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Norbury A, Rutter SB, Collins AB, Costi S, Jha MK, Horn SR, Kautz M, Corniquel M, Collins KA, Glasgow AM, Brallier J, Shin LM, Charney DS, Murrough JW, Feder A. Neuroimaging correlates and predictors of response to repeated-dose intravenous ketamine in PTSD: preliminary evidence. Neuropsychopharmacology 2021; 46:2266-2277. [PMID: 34333555 PMCID: PMC8580962 DOI: 10.1038/s41386-021-01104-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023]
Abstract
Promising initial data indicate that the glutamate N-methyl-D-aspartate (NMDA) receptor antagonist ketamine may be beneficial in post-traumatic stress disorder (PTSD). Here, we explore the neural correlates of ketamine-related changes in PTSD symptoms, using a rich battery of functional imaging data (two emotion-processing tasks and one task-free scan), collected from a subset of participants of a randomized clinical trial of repeated-dose intravenous ketamine vs midazolam (total N = 21). In a pre-registered analysis, we tested whether changes in an a priori set of imaging measures from a target neural circuit were predictive of improvement in PTSD symptoms, using leave-one-out cross-validated elastic-net regression models (regions of interest in the target circuit consisted of the dorsal and rostral anterior cingulate cortex, ventromedial prefrontal cortex, anterior hippocampus, anterior insula, and amygdala). Improvements in PTSD severity were associated with increased functional connectivity between the ventromedial prefrontal cortex (vmPFC) and amygdala during emotional face-viewing (change score retained in model with minimum predictive error in left-out subjects, standardized regression coefficient [β] = 2.90). This effect was stronger in participants who received ketamine compared to midazolam (interaction β = 0.86), and persisted following inclusion of concomitant change in depressive symptoms in the analysis model (β = 0.69). Improvement following ketamine was also predicted by decreased dorsal anterior cingulate activity during emotional conflict regulation, and increased task-free connectivity between the vmPFC and anterior insula (βs = -2.82, 0.60). Exploratory follow-up analysis via dynamic causal modelling revealed that whilst improvement in PTSD symptoms following either drug was associated with decreased excitatory modulation of amygdala→vmPFC connectivity during emotional face-viewing, increased top-down inhibition of the amygdala by the vmPFC was only observed in participants who improved under ketamine. Individuals with low prefrontal inhibition of amygdala responses to faces at baseline also showed greater improvements following ketamine treatment. These preliminary findings suggest that, specifically under ketamine, improvements in PTSD symptoms are accompanied by normalization of hypofrontal control over amygdala responses to social signals of threat.
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Affiliation(s)
- Agnes Norbury
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah B Rutter
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abigail B Collins
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Costi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manish K Jha
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah R Horn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marin Kautz
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Morgan Corniquel
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Collins
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | - Andrew M Glasgow
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jess Brallier
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lisa M Shin
- Department of Psychology, Tufts University, Medford, MA, USA
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Dennis S Charney
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adriana Feder
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Feder A, Costi S, Rutter SB, Collins AB, Govindarajulu U, Jha MK, Horn SR, Kautz M, Corniquel M, Collins KA, Bevilacqua L, Glasgow AM, Brallier J, Pietrzak RH, Murrough JW, Charney DS. A Randomized Controlled Trial of Repeated Ketamine Administration for Chronic Posttraumatic Stress Disorder. Am J Psychiatry 2021; 178:193-202. [PMID: 33397139 DOI: 10.1176/appi.ajp.2020.20050596] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a chronic and disabling disorder, for which available pharmacotherapies have limited efficacy. The authors' previous proof-of-concept randomized controlled trial of single-dose intravenous ketamine infusion in individuals with PTSD showed significant and rapid PTSD symptom reduction 24 hours postinfusion. The present study is the first randomized controlled trial to test the efficacy and safety of repeated intravenous ketamine infusions for the treatment of chronic PTSD. METHODS Individuals with chronic PTSD (N=30) were randomly assigned (1:1) to receive six infusions of ketamine (0.5 mg/kg) or midazolam (0.045 mg/kg) (psychoactive placebo control) over 2 consecutive weeks. Clinician-rated and self-report assessments were administered 24 hours after the first infusion and at weekly visits. The primary outcome measure was change in PTSD symptom severity, as assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), from baseline to 2 weeks (after completion of all infusions). Secondary outcome measures included the Impact of Event Scale-Revised, the Montgomery-Åsberg Depression Rating Scale (MADRS), and side effect measures. RESULTS The ketamine group showed a significantly greater improvement in CAPS-5 and MADRS total scores than the midazolam group from baseline to week 2. At week 2, the mean CAPS-5 total score was 11.88 points (SE=3.96) lower in the ketamine group than in the midazolam group (d=1.13, 95% CI=0.36, 1.91). Sixty-seven percent of participants in the ketamine group were treatment responders, compared with 20% in the midazolam group. Among ketamine responders, the median time to loss of response was 27.5 days following the 2-week course of infusions. Ketamine infusions were well tolerated overall, without serious adverse events. CONCLUSIONS This randomized controlled trial provides the first evidence of efficacy of repeated ketamine infusions in reducing symptom severity in individuals with chronic PTSD. Further studies are warranted to understand ketamine's full potential as a treatment for chronic PTSD.
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Affiliation(s)
- Adriana Feder
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Sara Costi
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Sarah B Rutter
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Abigail B Collins
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Usha Govindarajulu
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Manish K Jha
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Sarah R Horn
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Marin Kautz
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Morgan Corniquel
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Katherine A Collins
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Laura Bevilacqua
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Andrew M Glasgow
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Jess Brallier
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Robert H Pietrzak
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - James W Murrough
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
| | - Dennis S Charney
- Department of Psychiatry, Depression and Anxiety Center for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York (Feder, Costi, Rutter, A.B. Collins, Jha, Horn, Kautz, Corniquel, K.A. Collins, Bevilacqua, Murrough, Charney); Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (Govindarajulu); Nathan Kline Institute for Psychiatric Research, Orangeburg, N.Y. (K.A. Collins); Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York (Glasgow, Brallier); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Pietrzak); Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York (Murrough, Charney); and Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York (Charney).,Drs. Murrough and Charney share senior authorship
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