after repeated ketamine use, suggesting that betaine can be used as a novel adjunct therapy with ketamine for treatment-resistant depression and provide benefits for ketamine use disorders.
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Affiliation(s)
- Shao-Tsu Chen
- Department of Psychiatry, Tzu Chi University, 701, Section 3, Chung-Yang Road, Hualien, Taiwan
| | - Chung-Pin Hsieh
- Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan
| | - Mei-Yi Lee
- Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan
| | - Liao-Chen Chen
- Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan
| | - Chien-Min Huang
- Animal Behavior Core National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli, Taiwan
| | - Hwei-Hsien Chen
- Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan; Animal Behavior Core National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli, Taiwan; Institute of Neuroscience, National Chengchi Uinversity, Taipei, Taiwan.
| | - Ming-Huan Chan
- Institute of Neuroscience, National Chengchi Uinversity, Taipei, Taiwan; Research Center for Mind, Brain, and Learning, National Changchi University, 64, Section 2, Zhinan Road, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
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21
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Age affects temporal response, but not durability, to serial ketamine infusions for treatment refractory depression. Psychopharmacology (Berl) 2021; 238:3229-3237. [PMID: 34363507 DOI: 10.1007/s00213-021-05939-z] [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: 12/07/2020] [Accepted: 07/14/2021] [Indexed: 12/30/2022]
Abstract
RATIONALE Ketamine is a novel, rapid-acting antidepressant for treatment refractory depression (TRD); however, clinical durability is poor and treatment response trajectories vary. Little is known about which patient characteristics predict faster or more durable ketamine responses. Ketamine's antidepressant mechanism may involve modulation of glutamatergic signaling and long-term potentiation (LTP); these neuroplasticity pathways are also attenuated with older age. OBJECTIVE A retrospective analysis examining the impact of patient age on the speed and durability of ketamine's antidepressant effects in 49 veterans receiving serial intravenous ketamine infusions for TRD. METHOD The relationship between age and percent change in Beck Depression Inventory (BDI-II) scores was compared across six serial ketamine infusions (twice-weekly for 3 weeks) using a linear-mixed model. RESULTS A significant Age-X-Infusion number interaction (F = 3.01, p = .0274) indicated that the relationship between age and treatment response depended on infusion number. Follow-up tests showed that younger age significantly predicted greater clinical improvement at infusion #4 (t = 3.02, p = .004); this relationship was attenuated at infusion #5 (t = 1.95, p = .057) and was absent at infusion #6. Age was not a significant predictor of treatment durability, defined as percent change in BDI-II 3 weeks following infusion #6. CONCLUSIONS These data preliminarily suggest that younger age is associated with a faster response over six serial ketamine infusions; by infusion #6 and subsequent weeks of clinical follow-up, age no longer predicts ketamine's antidepressant activity. Age may mediate the speed but not the durability or total efficacy of ketamine treatment, suggesting that dissociable mechanisms may underlie differing aspects of ketamine's antidepressant activity.
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Wilkinson ST, Rhee TG, Joormann J, Webler R, Ortiz Lopez M, Kitay B, Fasula M, Elder C, Fenton L, Sanacora G. Cognitive Behavioral Therapy to Sustain the Antidepressant Effects of Ketamine in Treatment-Resistant Depression: A Randomized Clinical Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 90:318-327. [PMID: 34186531 DOI: 10.1159/000517074] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ketamine has emerged as a rapid-acting antidepressant. While ongoing treatment can prevent relapse, concerns exist regarding long-term exposure. OBJECTIVE We conducted a randomized trial to examine the feasibility and efficacy of cognitive behavioral therapy (CBT) following intravenous ketamine in treatment-resistant depression (TRD). METHODS Subjects with TRD were recruited and treated with 6 intravenous infusions of ketamine over 3 weeks. Subjects who experienced a clinical response (≥50% improvement in depression severity) were then randomized to receiving CBT or treatment as usual (TAU) for an additional 14 weeks, using a sequential treatment model. RESULTS Of the 42 patients who signed consent, 28 patients achieved a response and were randomized to CBT or TAU. When measured using the Montgomery-Asberg Depression Rating Scale (primary outcome measure), the effect size at the end of the study was moderate (Cohen d = 0.65; 95% CI -0.55 to 1.82), though the group-by-time interaction effect was not significant. There was a significant group-by-time interaction as measured by the Quick Inventory of Depressive Symptomatology (F = 4.58; p = 0.033), favoring a greater sustained improvement in the CBT group. This corresponded to a moderate-to-large effect size of the Cohen d = 0.71 (95% CI -0.30 to 1.70) at the end of the study (14 weeks following the last ketamine infusion). In a subset of patients (N = 20) who underwent cognitive testing using the emotional N-back assessments before and after ketamine, ketamine responders showed improvement in the accuracy of emotional N-back (t[8] = 2.33; p < 0.05) whereas nonresponders did not (t[10] <1; p ns). CONCLUSIONS This proof-of-concept study provides preliminary data indicating that CBT may sustain the antidepressant effects of ketamine in TRD. Further study and optimization of this treatment approach in well-powered clinical trials is recommended.
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Affiliation(s)
- Samuel T Wilkinson
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Interventional Psychiatric Service, Yale School of Medicine, New Haven, Connecticut, USA
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jutta Joormann
- Department of Psychology, Yale University, New Haven, Connecticut, USA
| | - Ryan Webler
- Department of Psychology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mayra Ortiz Lopez
- Department of Nursing, Southern Connecticut State University, New Haven, Connecticut, USA
| | - Brandon Kitay
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta, Georgia, USA
| | - Madonna Fasula
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christina Elder
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lisa Fenton
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Interventional Psychiatric Service, Yale School of Medicine, New Haven, Connecticut, USA
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Davis MT, DellaGiogia N, Maruff P, Pietrzak RH, Esterlis I. Acute cognitive effects of single-dose intravenous ketamine in major depressive and posttraumatic stress disorder. Transl Psychiatry 2021; 11:205. [PMID: 33833217 PMCID: PMC8032778 DOI: 10.1038/s41398-021-01327-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/19/2021] [Accepted: 03/17/2021] [Indexed: 02/02/2023] Open
Abstract
Intravenous (IV) subanesthetic doses of ketamine have been shown to reduce psychiatric distress in both major depressive (MDD) and posttraumatic stress disorder (PTSD). However, the effect of ketamine on cognitive function in these disorders is not well understood. To address this gap, we examined the effect of a single dose of IV ketamine on cognition in individuals with MDD and/or PTSD relative to healthy controls (HC). Psychiatric (n = 29; 15 PTSD, 14 MDD) and sex- age- and IQ matched HC (n = 29) groups were recruited from the community. A single subanesthetic dose of IV ketamine was administered. Mood and cognitive measures were collected prior to, 2 h and 1 day post-ketamine administration. MDD/PTSD individuals evidenced a large-magnitude improvement in severity of depressive symptoms at both 2-hours and 1 day post-ketamine administration (p's < .001, Cohen d's = 0.80-1.02). Controlling for baseline performance and years of education, IV ketamine induced declines in attention (ATTN), executive function (EF), and verbal memory (VM) 2 h post-administration, all of which had resolved by 1 day post-ketamine across groups. The magnitude of cognitive decline was significantly larger in MDD/PTSD relative to HC on attention only (p = .012, d = 0.56). Ketamine did not affect working memory (WM) performance. Cognitive function (baseline, change from baseline to post-ketamine) was not associated with antidepressant response to ketamine. Results suggest that while ketamine may have an acute deleterious effect on some cognitive domains in both MDD/PTSD and HC individuals, most notably attention, this reduction is transient and there is no evidence of ketamine-related cognitive dysfunction at 1 day post-administration.
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Affiliation(s)
- Margaret T Davis
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA
- Yale University, Department of Psychology, New Haven, USA
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Washington, DC, USA
| | - Nicole DellaGiogia
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA
| | | | - Robert H Pietrzak
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Washington, DC, USA
| | - Irina Esterlis
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA.
- Yale University, Department of Psychology, New Haven, USA.
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Washington, DC, USA.
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Use of subcutaneous ketamine to rapidly improve severe treatment-resistant depression in a patient with Alzheimer's disease. Int Clin Psychopharmacol 2021; 36:104-105. [PMID: 33230024 DOI: 10.1097/yic.0000000000000334] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Kayser RR, Haney M, Simpson HB. Human Laboratory Models of Cannabis Use: Applications for Clinical and Translational Psychiatry Research. Front Psychiatry 2021; 12:626150. [PMID: 33716825 PMCID: PMC7947318 DOI: 10.3389/fpsyt.2021.626150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/03/2021] [Indexed: 11/13/2022] Open
Abstract
Cannabis is increasingly used by individuals with mental health diagnoses and often purported to treat anxiety and various other psychiatric symptoms. Yet support for using cannabis as a psychiatric treatment is currently limited by a lack of evidence from rigorous placebo-controlled studies. While regulatory hurdles and other barriers make clinical trials of cannabis challenging to conduct, addiction researchers have decades of experience studying cannabis use in human laboratory models. These include methods to control cannabis administration, to delineate clinical and mechanistic aspects of cannabis use, and to evaluate potential treatment applications for cannabis and its constituents. In this paper, we review these human laboratory procedures and describe how each can be applied to study cannabis use in patients with psychiatric disorders. Because anxiety disorders are among the most common psychiatric illnesses affecting American adults, and anxiety relief is also the most commonly-reported reason for medicinal cannabis use, we focus particularly on applying human laboratory models to study cannabis effects in individuals with anxiety and related disorders. Finally, we discuss how these methods can be integrated to study cannabis effects in other psychiatric conditions and guide future research in this area.
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Affiliation(s)
- Reilly R. Kayser
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
- Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York, NY, United States
| | - Margaret Haney
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
- Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York, NY, United States
| | - Helen Blair Simpson
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
- Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York, NY, United States
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26
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Swainson J, McGirr A, Blier P, Brietzke E, Richard-Devantoy S, Ravindran N, Blier J, Beaulieu S, Frey BN, Kennedy SH, McIntyre RS, Milev RV, Parikh SV, Schaffer A, Taylor VH, Tourjman V, van Ameringen M, Yatham LN, Ravindran AV, Lam RW. The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder: Recommandations Du Groupe De Travail Du Réseau Canadien Pour Les Traitements De L'humeur Et De L'anxiété (Canmat) Concernant L'utilisation De La Kétamine Racémique Chez Les Adultes Souffrant De Trouble Dépressif Majeur. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:113-125. [PMID: 33174760 PMCID: PMC7918868 DOI: 10.1177/0706743720970860] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Patients with major depressive disorder often have limited response to first-line and second-line medications; hence, novel pharmacological treatments are needed for treatment-resistant depression (TRD). Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, has demonstrated rapid antidepressant effects in patients with TRD. The Canadian Network for Mood and Anxiety Treatments (CANMAT) convened a task force to review the evidence for efficacy and safety of racemic ketamine and to provide recommendations for its use in clinical practice. METHODS A systematic review was conducted with computerized search of electronic databases up to January 31, 2020 using combinations of search terms, inspection of bibliographies, and review of other ketamine guidelines and consensus statements. The level of evidence and lines of treatment were assigned according to CANMAT criteria. Recommendations were given in question-answer format. RESULTS Intravenous (IV) racemic ketamine given as a single infusion has Level 1 evidence for efficacy in adults with TRD. The evidence for multiple infusions, given as an acute series or as ongoing maintenance treatment, is limited to Level 3. Adverse events associated with ketamine infusions include behavioral (e.g., dissociative symptoms) and physiological (e.g., hypertension) events. There is only Level 3 or 4 evidence for non-IV formulations of racemic ketamine. Consensus recommendations are given for clinical administration of IV ketamine including patient selection, facility and personnel issues, monitoring, and maintaining response. CONCLUSIONS Single-dose IV racemic ketamine is a third-line recommendation for adults with TRD. The need for repeated and maintenance ketamine infusions should be carefully assessed on a case-by-case basis with consideration of potential risks and benefits. Because of limited evidence for efficacy and risk for misuse and diversion, the use of oral and other formulations of racemic ketamine should be limited to specialists with ketamine-prescribing expertise and affiliations with tertiary or specialized centers.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, 12357University of Alberta, Edmonton, Alberta, Canada
| | - Alexander McGirr
- Department of Psychiatry, 70401University of Calgary, Alberta, Canada
| | - Pierre Blier
- Department of Psychiatry, 12365University of Ottawa, Ontario, Canada
| | - Elisa Brietzke
- Department of Psychiatry, 104820Queen's University, Kingston, Ontario, Canada
| | | | - Nisha Ravindran
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Jean Blier
- Department of Anesthesiology and Pain Medicine, 12365University of Ottawa, Ontario, Canada
| | - Serge Beaulieu
- Department of Psychiatry, 12367McGill University, Montreal, Quebec, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, 62703McMaster University, Hamilton, Ontario, Canada
| | - Sidney H Kennedy
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Roger S McIntyre
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Roumen V Milev
- Department of Psychiatry, 104820Queen's University, Kingston, Ontario, Canada
| | - Sagar V Parikh
- Department of Psychiatry, 12266University of Michigan, Ann Arbor, Michigan, USA
| | - Ayal Schaffer
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Valerie H Taylor
- Department of Psychiatry, 70401University of Calgary, Alberta, Canada
| | - Valérie Tourjman
- Department of Psychiatry, 12368Université de Montréal, Québec, Canada
| | - Michael van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, 62703McMaster University, Hamilton, Ontario, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Arun V Ravindran
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Raymond W Lam
- Department of Psychiatry, 8166University of British Columbia, Vancouver, British Columbia, Canada
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27
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Weston RG, Fitzgerald PJ, Watson BO. Repeated Dosing of Ketamine in the Forced Swim Test: Are Multiple Shots Better Than One? Front Psychiatry 2021; 12:659052. [PMID: 34045982 PMCID: PMC8144297 DOI: 10.3389/fpsyt.2021.659052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022] Open
Abstract
The anesthetic drug ketamine has been successfully repurposed as an antidepressant in human subjects. This represents a breakthrough for clinical psychopharmacology, because unlike monoaminergic antidepressants, ketamine has rapid onset, including in Major Depressive Disorder (MDD) that is resistant to conventional pharmacotherapy. This rapid therapeutic onset suggests a unique mechanism of action, which continues to be investigated in reverse translational studies in rodents. A large fraction of rodent and human studies of ketamine have focused on the effects of only a single administration of ketamine, which presents a problem because MDD is typically a persistent illness that may require ongoing treatment with this drug to prevent relapse. Here we review behavioral studies in rodents that used repeated dosing of ketamine in the forced swim test (FST), with an eye toward eventual mechanistic studies. A subset of these studies carried out additional experiments with only a single injection of ketamine for comparison, and several studies used chronic psychosocial stress, where stress is a known causative factor in some cases of MDD. We find that repeated ketamine can in some cases paradoxically produce increases in immobility in the FST, especially at high doses such as 50 or 100 mg/kg. Several studies however provide evidence that repeated dosing is more effective than a single dose at decreasing immobility, including behavioral effects that last longer. Collectively, this growing literature suggests that repeated dosing of ketamine has prominent depression-related effects in rodents, and further investigation may help optimize the use of this drug in humans experiencing MDD.
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Affiliation(s)
- Ridge G Weston
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Paul J Fitzgerald
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Brendon O Watson
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
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28
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Gałuszko-Wȩgielnik M, Włodarczyk A, Cubała WJ, Wilkowska A, Górska N, Słupski J. Case Report: Repeated Series of Ketamine Infusions in Patients With Treatment-Resistant Depression: Presentation of Five Cases. Front Psychiatry 2021; 12:705190. [PMID: 34925081 PMCID: PMC8674554 DOI: 10.3389/fpsyt.2021.705190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/25/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose: Approximately 30% of patients with major depressive disorder (MDD) are treatment resistant. There is an unquestionable need for new treatment strategies. Subanesthetic doses of intravenous (IV) ketamine have a rapid antidepressant effect in treatment-resistant depression (TRD). This paper describes the efficacy of repeated series of intravenous ketamine infusions as an add-on treatment in five TRD inpatients. Methods: Eligible patients aged 43-63 were given eight ketamine infusions as an add-on treatment for patients with MDD. The subjects have readministered the intervention due to worsening depressive symptoms. Results: Of the five inpatients given ketamine as a series of eight infusions, one underwent three, and four had two treatment series. Four patients achieved remission after first series and three after the second series of ketamine infusions. The adverse reactions were mild and transient with no sequelae. Limitations: Presented case series applies to short-term intervention with IV ketamine as an add-on therapy. The results cannot be generalized to the long-term maintenance treatment nor other ketamine formulations as well as different administration schedules and dosing. Conclusions: This case series showed efficacy and safety of the repeated series of IV ketamine treatment in TRD in MDD and bipolar disorder type I. The subsequent interventions were safe and observed adverse events were mild and transient. Interestingly, the IV ketamine treatment at successive administrations seems to alter the major depression severity of the next affective episode. There is a critical need for further research regarding IV ketamine treatment effectiveness and long-term safety in future studies.
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Affiliation(s)
| | - Adam Włodarczyk
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Wiesław Jerzy Cubała
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Alina Wilkowska
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Natalia Górska
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Jakub Słupski
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Phillips JL, Norris S, Talbot J, Birmingham M, Hatchard T, Ortiz A, Owoeye O, Batten LA, Blier P. Single, Repeated, and Maintenance Ketamine Infusions for Treatment-Resistant Depression: A Randomized Controlled Trial. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:236-243. [PMID: 33343241 DOI: 10.1176/appi.focus.18206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/12/2018] [Accepted: 11/19/2018] [Indexed: 12/01/2022]
Abstract
(Reprinted with permission from The American Journal of Psychiatry 2019; 176:401-409).
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Affiliation(s)
- Jennifer L Phillips
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Sandhaya Norris
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Jeanne Talbot
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Meagan Birmingham
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Taylor Hatchard
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Abigail Ortiz
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Olabisi Owoeye
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Lisa A Batten
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Pierre Blier
- Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
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Sakurai H, Jain F, Foster S, Pedrelli P, Mischoulon D, Fava M, Cusin C. Long-term outcome in outpatients with depression treated with acute and maintenance intravenous ketamine: A retrospective chart review. J Affect Disord 2020; 276:660-666. [PMID: 32871698 DOI: 10.1016/j.jad.2020.07.089] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/27/2020] [Accepted: 07/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little is known about the long-term outcomes of repeated ketamine infusions for depression. We conducted a retrospective chart review to investigate outcomes of maintenance intravenous ketamine treatment at Massachusetts General Hospital. METHODS Eighty-five patients with treatment-resistant depression (TRD) who started intravenous ketamine from October 2018 to November 2019 were examined. Symptom severity was evaluated with the 16-item Quick Inventory of Depressive Symptomatology-Self Report scale (QIDS-SR16) at every visit prior to administration. The initial ketamine dose was usually 0.5 mg/kg infused over 40 min. Intravenous ketamine was administered twice-weekly for three weeks in an induction phase, followed by maintenance with a variable administration schedule and dose. Response was defined as a ≥50% reduction in total QIDS-SR16 score from baseline. RESULTS Forty (47.1%) of the 85 patients who started treatment discontinued during or right after the induction phase; 3 (3.5%) were still on induction at the time of this report, and 42 (49.4%) transitioned to maintenance after completing induction. Among these patients, 14 (16.5%) discontinued during maintenance and 28 (32.9%) continued on maintenance. The mean ketamine dosage during maintenance was 0.91±0.28 mg/kg. Fifteen out of 82 patients (18.3%) responded to induction treatment and 6 (7.3%) remained in responder status at the time of data analysis during maintenance. Three patients discontinued ketamine due to side-effects. CONCLUSIONS Despite the apparently low response rate in QIDS-SR16 scores and considerable out-of-pocket costs, almost half of real-world outpatients with TRD decided to continue with maintenance ketamine treatment due to perceived significant improvement.
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Affiliation(s)
- Hitoshi Sakurai
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Felipe Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Simmie Foster
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Paola Pedrelli
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Maurizio Fava
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Cristina Cusin
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
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Acevedo-Diaz EE, Cavanaugh GW, Greenstein D, Kraus C, Kadriu B, Park L, Zarate CA. Can 'floating' predict treatment response to ketamine? Data from three randomized trials of individuals with treatment-resistant depression. J Psychiatr Res 2020; 130:280-285. [PMID: 32861983 PMCID: PMC8073211 DOI: 10.1016/j.jpsychires.2020.06.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/23/2020] [Accepted: 06/16/2020] [Indexed: 01/04/2023]
Abstract
Ketamine has rapid-acting antidepressant properties but also potentially concerning transient dissociative side effects (SEs). Recent studies noted a positive correlation between treatment response to ketamine and general dissociative SEs, as well as "floating", a depersonalization SE (a subtype of the dissociative SEs). This analysis sought to determine whether floating mediates treatment response to ketamine. Data were pooled from three double-blind, crossover, placebo-controlled ketamine clinical trials across which 82 participants with treatment-resistant depression (TRD) (44 with bipolar depression and 38 with major depressive disorder) received placebo and ketamine (0.5 mg/kg) infusions. SEs were actively solicited in a standardized fashion before and after ketamine infusion. The hypothesis that a post-infusion experience of floating would mediate antidepressant response to ketamine was assessed at 230 min post-infusion and at Day 1. Montgomery-Asberg Depression Rating Scale (MADRS) total score was the dependent variable in a linear mixed effects model. Ketamine significantly decreased MADRS scores (p < 0.0001), but no relationship was detected between floating and MADRS score at either 230 min or Day 1 post-infusion. The hypothesized mediation effect of floating was also not detected at either 230 min or Day 1 post-infusion. Taken together, the findings do not support the hypothesis that ketamine's antidepressant effects are mediated by the dissociative depersonalization subtype SE of floating.
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Affiliation(s)
- Elia E Acevedo-Diaz
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Grace W Cavanaugh
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Dede Greenstein
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Christoph Kraus
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Bashkim Kadriu
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Lawrence Park
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Breeksema JJ, Niemeijer AR, Krediet E, Vermetten E, Schoevers RA. Psychedelic Treatments for Psychiatric Disorders: A Systematic Review and Thematic Synthesis of Patient Experiences in Qualitative Studies. CNS Drugs 2020; 34:925-946. [PMID: 32803732 PMCID: PMC7447679 DOI: 10.1007/s40263-020-00748-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Interest in the use of psychedelic substances for the treatment of mental disorders is increasing. Processes that may affect therapeutic change are not yet fully understood. Qualitative research methods are increasingly used to examine patient accounts; however, currently, no systematic review exists that synthesizes these findings in relation to the use of psychedelics for the treatment of mental disorders. OBJECTIVE To provide an overview of salient themes in patient experiences of psychedelic treatments for mental disorders, presenting both common and diverging elements in patients' accounts, and elucidating how these affect the treatment process. METHODS We systematically searched the PubMed, MEDLINE, PsycINFO, and Embase databases for English-language qualitative literature without time limitations. Inclusion criteria were qualitative research design; peer-reviewed studies; based on verbalized patient utterances; and a level of abstraction or analysis of the results. Thematic synthesis was used to analyze and synthesize results across studies. A critical appraisal of study quality and methodological rigor was conducted using the Critical Appraisal Skills Programme (CASP). RESULTS Fifteen research articles, comprising 178 patient experiences, were included. Studies exhibited a broad heterogeneity in terms of substance, mental disorder, treatment context, and qualitative methodology. Substances included psilocybin, lysergic acid diethylamide (LSD), ibogaine, ayahuasca, ketamine and 3,4-methylenedioxymethamphetamine (MDMA). Disorders included anxiety, depression, eating disorders, post-traumatic stress disorder, and substance use disorders. While the included compounds were heterogeneous in pharmacology and treatment contexts, patients reported largely comparable experiences across disorders, which included phenomenological analogous effects, perspectives on the intervention, therapeutic processes and treatment outcomes. Comparable therapeutic processes included insights, altered self-perception, increased connectedness, transcendental experiences, and an expanded emotional spectrum, which patients reported contributed to clinically and personally relevant responses. CONCLUSIONS This review demonstrates how qualitative research of psychedelic treatments can contribute to distinguishing specific features of specific substances, and carry otherwise undiscovered implications for the treatment of specific psychiatric disorders.
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Affiliation(s)
- Joost J Breeksema
- University Center of Psychiatry, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands.
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.
| | | | - Erwin Krediet
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Military Mental Health Care, Utrecht, The Netherlands
- ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Robert A Schoevers
- University Center of Psychiatry, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands
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Ketamine as a mental health treatment: Are acute psychoactive effects associated with outcomes? A systematic review. Behav Brain Res 2020; 392:112629. [DOI: 10.1016/j.bbr.2020.112629] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/17/2020] [Accepted: 03/24/2020] [Indexed: 12/16/2022]
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Feifel D, Dadiomov D, C. Lee K. Safety of Repeated Administration of Parenteral Ketamine for Depression. Pharmaceuticals (Basel) 2020; 13:ph13070151. [PMID: 32668686 PMCID: PMC7408561 DOI: 10.3390/ph13070151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 12/28/2022] Open
Abstract
The objective of this study was to investigate the safety of repeated parenteral ketamine for depression. An electronic survey inquiring about the frequency of adverse events was distributed to providers of parenteral ketamine for depression. In addition, the investigators conducted a search of published studies describing six or more repeated parenteral ketamine treatments administered to individuals for depression, and extracted reported adverse events. The survey was sent to 69 providers, of which 36 responded (52% response rate); after eliminating those that were incomplete, 27 were included in the analysis. The providers in the analysis collectively reported treating 6630 patients with parenteral ketamine for depression, one-third of whom received more than 10 treatments. Only 0.7% of patients experienced an adverse effect that required discontinuation of ketamine. Psychological distress during the treatment was the most frequent cause. Other adverse events were extremely rare (such as bladder dysfunction (0.1%), cognitive decline (0.03%) and psychotic symptoms (0.03%)). Among the 20 published reports of repeated parenteral ketamine treatments, rates of significant adverse events resulting in discontinuation were low (1.2%). The rate of adverse effects reported in the survey and the published literature is low, and suggests that long-term treatment of depression with ketamine is reasonably safe.
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Affiliation(s)
- David Feifel
- Department of Psychiatry, University of California, San Diego, CA 92037, USA
- Kadima Neuropsychiatry Institute, San Diego, CA 92037, USA
- Correspondence: ; Tel.: +01-858-412-4130
| | - David Dadiomov
- Department of Clinical Pharmacy, University of Southern California, Los Angeles, CA 90089, USA;
| | - Kelly C. Lee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA 92037, USA;
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Singh JB, Fedgchin M, Daly EJ, Drevets WC. Relapse prevention in treatment-resistant major depressive disorder with rapid-acting antidepressants. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2020; 89:237-259. [PMID: 32616208 DOI: 10.1016/bs.apha.2020.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Major depressive disorder (MDD) is the leading cause of disability worldwide and reduces life expectancy. Achieving and sustaining remission from depression is challenging after initial improvement of an acute episode with an antidepressant, especially for patients whose depressive episodes have proven treatment-resistant in response to conventional antidepressant pharmacotherapy. While standard antidepressants are at least partly effective for the short-term treatment of acute depressive episodes of MDD, many patients relapse within 6 months of apparent clinical remission, with faster and higher rates observed in those with treatment-resistant depression (TRD). Efficacy of IV ketamine, a rapid-acting N-methyl d-aspartate (NMDA) receptor antagonist, in maintaining antidepressant effect was suggested in a few small, single center, open-label studies and case series. More recently, maintenance of antidepressant effects beyond the initial acute (induction) treatment period has been shown with esketamine nasal spray, an enantiomer of ketamine, in conjunction with an oral antidepressant in three phase 2/3 registration studies (SYNAPSE, SUSTAIN-1, SUSTAIN-2) of adult patients with TRD. In these studies the maintenance of efficacy of an intermittently-dosed esketamine treatment regimen was established in which twice-weekly dose administration during a 4-week induction period was followed initially by weekly administration and later by either weekly or every-other-week administration. During long-term maintenance therapy the antidepressant effect persisted in most patients with this regimen, despite their history of being resistant to conventional antidepressants prior to entering esketamine studies. These data suggest that the neurobiological changes induced by initial esketamine treatment, which putatively underlie its antidepressant effect, can be maintained using repeated administration.
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Affiliation(s)
- Jaskaran B Singh
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, CA, United States; Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ, United States
| | - Maggie Fedgchin
- Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ, United States
| | - Ella J Daly
- Department of Clinical Medical Affairs, Janssen Scientific Affairs, LLC, Titusville, NJ, United States
| | - Wayne C Drevets
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, CA, United States.
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Bobo WV, Riva-Posse P, Goes FS, Parikh SV. Next-Step Treatment Considerations for Patients With Treatment-Resistant Depression That Responds to Low-Dose Intravenous Ketamine. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:181-192. [PMID: 33162856 DOI: 10.1176/appi.focus.20190048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Numerous short-term randomized trials support the acute-phase efficacy of low-dose intravenous (IV) ketamine for patients with treatment-resistant unipolar or bipolar depression. Ketamine's antidepressive effects generally have limited duration, highlighting the need for maintenance treatment after an acute-phase response. It is increasingly likely that psychiatrists will be called upon to manage the care of patients with treatment-resistant unipolar or bipolar depression who have responded acutely to ketamine and to recommend or initiate next-step treatments. However, there is a paucity of controlled evidence to guide best practices for managing treatment of patients with treatment-resistant unipolar or bipolar depression who have had a positive initial response to ketamine. This article reviews the available evidence supporting specific strategies for extending and maintaining acute antidepressive responses to low-dose IV ketamine in patients with treatment-resistant unipolar or bipolar depression and provides some preliminary considerations for clinical practice.
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Affiliation(s)
- William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| | - Patricio Riva-Posse
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| | - Fernando S Goes
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| | - Sagar V Parikh
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
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Dale RM, Bryant KA, Finnegan N, Cromer K, Thompson NR, Altinay M, Anand A. The NEO-FFI domain of openness to experience moderates ketamine response in treatment resistant depression. J Affect Disord 2020; 260:323-328. [PMID: 31521869 DOI: 10.1016/j.jad.2019.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/18/2019] [Accepted: 09/02/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND There are many putative mechanisms by which ketamine has its effect and many unanswered questions about risks and benefits of long-term ketamine therapy. A research imperative is the identification of predictors of response to intravenous ketamine, especially a sustained response to maintenance ketamine. Temperament is an inherited aspect of personality and is a predictive factor for outcome in treatment resistant depressed (TRD) patients. METHODS We analyzed which domains of personality impacted initial and sustained ketamine response. Utilizing the Neuroticism Extraversion Openness Five Factor Inventory (NEO-FFI) on 125 participants with TRD, we tested (1) whether the degree of neuroticism predicted initial and/or sustained response to ketamine; and (2) whether extraversion, agreeableness, openness to experience, and conscientiousness had an impact on response. RESULTS Our findings confirmed previous literature that elevated neuroticism, low conscientiousness, and low extraversion was the pattern of our TRD population regardless of response. Openness was the only factor to significantly predict sustained treatment outcome. LIMITATIONS Our findings are limited by the lack of placebo control, small sample size, non- standardized infusion intervals, polypharmacy rather than ketamine monotherapy, a select TRD population in that they had all failed ECT, and a primarily Caucasian population. CONCLUSIONS Our registry adds to the literature that factors making up temperament may have predictive value in regard to treatment response, specifically the outcome for TRD patients receiving long-term ketamine infusion therapy. If confirmed, assessing for Openness could reduce inappropriate exposure to ketamine with its attendant unknown long-term risks.
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Affiliation(s)
- Roman M Dale
- Center for Behavioral Health, Lutheran Hospital, 1730 West 25th St., Cleveland, OH 44113, United States.
| | - Kelly A Bryant
- Center for Behavioral Health, Lutheran Hospital, 1730 West 25th St., Cleveland, OH 44113, United States
| | - Nora Finnegan
- Center for Behavioral Health, Lutheran Hospital, 1730 West 25th St., Cleveland, OH 44113, United States
| | - Kim Cromer
- Center for Behavioral Health, Lutheran Hospital, 1730 West 25th St., Cleveland, OH 44113, United States
| | - Nicolas R Thompson
- Quantitative Health Sciences, 9211 Euclid Avenue, Cleveland, OH 44106, United States
| | - Murat Altinay
- Center for Behavioral Health, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, United States
| | - Amit Anand
- Center for Behavioral Health, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, United States
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Phillips JL, Norris S, Talbot J, Birmingham M, Hatchard T, Ortiz A, Owoeye O, Batten LA, Blier P. Single, Repeated, and Maintenance Ketamine Infusions for Treatment-Resistant Depression: A Randomized Controlled Trial. Am J Psychiatry 2019; 176:401-409. [PMID: 30922101 DOI: 10.1176/appi.ajp.2018.18070834] [Citation(s) in RCA: 234] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Subanesthetic ketamine doses have been shown to have rapid yet transient antidepressant effects in patients with treatment-resistant depression, which may be prolonged by repeated administration. The purpose of this study was to evaluate the antidepressant effects of a single ketamine infusion, a series of repeated ketamine infusions, and prolongation of response with maintenance infusions. METHODS Forty-one participants with treatment-resistant depression completed a single-site randomized double-blind crossover comparison of single infusions of ketamine and midazolam (an active placebo control). After relapse of depressive symptoms, participants received a course of six open-label ketamine infusions administered thrice weekly over 2 weeks. Responders, classified as those participants who had a ≥50% decrease in their scores on the Montgomery-Åsberg Depression Rating Scale (MADRS), received four additional infusions administered once weekly (maintenance phase). RESULTS Compared with midazolam, a single ketamine infusion elicited a significantly greater reduction in depressive symptoms at the primary efficacy endpoint (24 hours postinfusion). Linear mixed models revealed cumulative antidepressant effects with repeated infusions and doubling of the antidepressant response rate. Fifty-nine percent of participants met response criteria after repeated infusions, with a median of three infusions required before achieving response. Participants had no further change in MADRS scores during weekly maintenance infusions. CONCLUSIONS Repeated ketamine infusions have cumulative and sustained antidepressant effects. Reductions in depressive symptoms were maintained among responders through once-weekly infusions. These findings provide novel data on efficacious administration strategies for ketamine in patients with treatment-resistant depression. Future studies should further expand on optimizing administration to better translate the use of ketamine into clinical settings.
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Affiliation(s)
- Jennifer L Phillips
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Sandhaya Norris
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Jeanne Talbot
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Meagan Birmingham
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Taylor Hatchard
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Abigail Ortiz
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Olabisi Owoeye
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Lisa A Batten
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
| | - Pierre Blier
- From the Mood Disorders Research Unit, The Royal's Institute of Mental Health Research, Ottawa (Phillips, Norris, Talbot, Birmingham, Hatchard, Ortiz, Owoeye, Batten, Blier); the Department of Psychiatry, University of Ottawa (Phillips, Norris, Talbot, Owoeye, Blier); and the Department of Cellular and Molecular Medicine, University of Ottawa (Blier)
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Stress-sensitive antidepressant-like effects of ketamine in the mouse forced swim test. PLoS One 2019; 14:e0215554. [PMID: 30986274 PMCID: PMC6464213 DOI: 10.1371/journal.pone.0215554] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 04/03/2019] [Indexed: 01/18/2023] Open
Abstract
Major depression is a stress-linked disease with significant morbidity and the anesthetic drug ketamine is of growing interest in the treatment of depression, since in responsive individuals a single dose has rapid (within hours) antidepressant effects that can be sustained for over a week in some instances. This combination of fast action and a therapeutic effect that lasts far beyond the drug’s half-life points to a unique mechanism of action. In this reverse translational study, we investigate the degree to which ketamine counteracts stress-related depression-like behavioral responses by determining whether it affects unstressed animals similarly to stressed mice. To test this, male C57BL/6J mice were given a single injection of vehicle (0.9% saline; i.p.), 10 mg/kg ketamine, or 30 mg/kg ketamine, and were tested in the forced swim test (FST) 24 hours and 7 days later, as well as in the open field test on the eighth day. Unstressed mice had normal group housing, environmental enrichment, and experimenter pre-handling (5 days), whereas stressed animals were subjected to chronic mild stress (single housing, reduced enrichment and minimal handling), where some mice also had daily two-week unpredictable chronic stress (UCS). We find that ketamine (24 hours post-injection) decreases immobility and increases mobile (swimming) behavior (antidepressant-like effects) in UCS animals but does the opposite in unstressed mice, similar to recent human findings. In summary, these data suggest that chronic psychological stress interacts with ketamine treatment to modulate its effects in the C57BL/6J mouse FST, which reinforces the relevance of this test, and this strain of mice, to human, stress-induced depression.
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Mathew SJ, Wilkinson ST, Altinay M, Asghar-Ali A, Chang LC, Collins KA, Dale RM, Hu B, Krishnan K, Kellner CH, Malone DA, Murrough JW, Ostroff RB, Sanacora G, Shao M, Anand A. ELEctroconvulsive therapy (ECT) vs. Ketamine in patients with Treatment-resistant Depression: The ELEKT-D study protocol. Contemp Clin Trials 2019; 77:19-26. [PMID: 30572160 DOI: 10.1016/j.cct.2018.12.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/04/2018] [Accepted: 12/16/2018] [Indexed: 12/16/2022]
Abstract
Major depressive disorder (MDD) is the most common mental illness and the leading cause of disability worldwide. Electroconvulsive therapy (ECT) is the most effective treatment for MDD and the gold-standard therapy for treatment-resistant depression (TRD), yet it remains underutilized due to factors such as limited availability, stigma, and concerns about cognitive side effects. Ketamine has emerged as the first rapid-acting antidepressant and shows robust short-term efficacy in clinical trials, but there are concerns about its long-term safety and efficacy. While response rates are similar between ECT and ketamine in clinical trials, these treatments have never been compared head-to-head in a sufficiently large, well-powered randomized study. Here we describe the study protocol for ELEctroconvulsive therapy (ECT) vs. Ketamine in patients with Treatment-resistant Depression (ELEKT-D), a non-inferiority, comparative effectiveness trial. Patients with TRD seeking clinical treatment are randomized (1:1) to receive ECT (thrice weekly) or intravenous ketamine (twice weekly) for 3-5 weeks. The primary outcome is the proportion of responders in each group at the end of study visit, as measured by a patient-reported outcome measure (Quick Inventory of Depressive Symptomatology-Self Report). The study is powered such that the non-inferiority margin allows for ketamine to retain 90% of the ECT treatment effect, with a projected sample size of 400 patients (200 per group). Secondary outcomes include remission rates, depression severity, cognitive functioning, quality of life, adverse events, and tolerability. The results of the ELEKT-D study will have important implications for patient choice, clinical practice, and health insurance policies.
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Affiliation(s)
- Sanjay J Mathew
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, United States; Mental Health Care Line, Michael E. Debakey VA Medical Center, United States
| | - Samuel T Wilkinson
- Department of Psychiatry, Yale University School of Medicine, United States
| | - Murat Altinay
- Center for Behavioral Health, Cleveland Clinic, United States; Center for Behavioral Health, Lutheran Hospital, United States; Cleveland Clinic Lerner, College of Medicine of Case Western Reserve University, United States
| | - Ali Asghar-Ali
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, United States; Mental Health Care Line, Michael E. Debakey VA Medical Center, United States
| | - Lee C Chang
- Department of Anesthesiology, Baylor College of Medicine, United States
| | - Katherine A Collins
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, United States
| | - Roman M Dale
- Center for Behavioral Health, Cleveland Clinic, United States; Center for Behavioral Health, Lutheran Hospital, United States; Cleveland Clinic Lerner, College of Medicine of Case Western Reserve University, United States
| | - Bo Hu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, United States
| | - Kamini Krishnan
- Cleveland Clinic Lou Ruvo Center for Brain Health, United States
| | - Charles H Kellner
- Department of Psychiatry, New York Community Hospital, United States
| | - Donald A Malone
- Center for Behavioral Health, Cleveland Clinic, United States; Center for Behavioral Health, Lutheran Hospital, United States; Cleveland Clinic Lerner, College of Medicine of Case Western Reserve University, United States
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, United States; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, United States
| | - Robert B Ostroff
- Department of Psychiatry, Yale University School of Medicine, United States
| | - Gerard Sanacora
- Department of Psychiatry, Yale University School of Medicine, United States
| | - Mingyuan Shao
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, United States
| | - Amit Anand
- Center for Behavioral Health, Cleveland Clinic, United States; Center for Behavioral Health, Lutheran Hospital, United States; Cleveland Clinic Lerner, College of Medicine of Case Western Reserve University, United States.
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Sanacora G, Katz R. Ketamine: A Review for Clinicians. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2018; 16:243-250. [PMID: 31975918 DOI: 10.1176/appi.focus.20180012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A growing series of clinical trials and case series now suggest that ketamine-originally used as an anesthetic agent-potentially offers an exciting new treatment option for severe depression. Increasing numbers of studies show that ketamine can provide prompt relief for many depressed patients, including those with severe treatment-refractory depression. Although the effects of a single treatment are commonly short-lived, multiple infusion protocols may offer sustained relief. The uniquely rapid onset of antidepressant action raises the potential for ketamine use in a variety of clinical situations, including the prevention or shortening of hospital stays, the treatment of acute suicidal ideation, and the facilitation of medication crossovers. Ketamine, in combination with other multimodal treatment approaches, including psychotherapy, may further augment response effect and duration. Promises of efficacy have led to increasingly unbridled use to treat a variety of psychiatric disorders, with diverse approaches and treatment environments, despite inadequate data demonstrating the true clinical efficacy and safety of the various protocols or a thorough understanding of mechanisms of action. This article briefly reviews the history of ketamine's development as a potential antidepressant, current hypotheses related to its mechanisms of action, and existing evidence for its safety and efficacy with a focus on clinicians' interests.
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Affiliation(s)
- Gerard Sanacora
- Drs. Sanacora and Katz are both with the Yale Department of Psychiatry, Yale University, New Haven CT, and the Yale Interventional Psychiatry Service, Yale New Haven Psychiatric Hospital, New Haven, CT
| | - Rachel Katz
- Drs. Sanacora and Katz are both with the Yale Department of Psychiatry, Yale University, New Haven CT, and the Yale Interventional Psychiatry Service, Yale New Haven Psychiatric Hospital, New Haven, CT
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Concurrent use of ketamine and monoamine oxidase inhibitors in the treatment of depression: A letter to the editor. Gen Hosp Psychiatry 2018; 54:62-64. [PMID: 30100209 PMCID: PMC6292194 DOI: 10.1016/j.genhosppsych.2018.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/18/2018] [Accepted: 05/20/2018] [Indexed: 12/26/2022]
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