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Stroud J, Rice C, Orsini A, Schlosser M, Lee J, Mandy W, Kamboj SK. Perceived changes in mental health and social engagement attributed to a single psychedelic experience in autistic adults: results from an online survey. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06685-8. [PMID: 39367164 DOI: 10.1007/s00213-024-06685-8] [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: 03/26/2024] [Accepted: 09/05/2024] [Indexed: 10/06/2024]
Abstract
RATIONALE Anecdotal reports suggest that psychedelic drugs can improve psychological wellbeing and social engagement in autistic people. However, there are few contemporary studies on this topic. OBJECTIVES To examine autistic participants' experiences with psychedelic drugs and the extent to which they attributed changes in mental health and social engagement to their most 'impactful' psychedelic experience. We also explored associations between these changes and mechanistically important variables (e.g., aspects of the acute psychedelic experience and changes in 'psychological flexibility'). METHODS Self-selecting autistic participants (n = 233) with high autism quotient scores completed an online survey relating to their most impactful psychedelic experience. Questionnaires assessed the acute psychedelic experience and perceived psychedelic-induced changes in distress, social engagement and psychological flexibility, among other relevant variables. RESULTS The majority of participants attributed reductions in psychological distress (82%) and social anxiety (78%) and increases in social engagement (70%) to their most 'impactful' psychedelic experience. A substantial minority (20%) also reported undesirable effects such as increases in anxiety with some describing their psychedelic experience as among the most negatively impactful experiences of their lives. The only substantial predictor of reductions in psychological distress was increased psychological flexibility. CONCLUSION Autistic people attributed changes in mental health and social engagement to a single highly impactful psychedelic experience. The results and their implications are discussed with caution considering the use of a non-experimental design and biased sampling.
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Affiliation(s)
- Jack Stroud
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
| | - Charlotte Rice
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Aaron Orsini
- Autistic Psychedelic Community (Co-production Organisation), Los Angeles, USA
| | - Marco Schlosser
- Division of Psychiatry, University College London, London, UK
| | - Justine Lee
- Autistic Psychedelic Community (Co-production Organisation), Los Angeles, USA
| | - Will Mandy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Sunjeev K Kamboj
- Clinical Psychopharmacology Unit, University College London, London, UK
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Palhano-Fontes F, Cavalcanti-Ribeiro P, da Costa Gonçalves KT, de Almeida VRN, Barbosa DC, de Araújo Ferreira MA, Bolcont R, De Souza LCAM, Santos NC, Lopes EITC, de Medeiros Lima NB, de Brito AJC, Falchi-Carvalho M, Arcoverde E, Araujo D, Galvão-Coelho NL. Repeated subcutaneous esketamine on treatment-resistant depression: An open-label dose titration study. J Affect Disord 2024; 369:155-163. [PMID: 39341294 DOI: 10.1016/j.jad.2024.09.141] [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: 05/14/2024] [Revised: 09/10/2024] [Accepted: 09/21/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Ketamine has gained prominence as one of the most effective therapeutic options in unipolar treatment-resistant depression (TRD). However, most studies related to the antidepressant action of ketamine used intravenous (IV) or intranasal (IN) administration. The subcutaneous (SC) route of administration is a promising alternative, as it results in plasma levels comparable to IV, causes fewer side effects, and is easier and cheaper to administer than both IV and/or IN routes. METHODS In this context, we conducted an open-label clinical trial for investigating the efficacy and safety of 8 weekly sessions of SC esketamine in TRD patients (n = 30). RESULTS At the end of the treatment, a partial response rate of 26.09 %, a response rate of 52.17 % and remission rate of 34.78 % were observed, assessed by Montgomery-Åsberg Depression Rating Scale. Moreover, the self-reported depressive symptoms, as measured by the Beck Depression Inventory II (BDI-II), significantly decreased from the baseline to the final session, and the improvements were sustained throughout the week. Follow-up evaluations (BDI-II) up to the sixth month consistently showed scores lower than the baseline. LIMITATIONS The small sample size and the drop-out during the follow-up phase may limit the generalizability of the findings. Additionally, the absence of a control group necessitates cautious interpretation of causality. CONCLUSIONS This groundbreaking study, which addresses SC esketamine treatment for TRD, reported promising response and remission rates, as well as sustained antidepressant effects. It highlights the need for further research to improve and expand our knowledge of this innovative, more accessible, and cost-effective therapeutic approach.
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Affiliation(s)
- Fernanda Palhano-Fontes
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Center for Advanced Psychedelic Medicine, Natal, RN, Brazil
| | - Patricia Cavalcanti-Ribeiro
- University Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Psychobiology Postgraduate Program, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Emerson Arcoverde
- University Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Draulio Araujo
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Center for Advanced Psychedelic Medicine, Natal, RN, Brazil
| | - Nicole Leite Galvão-Coelho
- Psychobiology Postgraduate Program, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Center for Advanced Psychedelic Medicine, Natal, RN, Brazil.
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Long Z, Li J, Marino M. Brain structural changes underlying clinical symptom improvement following fast-acting treatments in treatment resistant depression. J Affect Disord 2024; 369:52-60. [PMID: 39326585 DOI: 10.1016/j.jad.2024.09.150] [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: 06/19/2024] [Revised: 09/17/2024] [Accepted: 09/21/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Electroconvulsive therapy (ECT), ketamine infusion (KI), and total sleep deprivation (TSD) are effective and fast in treating patients with treatment-resistant depression (TRD). However, it remains unclear whether the three treatments have the same effect on clinical symptom improvement and have common brain structural mechanisms. METHODS The current study included 127 TRD patients and 37 healthy controls, which were obtained from the Perturbation of the Treatment Resistant Depression Connectome Project. We aimed to investigate the shared and distinct brain structural changes underlying clinical symptom improvement among ECT, KI, and TSD treatments. RESULTS All of the three treatments significantly reduced the depressive symptoms in TRD patients, but they differently affected other clinical measurements. Neuroimaging results also revealed that all of ECT, KI, and TSD treatments significantly increased gray matter volume of left caudate after treatment in TRD patients. However, the gray matter volume of other brain regions including hippocampus, parahippocampus, amygdala, insula, fusiform gyrus, several occipital and temporal areas was increased only after ECT treatment. Still, the baseline or the change of gray matter volume did not correlate with the depressive symptom improvement for all of the three treatments. LIMITATIONS A higher sample size would be required to further validate our findings. CONCLUSIONS The results observed in the current study suggested that the ECT, KI, and TSD treatments differently affected clinical measurements and brain structures in TRD patients, though all of them were effective in depressive symptom improvement, which might facilitate the development of personalized treatment protocol for this disease.
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Affiliation(s)
- Zhiliang Long
- Sleep and NeuroImaging Center, Faculty of Psychology, Southwest University, Chongqing, PR China.
| | - Jiao Li
- Clinical Hospital of Chengdu Brain Science Institute, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, PR China; MOE Key Laboratory for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Marco Marino
- Department of General Psychology, University of Padua, Italy; Movement Control and Neuroplasticity Research Group, KU Leuven, Leuven, Belgium
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Guida CR, Maia JM, Ferreira LFR, Rahdar A, Branco LGS, Soriano RN. Advancements in addressing drug dependence: A review of promising therapeutic strategies and interventions. Prog Neuropsychopharmacol Biol Psychiatry 2024; 134:111070. [PMID: 38908501 DOI: 10.1016/j.pnpbp.2024.111070] [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: 02/24/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 06/24/2024]
Abstract
Substance dependence represents a pervasive global concern within the realm of public health. Presently, it is delineated as a persistent and recurrent neurological disorder stemming from drug-triggered neuroadaptations in the brain's reward circuitry. Despite the availability of various therapeutic modalities, there has been a steady escalation in the mortality rate attributed to drug overdoses. Substantial endeavors have been directed towards the exploration of innovative interventions aimed at mitigating cravings and drug-induced repetitive behaviors. Within this review, we encapsulate the most auspicious contemporary treatment methodologies, accentuating meta-analyses of efficacious pharmacological and non-pharmacological approaches: including gabapentin, topiramate, prazosin, physical exercise regimens, and cerebral stimulation techniques.
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Affiliation(s)
- Clara Rodrigues Guida
- Department of Medicine, Federal University of Juiz de Fora, Governador Valadares, MG 35032-620, Brazil
| | - Juliana Marino Maia
- Department of Medicine, Federal University of Juiz de Fora, Governador Valadares, MG 35032-620, Brazil
| | | | - Abbas Rahdar
- Department of Physics, Faculty of Sciences, University of Zabol, Zabol 538-98615, Iran
| | - Luiz G S Branco
- Department of Basic and Oral Biology, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP 14040-904, Brazil; Department of Physiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP 14040-900, Brazil.
| | - Renato Nery Soriano
- Division of Physiology and Biophysics, Department of Basic Life Sciences, Federal University of Juiz de Fora, Governador Valadares, MG 35020-360, Brazil.
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Hsu TW, Tsai CK, Kao YC, Thompson T, Carvalho AF, Yang FC, Tseng PT, Hsu CW, Yu CL, Tu YK, Liang CS. Comparative oral monotherapy of psilocybin, lysergic acid diethylamide, 3,4-methylenedioxymethamphetamine, ayahuasca, and escitalopram for depressive symptoms: systematic review and Bayesian network meta-analysis. BMJ 2024; 386:e078607. [PMID: 39168500 PMCID: PMC11337322 DOI: 10.1136/bmj-2023-078607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVE To evaluate the comparative effectiveness and acceptability of oral monotherapy using psychedelics and escitalopram in patients with depressive symptoms, considering the potential for overestimated effectiveness due to unsuccessful blinding. DESIGN Systematic review and Bayesian network meta-analysis. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, ClinicalTrial.gov, and World Health Organization's International Clinical Trials Registry Platform from database inception to 12 October 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials on psychedelics or escitalopram in adults with depressive symptoms. Eligible randomised controlled trials of psychedelics (3,4-methylenedioxymethamphetamine (known as MDMA), lysergic acid diethylamide (known as LSD), psilocybin, or ayahuasca) required oral monotherapy with no concomitant use of antidepressants. DATA EXTRACTION AND SYNTHESIS The primary outcome was change in depression, measured by the 17-item Hamilton depression rating scale. The secondary outcomes were all cause discontinuation and severe adverse events. Severe adverse events were those resulting in any of a list of negative health outcomes including, death, admission to hospital, significant or persistent incapacity, congenital birth defect or abnormality, and suicide attempt. Data were pooled using a random effects model within a Bayesian framework. To avoid estimation bias, placebo responses were distinguished between psychedelic and antidepressant trials. RESULTS Placebo response in psychedelic trials was lower than that in antidepression trials of escitalopram (mean difference -3.90 (95% credible interval -7.10 to -0.96)). Although most psychedelics were better than placebo in psychedelic trials, only high dose psilocybin was better than placebo in antidepression trials of escitalopram (mean difference 6.45 (3.19 to 9.41)). However, the effect size (standardised mean difference) of high dose psilocybin decreased from large (0.88) to small (0.31) when the reference arm changed from placebo response in the psychedelic trials to antidepressant trials. The relative effect of high dose psilocybin was larger than escitalopram at 10 mg (4.66 (95% credible interval 1.36 to 7.74)) and 20 mg (4.69 (1.64 to 7.54)). None of the interventions was associated with higher all cause discontinuation or severe adverse events than the placebo. CONCLUSIONS Of the available psychedelic treatments for depressive symptoms, patients treated with high dose psilocybin showed better responses than those treated with placebo in the antidepressant trials, but the effect size was small. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42023469014.
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Affiliation(s)
- Tien-Wei Hsu
- Department of Psychiatry, E-DA Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
- Department of Psychiatry, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Kuang Tsai
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Yu-Chen Kao
- Department of Psychiatry, National Defense Medical Centre, Taipei, Taiwan
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Andre F Carvalho
- IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Ping-Tao Tseng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung, Taiwan
- Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Ling Yu
- Department of Pharmacy, Chang Gung Memorial Hospital Linkou, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Institute of Health Data Analytics and Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, National Defense Medical Centre, Taipei, Taiwan
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
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Martin J, Gholamali Nezhad F, Rueda A, Lee GH, Charlton CE, Soltanzadeh M, Ladha KS, Krishnan S, Diaconescu AO, Bhat V. Predicting treatment response to ketamine in treatment-resistant depression using auditory mismatch negativity: Study protocol. PLoS One 2024; 19:e0308413. [PMID: 39116153 PMCID: PMC11309493 DOI: 10.1371/journal.pone.0308413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 07/23/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Ketamine has recently attracted considerable attention for its rapid effects on patients with major depressive disorder, including treatment-resistant depression (TRD). Despite ketamine's promising results in treating depression, a significant number of patients do not respond to the treatment, and predicting who will benefit remains a challenge. Although its antidepressant effects are known to be linked to its action as an antagonist of the N-methyl-D-aspartate (NMDA) receptor, the precise mechanisms that determine why some patients respond and others do not are still unclear. OBJECTIVE This study aims to understand the computational mechanisms underlying changes in the auditory mismatch negativity (MMN) response following treatment with intravenous ketamine. Moreover, we aim to link the computational mechanisms to their underlying neural causes and use the parameters of the neurocomputational model to make individual treatment predictions. METHODS This is a prospective study of 30 patients with TRD who are undergoing intravenous ketamine therapy. Prior to 3 out of 4 ketamine infusions, EEG will be recorded while patients complete the auditory MMN task. Depression, suicidality, and anxiety will be assessed throughout the study and a week after the last ketamine infusion. To translate the effects of ketamine on the MMN to computational mechanisms, we will model changes in the auditory MMN using the hierarchical Gaussian filter, a hierarchical Bayesian model. Furthermore, we will employ a conductance-based neural mass model of the electrophysiological data to link these computational mechanisms to their neural causes. CONCLUSION The findings of this study may improve understanding of the mechanisms underlying response and resistance to ketamine treatment in patients with TRD. The parameters obtained from fitting computational models to EEG recordings may facilitate single-patient treatment predictions, which could provide clinically useful prognostic information. TRIAL REGISTRATION Clinicaltrials.gov NCT05464264. Registered June 24, 2022.
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Affiliation(s)
- Josh Martin
- Interventional Psychiatry Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Fatemeh Gholamali Nezhad
- Interventional Psychiatry Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Alice Rueda
- Interventional Psychiatry Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Gyu Hee Lee
- Interventional Psychiatry Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Colleen E. Charlton
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Milad Soltanzadeh
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karim S. Ladha
- Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Sridhar Krishnan
- Department of Electrical, Computer, and Biomedical Engineering, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Andreea O. Diaconescu
- Department of Electrical, Computer, and Biomedical Engineering, Toronto Metropolitan University, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Venkat Bhat
- Interventional Psychiatry Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Wang C, Lan X, Liu W, Zhan Y, Zheng W, Chen X, Liu G, Mai S, Lu H, McIntyre RS, Zhou Y, Ning Y. Non-improvement predicts subsequent non-response to repeated-dose intravenous ketamine for depression: a re-analysis of a 2-week open-label study in patients with unipolar and bipolar depression. Transl Psychiatry 2024; 14:324. [PMID: 39107286 PMCID: PMC11303529 DOI: 10.1038/s41398-024-03027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 05/09/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024] Open
Abstract
There is insufficient evidence to guide dose and frequency optimization with repeated-dose ketamine for depression. This study assessed the value of symptomatic non-improvement after the first few ketamine infusions as a predictor of overall non-response in depression for early decision-making to discontinue treatment. A total of 135 individuals with major depressive disorder or bipolar disorder experiencing a current major depressive episode were administered six repeated doses of intravenous ketamine. Depressive symptoms were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) at baseline, 4 h after the first infusion, and 24 h after each infusion. Improvement, partial response, and response were defined as a reduction rate of ≥ 20%, 30%, and 50% in MADRS scores, respectively. This study examined the relationship between improvement (as opposed to non-improvement after each infusion or consecutive non-improvements after the first few infusions) and partial response and response after the sixth infusion. This analysis was summarized using sensitivity, specificity, and other diagnostic test parameters. The sensitivities of improvement at 24 h post-infusion 4 and improvement at 24 h post-infusion 3, vs. three consecutive non-improvements, as predictors for overall partial response and response exceeded 90%. No significant reduction in depressive symptoms was seen in non-improvers following the remaining infusions after the above-identified point. Our study suggests that non-improvement after four infusions, or more conservatively three consecutive non-improvements after three infusions, could serve as a signal of overall non-response to repeated-dose intravenous ketamine for depression and that subsequent treatments would not be warranted.
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Affiliation(s)
- Chengyu Wang
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
| | - Xiaofeng Lan
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
| | - Weijian Liu
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Peking University, Beijing, China
| | - Yanni Zhan
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
| | - Wei Zheng
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
| | - Xiaoyu Chen
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
| | - Guanxi Liu
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Siming Mai
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China
| | - Hanna Lu
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Yanling Zhou
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China.
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China.
| | - Yuping Ning
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, China.
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China.
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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8
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Zeiss R, Schweizer M, Connemann B, Malejko K. Case report: two cases of rhabdomyolysis following esketamine treatment. Front Psychiatry 2024; 15:1450092. [PMID: 39143959 PMCID: PMC11322109 DOI: 10.3389/fpsyt.2024.1450092] [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: 06/16/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Major depressive disorder is a mental disorder affecting millions of people worldwide. A considerable proportion of patients demonstrate a lack of response to conventional treatment. With the recent introduction of esketamine, a new treatment option has been approved for treatment-resistant depression. Although the medication is efficacious in a substantial portion of cases, rare, but possibly serious, adverse effects may occur. This case series shows two cases of rhabdomyolysis, a destruction of muscle tissue with elevated creatine kinase levels, after administration of esketamine. The first case presented is about a 33 year old male patient who suffered from a severe episode of a depressive disorder. He got nasal esketamine as an emergency treatment. While there was an initial improvement regarding the depressive symptoms, the patient developed muscle pain and fatigue after the administration of the fourth dose, with creatine kinase (CK) levels above 22,000 U/L, indicating rhabdomyolysis. Following the discontinuation of esketamine and the implementation of supportive care, the CK levels returned to normal and the depressive symptoms abated. The second case is about a 22-year-old male patient who also suffered from a severe depressive episode and got eketamine as an emergency treatment. Following the tenth dose, the patient exhibited muscle weakness and elevated CK levels (8,032 U/L), which persisted even after dose reduction. Esketamine administration was stopped, and the following monitoring demonstrated a slow return to normal levels of CK and liver enzymes. In both cases, there was no known medical history and both patients developed rhabdomyolysis after administration of esketamine. The temporal connection suggests a possible causal relationship. We found no literature on esketamine-induced rhabdomyolysis following the administration of nasal esketamine. However, these two cases emphasize the need of monitoring for laboratory changes like elevated CK-levels in patients receiving esketamine, especially considering its growing use in treatment-resistant depression.
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Affiliation(s)
- René Zeiss
- Department of Psychiatry and Psychotherapy III, Ulm University Hospital, Ulm, Germany
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Pattanaseri K, Lortrakul J, Jaisin K, Srifuengfung M, Sa-Nguanpanich N, Viravan N, Pariwatcharakul P, Makarasara W, Ratta-Apha W. A randomized controlled pilot study of daily intravenous ketamine over three days for treatment-resistant depression. BMC Psychiatry 2024; 24:512. [PMID: 39026266 PMCID: PMC11256507 DOI: 10.1186/s12888-024-05951-5] [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: 03/28/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Studies have confirmed the rapid antidepressant action of ketamine in depressive episodes. Nevertheless, a standardized procedure for the delivery of ketamine infusion in individuals suffering from treatment-resistant depression, particularly in terms of infusion frequency and total dosage, remains undetermined. In addition, an efficacious ketamine regimen for persistent pain management involved a continuous 10-day infusion period with no notable adverse effects. Consequently, the primary objective of this study was to evaluate the antidepressant capacity of consecutive ketamine infusions spanning over three successive days, the duration of therapeutic response, and the overall safety profile of the treatment. METHODS In this randomized controlled trial, participants aged 18-64 with treatment-resistant depression were randomized to receive either intravenous ketamine or midazolam (used as an active placebo) for 40 min daily over three consecutive days. Statistical analysis using repeated measures ANOVA was employed to assess the changes in the total score of the Montgomery-Åsberg Depression Rating Scale (MADRS) and the clinical global impression-Severity from the initial assessment to 10 and 31 days post-infusion. Additionally, the duration of response and remission was evaluated using Kaplan-Meier survival analysis. RESULTS Out of 33 randomized participants, 20 underwent the treatment as planned. By day 10th, the ketamine group had a mean reduction in MADRS score of 12.55 (95% CI = 6.70-18.09), whereas the midazolam group had a decrease of 17.22 (95% CI = 11.09-23.36). This pattern continued to day 31, with ketamine showing a mean score decrease of 13.73 (95% CI = 7.54-19.91) and midazolam a fall of 12.44 (95% CI = 5.61-19.28). Both treatments were well tolerated, with dissociative symptoms in the ketamine group being temporary and ceasing by the end of each infusion. CONCLUSION Intravenous ketamine given for three consecutive days did not show a notable antidepressant advantage when compared to the active placebo midazolam, highlighting the need for further research into effective treatments schedules for treatment-resistant depression. TRIAL REGISTRATION NCT05026203, ClinicalTrials.gov, registered on 24/08/2021.
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Affiliation(s)
- Keerati Pattanaseri
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand.
| | - Juthawadee Lortrakul
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Kankamol Jaisin
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Maytinee Srifuengfung
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Naratip Sa-Nguanpanich
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Research Department, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Natee Viravan
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Pornjira Pariwatcharakul
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Wattanan Makarasara
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok Noi, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Siriraj Informatics and Data Innovation Center, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Woraphat Ratta-Apha
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
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10
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Calder CN, Kwan ATH, Teopiz KM, Wong S, Rosenblat JD, Mansur RB, Rhee TG, Ho R, Cao B, McIntyre RS. Number needed to treat (NNT) for ketamine and esketamine in adults with treatment-resistant depression: A systematic review and meta-analysis. J Affect Disord 2024; 356:753-762. [PMID: 38636712 DOI: 10.1016/j.jad.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Ketamine has been established as efficacious in adults living with Treatment-resistant Depression (TRD). Toward providing a quantifiable estimate of the clinical meaningfulness of the therapeutic benefit of ketamine, herein, we conduct a systematic review that aims to report the Number Needed to Treat (NNT) and the Number Needed to Harm (NNH). METHODS This systematic review searched Embase, Medline/Pubmed, PsycINFO and ClinicalTrials.gov from inception up to October 15th 2023, for placebo-controlled, Randomized Controlled Trials (RCTs) assessing racemic ketamine or esketamine therapy for unipolar TRD. We calculated NNT and NNH for ketamine treatments over various time points. RESULTS A total of 21 studies with 2042 participants were included. Racemic ketamine treatments had pooled NNTs for response of 7 at 4 h, 3 from one day to one week and 9 for studies at four weeks. Esketamine treatment was found to have a similar efficacy with an NNT of 2 at one day and 11 at four weeks. NNH values indicated low risk for ketamine treatments. LIMITATIONS Limitations in the data used include the possibility of functional unblinding and selective reporting bias. Moreover, the meta-analysis may have been limited in its precision by including low threshold definitions of treatment resistance (≥ 1 failed antidepressant) and low-dose ketamine treatments. CONCLUSION Herein, we determined that the NNT for ketamine treatment in adults living with TRD across different intervals of observation was <10. We conclude that the NNTs observed herein are highly clinically meaningful in this difficult to treat disorder.
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Affiliation(s)
| | - Angela T H Kwan
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada.
| | - Sabrina Wong
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
| | - Joshua D Rosenblat
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Rodrigo B Mansur
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore.
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing 400715, PR China.
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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11
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Shibata K, Enomoto K, Tsutsumi T, Muraoka H, Fuwa T, Kawano M, Ishigooka J, Inada K, Nishimura K, Oshibuchi H. Effect of intermittent subchronic MK-801 administration on dopamine synthesis capacity and responsiveness in the prefrontal cortex. Neuropsychopharmacol Rep 2024; 44:333-341. [PMID: 38376999 PMCID: PMC11144610 DOI: 10.1002/npr2.12420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/30/2023] [Accepted: 01/15/2024] [Indexed: 02/22/2024] Open
Abstract
AIM The therapeutic potential of N-methyl-D-aspartate glutamate receptor (NMDAR) antagonists, particularly ketamine, in mood disorders, is linked to their modulation of dopamine dynamics in the medial prefrontal cortex (mPFC). However, conflicting effects of distinct NMDAR antagonists, like ketamine and phencyclidine, on mPFC dopamine levels stem from variances in their receptor affinity profiles. This study investigates the impact of intermittent subchronic administration of an NMDAR antagonist on dopamine synthesis capacity and responsiveness within the mPFC, focusing on Dizocilpine (MK-801), a highly selective NMDAR antagonist. METHODS In vivo microdialysis and high-performance liquid chromatography assessed extracellular dopamine levels in the mPFC following subchronic MK-801 treatment. Locomotor activity was measured using a computed video tracking system. RESULTS Intermittent subchronic MK-801 administration, followed by a 24-h withdrawal, preserved both dopamine synthesis capacity and responsiveness to MK-801 challenge in the mPFC. However, altered locomotor activity was observed, deviating from previous findings indicating impaired dopamine synthesis and responsiveness in the mPFC with twice-daily subchronic NMDAR antagonist treatment. CONCLUSION These findings offer crucial biochemical insights into the diverse impacts of NMDAR antagonists on dopamine dynamics and the distinct therapeutic mechanisms associated with ketamine in depression treatment. However, further investigation is imperative to pinpoint potential inconsistencies stemming from variances in drug type, dosage, or administration frequency.
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Affiliation(s)
- Kazuro Shibata
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
| | - Kosuke Enomoto
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
| | - Takahiro Tsutsumi
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
| | - Hiroyuki Muraoka
- Department of PsychiatryKitasato UniversitySagamihara‐ShiKanagawaJapan
| | - Tatsu Fuwa
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
| | | | - Jun Ishigooka
- CNS Pharmacological Research InstituteShibuya‐kuTokyoJapan
| | - Ken Inada
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
- Department of PsychiatryKitasato UniversitySagamihara‐ShiKanagawaJapan
| | - Katsuji Nishimura
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
| | - Hidehiro Oshibuchi
- Department of PsychiatryTokyo Women's Medical UniversityShinjuku‐kuTokyoJapan
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12
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Bruton AM, Wesemann DG, Machingo TA, Majak G, Johnstone JM, Marshall RD. Ketamine for mood disorders, anxiety, and suicidality in children and adolescents: a systematic review. Eur Child Adolesc Psychiatry 2024:10.1007/s00787-024-02458-y. [PMID: 38750191 DOI: 10.1007/s00787-024-02458-y] [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: 01/13/2024] [Accepted: 04/29/2024] [Indexed: 07/13/2024]
Abstract
Mood disorders, anxiety, and suicidality in youth are increasing and rapid-acting treatments are urgently needed. One potential is ketamine or its enantiomer esketamine, which was FDA approved in 2019 to treat major depressive disorder with suicidality in adults. This systematic review evaluated the evidence for the clinical use of ketamine to treat mood disorders, anxiety, and suicidality in youth. The PRISMA guidelines were used, and a protocol registered prospectively ( https://osf.io/9ucsg/ ). The literature search included Pubmed/MEDLINE, Ovid/MEDLINE, Scopus, CINAHL, PsychInfo, and Google Scholar. Trial registries and preprint servers were searched, and authors contacted for clarification. Studies reported on the clinical use of ketamine to treat anxiety, depression, bipolar disorder, or suicidality in youth ≤19 years old and assessed symptoms before and after ketamine use. Study screening and data extraction were conducted independently by 2-4 authors. Safety, tolerability, and efficacy data were collected. The Cochrane Risk of Bias guidelines assessed the quality of the evidence. Twenty-two published reports based on 16 studies were identified: 7 case studies, 6 observational studies, 3 randomized trials, and 6 secondary data analyses. Studies reported immediate improvements in depression, anxiety, and suicidality. Improvements were maintained for weeks-months following treatment. Ketamine was well-tolerated with the most common side effects being dizziness, nausea, and mild dissociation. Transient hemodynamic changes were reported, all of which resolved quickly and did not require medical intervention. Initial evidence suggests ketamine is safe and may be effective for mood disorders, anxiety, and suicidality in youth. Further randomized trials are warranted.
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Affiliation(s)
| | | | | | - Gop Majak
- University of Lethbridge, Lethbridge, Canada
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13
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Jelen LA, McShane R, Young AH. Guidelines for ketamine use in clinical psychiatry practice. BJPsych Open 2024; 10:e107. [PMID: 38725375 PMCID: PMC11094435 DOI: 10.1192/bjo.2024.62] [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: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 05/18/2024] Open
Abstract
In this editorial, we emphasise the efficacy and challenges of using ketamine in treatment-resistant depression. We highlight the need for comprehensive evidence-based guidelines to manage the use of both licensed and off-licence ketamine formulations and discuss recent efforts by Beaglehole et al to develop ketamine guidelines in New Zealand. We finally advocate for national registries to monitor ketamine therapy, ensuring its responsible and effective use in the management of depression.
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Affiliation(s)
- Luke A. Jelen
- The Maudsley Hospital, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Rupert McShane
- Department of Psychiatry, Oxford University, UK; and Oxfordshire ECT and Ketamine Service, Oxford, UK
| | - Allan H. Young
- Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
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14
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Stecher C, Cloonan S, Domino ME. The Economics of Treatment for Depression. Annu Rev Public Health 2024; 45:527-551. [PMID: 38100648 DOI: 10.1146/annurev-publhealth-061022-040533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.
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Affiliation(s)
- Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA;
- The Center for Health Information and Research, Arizona State University, Phoenix, Arizona, USA
| | - Sara Cloonan
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Marisa Elena Domino
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA;
- The Center for Health Information and Research, Arizona State University, Phoenix, Arizona, USA
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15
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Colla M, Offenhammer B, Scheerer H, Kronenberg G, Vetter S, Mutschler J, Mikoteit T, Bankwitz A, Adank A, Schaekel L, Eicher C, Brühl AB, Seifritz E. Oral prolonged-release ketamine in treatment-resistant depression - A double-blind randomized placebo-controlled multicentre trial of KET01, a novel ketamine formulation - Clinical and safety results. J Psychiatr Res 2024; 173:124-130. [PMID: 38522166 DOI: 10.1016/j.jpsychires.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/26/2024] [Accepted: 03/03/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION We investigated the antidepressant effects of a novel oral prolonged-release formulation of racemic ketamine (KET01) in patients suffering from treatment-resistant depression (TRD) as add-on therapy. MATERIAL AND METHODS Patients were randomized to an additional 160 mg/day or 240 mg/day KET01 or placebo for 14 days. The primary endpoint was change in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline to day 15. For treatment group comparisons, we used ANOVA with pairwise least squares mean difference tests in a mixed model repeated measures analysis. RESULTS Twenty-seven patients completed the double-blind protocol before trial premature termination due to poor recruitment during the COVID-19 pandemic. Mean (SD) MADRS scores on day 15 were 23 (10.32) in placebo, 25 (8.28) with 160 mg/day and 17 (10.32) with 240 mg/day KET01. MADRS change was numerically larger but statistically non-significant in the 240 mg/day KET01 group vs placebo on day 7 (-5.67; p = 00.106) and day 15 was (difference: 4.99; p = 00.15). In exploratory analysis, baseline leukocyte count correlated with response to KET01 (p = 00.01). Distribution of adverse event rates were comparable between the treatment arms. Safety analysis did not identify increased risk of suicidality, dissociation, hear rate, systolic and diastolic blood pressure associated with trial treatment. DISCUSSION Our results suggest that adjunctive oral administration of prolonged-release ketamine at a dose of 240 mg/day shows a positive, although statistically non-significant, trend towards antidepressant efficacy, however, the benefit could not be confirmed due to premature trial termination. Given its ease of use and low side effects, further trials are warranted to investigate this route of ketamine administration as a promising potential treatment of TRD.
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Affiliation(s)
- M Colla
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland.
| | - B Offenhammer
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - H Scheerer
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - G Kronenberg
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - S Vetter
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - J Mutschler
- Psychiatric Hospital Meiringen, Meiringen, Switzerland; Psychiatric Services Lucerne, Lucerne, Switzerland
| | - T Mikoteit
- Psychiatric Services Solothurn and University of Basel, Solothurn, Switzerland
| | - A Bankwitz
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - A Adank
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - L Schaekel
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - C Eicher
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
| | - A B Brühl
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland; University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - E Seifritz
- Department of Adult Psychiatry and Psychotherapy, Psychiatric University Clinic Zurich and University of Zurich, Switzerland
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16
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Sandström K, Kampman O, Asellus P. A retrospective analysis of iv ketamine outcome on hospitalisations in an unselected psychiatric sample. Acta Neuropsychiatr 2024:1-7. [PMID: 38659205 DOI: 10.1017/neu.2024.18] [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] [Indexed: 04/26/2024]
Abstract
OBJECTIVE This study aims to explore the outcome with iv ketamine treatment in a real-world clinical setting, primarily measured as posttreatment days hospitalised. METHODS The psychiatric medical records of 46 patients having received iv ketamine on a psychiatric treatment indication between 2015 and 2018 were retrospectively examined. Analysis comparing the number and duration of hospital admissions before and after ketamine treatment as well as logistic regression analysis to investigate clinical predictors of effectiveness, were performed. To assess patients' severity of depressed symptoms records were screened for MADRS-S scores. RESULTS No significant difference between pre- and posttreatment hospital days (p = 0.170), or number of hospitalisations (p = 0.740) were found. The response rate was 31% and remission rate 21%. None of the predictors showed statistical significance in the logistic model. CONCLUSION Iv ketamine treatment showed effectiveness in reducing depressive symptoms even with complex patients in a real-world clinical setting. However, this did not translate to a reduction in hospitalisation. Highlighting the multifaceted challenges posed when implementing iv ketamine treatment in clinical practice.
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Affiliation(s)
- Karl Sandström
- Department of Clinical Sciences (Psychiatry), Umeå University, Umeå, Sweden
| | - Olli Kampman
- Department of Clinical Sciences (Psychiatry), Umeå University, Umeå, Sweden
- Faculty of Medicine, Department of Clinical Medicine (Psychiatry), University of Turku, Turku, Finland
- Department of Psychiatry, The Wellbeing Services County of Ostrobothnia, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Psychiatry, The Pirkanmaa Wellbeing Services County, Tampere, Finland
| | - Peter Asellus
- Department of Clinical Sciences (Psychiatry), Umeå University, Umeå, Sweden
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17
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Wang S, Deng CM, Zeng Y, Chen XZ, Li AY, Feng SW, Xu LL, Chen L, Yuan HM, Hu H, Yang T, Han T, Zhang HY, Jiang M, Sun XY, Guo HN, Sessler DI, Wang DX. Efficacy of a single low dose of esketamine after childbirth for mothers with symptoms of prenatal depression: randomised clinical trial. BMJ 2024; 385:e078218. [PMID: 38808490 DOI: 10.1136/bmj-2023-078218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
OBJECTIVE To determine whether a single low dose of esketamine administered after childbirth reduces postpartum depression in mothers with prenatal depression. DESIGN Randomised, double blind, placebo controlled trial with two parallel arms. SETTING Five tertiary care hospitals in China, 19 June 2020 to 3 August 2022. PARTICIPANTS 364 mothers aged ≥18 years who had at least mild prenatal depression as indicated by Edinburgh postnatal depression scale scores of ≥10 (range 0-30, with higher scores indicating worse depression) and who were admitted to hospital for delivery. INTERVENTIONS Participants were randomly assigned 1:1 to receive either 0.2 mg/kg esketamine or placebo infused intravenously over 40 minutes after childbirth once the umbilical cord had been clamped. MAIN OUTCOME MEASURES The primary outcome was prevalence of a major depressive episode at 42 days post partum, diagnosed using the mini-international neuropsychiatric interview. Secondary outcomes included the Edinburgh postnatal depression scale score at seven and 42 days post partum and the 17 item Hamilton depression rating scale score at 42 days post partum (range 0-52, with higher scores indicating worse depression). Adverse events were monitored until 24 hours after childbirth. RESULTS A total of 364 mothers (mean age 31.8 (standard deviation 4.1) years) were enrolled and randomised. At 42 days post partum, a major depressive episode was observed in 6.7% (12/180) of participants in the esketamine group compared with 25.4% (46/181) in the placebo group (relative risk 0.26, 95% confidence interval (CI) 0.14 to 0.48; P<0.001). Edinburgh postnatal depression scale scores were lower in the esketamine group at seven days (median difference -3, 95% CI -4 to -2; P<0.001) and 42 days (-3, -4 to -2; P<0.001). Hamilton depression rating scale scores at 42 days post partum were also lower in the esketamine group (-4, -6 to -3; P<0.001). The overall incidence of neuropsychiatric adverse events was higher in the esketamine group (45.1% (82/182) v 22.0% (40/182); P<0.001); however, symptoms lasted less than a day and none required drug treatment. CONCLUSIONS For mothers with prenatal depression, a single low dose of esketamine after childbirth decreases major depressive episodes at 42 days post partum by about three quarters. Neuropsychiatric symptoms were more frequent but transient and did not require drug intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT04414943.
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Affiliation(s)
- Shuo Wang
- Department of Anaesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Chun-Mei Deng
- Department of Anaesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Yuan Zeng
- Department of Anaesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Xin-Zhong Chen
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Ai-Yuan Li
- Department of Anaesthesiology, Hunan Province Maternal and Child Health Care Hospital, Changsha, Hunan Province, China
| | - Shan-Wu Feng
- Department of Anaesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Li-Li Xu
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Liang Chen
- Department of Anaesthesiology, Hunan Province Maternal and Child Health Care Hospital, Changsha, Hunan Province, China
| | - Hong-Mei Yuan
- Department of Anaesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Han Hu
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Tian Yang
- Department of Anaesthesiology, Hunan Province Maternal and Child Health Care Hospital, Changsha, Hunan Province, China
| | - Tao Han
- Department of Anaesthesiology, Hunan Province Maternal and Child Health Care Hospital, Changsha, Hunan Province, China
| | - Hui-Ying Zhang
- Department of Anaesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Ming Jiang
- Department of Anaesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu Province, China
| | - Xin-Yu Sun
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Centre for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Hui-Ning Guo
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Centre for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Dong-Xin Wang
- Department of Anaesthesiology, Peking University First Hospital, Beijing 100034, China
- Outcomes Research Consortium, Cleveland, OH, USA
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18
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Vestring S, Galuba V, Kern E, Voita S, Berens F, Nasiri D, Domschke K, Normann C. Ketamine in multiple treatment-resistant depressed inpatients: A naturalistic cohort study. J Affect Disord 2024; 350:895-899. [PMID: 38266928 DOI: 10.1016/j.jad.2024.01.165] [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: 08/17/2023] [Revised: 12/02/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Ketamine has emerged as an effective treatment option for patients with treatment-resistant depression. However, there is limited evidence of the benefits of ketamine in inpatients with multiple treatment resistance (MTR), who far exceed the formal criteria for treatment resistance and suffer from extensive psychiatric comorbidities. OBJECTIVE The aim of this naturalistic study was to provide preliminary evidence for the use of ketamine in the treatment of MTR depression in a naturalistic inpatient setting. METHODS Seventy-seven patients (mean age 45.1 ± 13.8 years) were treated with intravenous or intranasal ketamine (1068 administrations) twice weekly for five weeks, followed by maintenance therapy if clinically indicated. Treatment effects were assessed with the BDI, and side effects were assessed by clinicians. We analyzed dose- and route of application-related changes in depression severity, response and remission rates as well as effects on suicidality and frequency of adverse events. RESULTS Depression severity and suicidality decreased in the acute treatment phase and these changes persisted during the maintenance therapy phase. A total of 28.9 % of the patients met the criteria for response, and 15 % met the criteria for remission. The initial treatment response was highly predictive of the outcome at the end of the acute treatment phase. None of the reported side effects required medical intervention. High-dose intravenous ketamine (0.75-1 mg/kg) resulted in the most pronounced clinical effects. LIMITATIONS This observational, retrospective, and naturalistic study may be subject to bias and did not allow control of external variables. CONCLUSIONS We outlined a clinically feasible, high-dose ketamine treatment regimen for hospitalized patients with MTR depression.
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Affiliation(s)
- Stefan Vestring
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktoria Galuba
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elisa Kern
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sabine Voita
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Franziska Berens
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Danial Nasiri
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Neuromodulation, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Neuromodulation, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Arango-Posada MDM, Prada-Escobar AI, Marín-Hernández C, Monsalve-Franco V, Restrepo-Bernal D. Successful treatment for serious depression with suicidal risk in a heart transplant patient. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2024; 53:210-216. [PMID: 39127545 DOI: 10.1016/j.rcpeng.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/18/2022] [Accepted: 03/07/2022] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Major depressive disorder is related to unfavourable outcomes in patients with severe comorbidities. In transplant patients, major depression is associated with worse clinical outcomes. CASE REPORT We present the case of a 55-year-old man with a heart transplant due to heart failure of ischaemic origin. Six months after the transplant he developed depressed mood, anhedonia and suicidal ideation with a score of 20/27 on the PHQ-9 depression screening scale. After receiving mirtazapine 30 mg/night for a week and persisting with a high suicide risk, it was decided to administer ketamine infusion for 24 h, with which a significant improvement in mood was observed, and the disappearance of suicidal ideation 24 h after the infusion. DISCUSSION Depression in transplant patients is a factor associated with graft loss and post-transplant mortality, in addition to favouring other negative outcomes such as deep vein thrombosis. CONCLUSIONS Ketamine infusion was shown to be an effective and safe option to treat major depression with suicidal risk in a heart transplant patient.
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20
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Algin S, Banik D, Rahman SA, Mahmud Tusher S, Tuj Johora F, Akter A, Ahmed T, Biswas MAM, Sinha S, Haque M. Ketamine Infusion in a Resistant Obsessive-Compulsive Disorder Patient in Bangladesh with Severe Suicidal Ideation: A Case Report. Cureus 2024; 16:e57877. [PMID: 38596207 PMCID: PMC11002706 DOI: 10.7759/cureus.57877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
Treatment of resistant obsessive-compulsive disorder (OCD) typically results in insufficient symptom alleviation, and even long-term medication often fails to have the intended effect. Ketamine is a potent non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Studies have shown that low-dose ketamine infusion results in a considerable reduction in obsessive-compulsive symptoms and a rapid resolution of suicidal ideation. This is a case report on the effect of intravenous ketamine infusion on a patient with resistant OCD and severe suicidal ideation. Intravenous (IV) ketamine was given once a week over consecutive three weeks with necessary precautions. Psychometric tools such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Clinical Global Impressions Scale (CGI-S), the Beck Scale for Suicidal Ideations (BSSI), and Depression Anxiety and Stress Scale 21 (DASS-21) were applied before and after infusions. Obsessive-compulsive symptoms and suicidal severity started to decrease rapidly after the first infusion. However, after a transient improvement, these symptoms again began to increase after a stressful incident on the second day of the first infusion. All the symptoms measured by validated rating scales showed continued improvement after the following two infusions. The improvement was sustained until discharge (one week after the last infusion) and subsequent follow-up in the sixth and 12th weeks. The role of ketamine in reducing suicidal thoughts and behavior is already established. Very few studies emphasized its effectiveness in improving severe/resistant obsessive-compulsive symptoms. This pioneering work may offer scope for similar research in the relevant field.
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Affiliation(s)
- Sultana Algin
- Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Debasish Banik
- Anesthesia, Analgesia, and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Sm Atikur Rahman
- Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Saiful Mahmud Tusher
- Anesthesia, Analgesia, and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Fatema Tuj Johora
- Child and Adolescent Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Asha Akter
- Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Tanbir Ahmed
- Child and Adolescent Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | | | - Susmita Sinha
- Physiology, Khulna City Medical College and Hospital, Khulna, BGD
| | - Mainul Haque
- Karnavati Scientific Research Center (KSRC), School of Dentistry, Karnavati University, Gandhinagar, IND
- Pharmacology and Therapeutics, National Defence University of Malaysia, Kuala Lumpur, MYS
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21
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Evans VD, Arenas A, Shinozuka K, Tabaac BJ, Beutler BD, Cherian K, Fasano C, Muir OS. Psychedelic Therapy: A Primer for Primary Care Clinicians-Ketamine. Am J Ther 2024; 31:e155-e177. [PMID: 38518272 DOI: 10.1097/mjt.0000000000001721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
BACKGROUND Ketamine, an arylcyclohexylamine dissociative anesthetic agent, has evolved into a versatile therapeutic. It has a rapid-onset, well-understood cardiovascular effects and a favorable safety profile in clinical use. Its enantiomeric compound, esketamine, was approved by the Food and Drug Administration in 2019 for both treatment-resistant depression and major depressive disorder with suicidal ideation. AREAS OF UNCERTAINTY Research indicates dose-dependent impacts on cognition, particularly affecting episodic and working memory following both acute administration and chronic use, albeit temporarily for the former and potentially persistent for the latter. Alongside acute risks to cardiovascular stability, ketamine use poses potential liver toxicity concerns, especially with prolonged or repeated exposure within short time frames. The drug's association with "ketamine cystitis," characterized by bladder inflammation, adds to its profile of physiological risks. THERAPEUTIC ADVANCES Data demonstrate a single intravenous infusion of ketamine exhibits antidepressant effects within hours (weighted effect size averages of depression scores (N = 518) following a single 0.5 mg/kg infusion of ketamine is d = 0.96 at 24 hours). Ketamine is also effective at reducing posttraumatic stress disorder (PTSD) symptom severity following repeated infusions (Clinician-Administered PTSD Scale scores: -11.88 points compared with midazolam control). Ketamine also decreased suicidal ideation in emergency settings (Scale for Suicidal Ideation scores: -4.96 compared with midazolam control). Through its opioid-sparing effect, ketamine has revolutionized postoperative pain management by reducing analgesic consumption and enhancing recovery. LIMITATIONS Many studies indicate that ketamine's therapeutic effects may subside within weeks. Repeated administrations, given multiple times per week, are often required to sustain decreases in suicidality and depressive symptoms. CONCLUSIONS Ketamine's comprehensive clinical profile, combined with its robust effects on depression, suicidal ideation, PTSD, chronic pain, and other psychiatric conditions, positions it as a substantial contender for transformative therapeutic application.
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Affiliation(s)
- Viviana D Evans
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alejandro Arenas
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA
| | - Kenneth Shinozuka
- Centre for Eudaimonia and Human Flourishing, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Burton J Tabaac
- University of Nevada, Reno School of Medicine, Reno, NV
- Department of Neurology, Carson Tahoe Health, Carson City, NV
| | - Bryce D Beutler
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Kirsten Cherian
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA
| | | | - Owen S Muir
- Fermata Health, Brooklyn, NY; and
- Acacia Clinics, Sunnyvale, CA
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22
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Fritz BA, Tellor Pennington BR, Dalton C, Horan C, Palanca BJ, Schweiger JA, Griffin L, Tumwesige W, Willie JT, Farber NB. Ketamine for postoperative avoidance of depressive symptoms: the K-PASS feasibility randomised trial. BJA OPEN 2024; 9:100245. [PMID: 38179107 PMCID: PMC10764255 DOI: 10.1016/j.bjao.2023.100245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
Background Surgical patients with previous depression frequently experience postoperative depressive symptoms. This study's objective was to determine the feasibility of a placebo-controlled trial testing the impact of a sustained ketamine infusion on postoperative depressive symptoms. Methods This single-centre, triple-blind, placebo-controlled randomised clinical trial included adult patients with depression scheduled for inpatient surgery. After surgery, patients were randomly allocated to receive ketamine (0.5 mg kg-1 over 10 min followed by 0.3 mg kg-1 h-1 for 3 h) or an equal volume of normal saline. Depressive symptoms were measured using the Montgomery-Asberg Depression Rating Scale. On post-infusion day 1, participants guessed which intervention they received. Feasibility endpoints included the fraction of patients approached who were randomised, the fraction of randomised patients who completed the study infusion, and the fraction of scheduled depression assessments that were completed. Results In total, 32 patients were allocated a treatment, including 31/101 patients approached after a protocol change (31%, 1.5 patients per week). The study infusion was completed without interruption in 30/32 patients (94%). In each group, 7/16 participants correctly guessed which intervention they received. Depression assessments were completed at 170/192 scheduled time points (89%). Between baseline and post-infusion day 4 (pre-specified time point of interest), median depressive symptoms decreased in both groups, with difference-in-differences of -1.00 point (95% confidence interval -3.23 to 1.73) with ketamine compared with placebo. However, the between-group difference did not persist at other time points. Conclusions Patient recruitment, medication administration, and clinical outcome measurement appear to be highly feasible, with blinding maintained. A fully powered trial may be warranted. Clinical trial registration NCT05233566.
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Affiliation(s)
- Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | | | - Catherine Dalton
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Christine Horan
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ben J.A. Palanca
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Julie A. Schweiger
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Logan Griffin
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Wilberforce Tumwesige
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jon T. Willie
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nuri B. Farber
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
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23
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Lewis V, Rurak G, Salmaso N, Aguilar-Valles A. An integrative view on the cell-type-specific mechanisms of ketamine's antidepressant actions. Trends Neurosci 2024; 47:195-208. [PMID: 38220554 DOI: 10.1016/j.tins.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/08/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
Over the past six decades, the use of ketamine has evolved from an anesthetic and recreational drug to the first non-monoaminergic antidepressant approved for treatment-resistant major depressive disorder (MDD). Subanesthetic doses of ketamine and its enantiomer (S)-ketamine (esketamine) directly bind to several neurotransmitter receptors [including N-methyl-d-aspartic acid receptor (NMDAR), κ and μ opioid receptor (KOR and MOR)] widely distributed in the brain and across different cell types, implicating several potential molecular mechanisms underlying the action of ketamine as an antidepressant. This review examines preclinical studies investigating cell-type-specific mechanisms underlying the effects of ketamine on behavior and synapses. Cell-type-specific approaches are crucial for disentangling the critical mechanisms involved in the therapeutic effect of ketamine.
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Affiliation(s)
- Vern Lewis
- Department of Neuroscience, Carleton University, Health Sciences Building, 1125 Colonel By Drive, Ottawa, Ontario K1S 5B6, Canada
| | - Gareth Rurak
- Department of Neuroscience, Carleton University, Health Sciences Building, 1125 Colonel By Drive, Ottawa, Ontario K1S 5B6, Canada
| | - Natalina Salmaso
- Department of Neuroscience, Carleton University, Health Sciences Building, 1125 Colonel By Drive, Ottawa, Ontario K1S 5B6, Canada
| | - Argel Aguilar-Valles
- Department of Neuroscience, Carleton University, Health Sciences Building, 1125 Colonel By Drive, Ottawa, Ontario K1S 5B6, Canada.
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24
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De Filippo R, Schmitz D. Synthetic surprise as the foundation of the psychedelic experience. Neurosci Biobehav Rev 2024; 157:105538. [PMID: 38220035 PMCID: PMC10839673 DOI: 10.1016/j.neubiorev.2024.105538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/16/2024]
Abstract
Psychedelic agents, such as LSD and psilocybin, induce marked alterations in consciousness via activation of the 5-HT2A receptor (5-HT2ARs). We hypothesize that psychedelics enforce a state of synthetic surprise through the biased activation of the 5-HTRs system. This idea is informed by recent insights into the role of 5-HT in signaling surprise. The effects on consciousness, explained by the cognitive penetrability of perception, can be described within the predictive coding framework where surprise corresponds to prediction error, the mismatch between predictions and actual sensory input. Crucially, the precision afforded to the prediction error determines its effect on priors, enabling a dynamic interaction between top-down expectations and incoming sensory data. By integrating recent findings on predictive coding circuitry and 5-HT2ARs transcriptomic data, we propose a biological implementation with emphasis on the role of inhibitory interneurons. Implications arise for the clinical use of psychedelics, which may rely primarily on their inherent capacity to induce surprise in order to disrupt maladaptive patterns.
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Affiliation(s)
- Roberto De Filippo
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Neuroscience Research Center, 10117 Berlin, Germany.
| | - Dietmar Schmitz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Neuroscience Research Center, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Einstein Center for Neuroscience, 10117 Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, NeuroCure Cluster of Excellence, 10117 Berlin, Germany; Humboldt-Universität zu Berlin, Bernstein Center for Computational Neuroscience, Philippstr. 13, 10115 Berlin, Germany
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25
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Wang YT, Wang XL, Lei L, Guo ZY, Kan FF, Hu D, Gai C, Zhang Y. A systematic review and meta-analysis of the efficacy of ketamine and esketamine on suicidal ideation in treatment-resistant depression. Eur J Clin Pharmacol 2024; 80:287-296. [PMID: 38117332 DOI: 10.1007/s00228-023-03605-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE To systematically assess the evidence of efficacy and safety of the use of ketamine and esketamine for patients with treatment-resistant depression (TRD) with suicidal ideation (SI). METHODS We independently searched for clinical trials from inception to January 2023 using electronic databases, e.g., PubMed and EMBASE. A systematic review and meta-analysis were performed to assess SI scores of depression rating scales, which were regarded as the outcomes. RESULTS A total of five independent double-blind, placebo controlled randomized clinical trials (RCTs) are eligible for inclusion. Four of the studies used ketamine as an intervention and one used esketamine as an intervention. Three hundred ninety-one patients with TRD were included (the intervention group with ketamine or esketamine is 246, and the control group is 145). No statistically significant interaction between the subscales of suicide ideation (SMD = - 0.66, 95% CI (- 1.61, 0.29); Z = 1.36, P = 0.17) and antidepressant effects (SMD = - 0.99, 95% CI (- 2.33, 0.34); Z = 1.46, P = 0.15) based on the results of ketamine and esketamine, compared with placebo groups. CONCLUSION This meta-analysis suggested that esketamine and ketamine have failed to reduce suicidal ideation in patients with TRD. Further studies are desirable to confirm the effects of ketamine and esketamine in TRD patients.
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Affiliation(s)
- Ya-Ting Wang
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Xiao-Le Wang
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Lan Lei
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Zhen-Yu Guo
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Fei-Fei Kan
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Die Hu
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Cong Gai
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China
| | - Yi Zhang
- Department of Anatomy, School of Chinese Medicine, Beijing University of Chinese Medicine, Sunshine Southern Avenue, Fang-Shan District, Beijing, 102488, China.
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Zhang Y, Pan YD, Zheng WY, Li HY, Zhu MZ, Ou Yang WJ, Qian Y, Turecki G, Mechawar N, Zhu XH. Enhancing HIF-1α-P2X2 signaling in dorsal raphe serotonergic neurons promotes psychological resilience. Redox Biol 2024; 69:103005. [PMID: 38150991 PMCID: PMC10788260 DOI: 10.1016/j.redox.2023.103005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/29/2023] Open
Abstract
Major depressive disorder (MDD) is a devastating condition. Although progress has been made in the past seven decades, patients with MDD continue to receive an inadequate treatment, primarily due to the late onset of first-line antidepressant drugs and to their acute withdrawal symptoms. Resilience is the ability to rebound from adversity in a healthy manner and many people have psychological resilience. Revealing the mechanisms and identifying methods promoting resilience will hopefully lead to more effective prevention strategies and treatments for depression. In this study, we found that intermittent hypobaric hypoxia training (IHHT), a method for training pilots and mountaineers, enhanced psychological resilience in adult mice. IHHT produced a sustained antidepressant-like effect in mouse models of depression by inducing long-term (up to 3 months after this treatment) overexpression of hypoxia-inducible factor (HIF)-1α in the dorsal raphe nucleus (DRN) of adult mice. Moreover, DRN-infusion of cobalt chloride, which mimics hypoxia increasing HIF-1α expression, triggered a rapid and long-lasting antidepressant-like effect. Down-regulation of HIF-1α in the DRN serotonergic (DRN5-HT) neurons attenuated the effects of IHHT. HIF-1α translationally regulated the expression of P2X2, and conditionally knocking out P2rx2 (encodes P2X2 receptors) in DRN5-HT neurons, in turn, attenuated the sustained antidepressant-like effect of IHHT, but not its acute effect. In line with these results, a single sub-anesthetic dose of ketamine enhanced HIF-1α-P2X2 signaling, which is essential for its rapid and long-lasting antidepressant-like effect. Notably, we found that P2X2 protein levels were significantly lower in the DRN of patients with MDD than that of control subjects. Together, these findings elucidate the molecular mechanism underlying IHHT promoting psychological resilience and highlight enhancing HIF-1α-P2X2 signaling in DRN5-HT neurons as a potential avenue for screening novel therapeutic treatments for MDD.
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Affiliation(s)
- Yuan Zhang
- School of Psychology, Shenzhen University, Shenzhen, China; Research Center for Brain Health, Pazhou Lab, Guangzhou, China
| | - Yi-da Pan
- Research Center for Brain Health, Pazhou Lab, Guangzhou, China
| | - Wen-Ying Zheng
- School of Psychology, Shenzhen University, Shenzhen, China; Research Center for Brain Health, Pazhou Lab, Guangzhou, China
| | - Huan-Yu Li
- Research Center for Brain Health, Pazhou Lab, Guangzhou, China
| | - Min-Zhen Zhu
- Research Center for Brain Health, Pazhou Lab, Guangzhou, China
| | - Wen-Jie Ou Yang
- School of Psychology, Shenzhen University, Shenzhen, China; Research Center for Brain Health, Pazhou Lab, Guangzhou, China
| | - Yu Qian
- Research Center for Brain Health, Pazhou Lab, Guangzhou, China; School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Gustavo Turecki
- Department of Psychiatry, McGill University, McGill Group for Suicide Studies, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Verdun, (Québec), Canada
| | - Naguib Mechawar
- Department of Psychiatry, McGill University, McGill Group for Suicide Studies, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Verdun, (Québec), Canada
| | - Xin-Hong Zhu
- School of Psychology, Shenzhen University, Shenzhen, China; Research Center for Brain Health, Pazhou Lab, Guangzhou, China; School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China.
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27
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Rodolico A, Cutrufelli P, Di Francesco A, Aguglia A, Catania G, Concerto C, Cuomo A, Fagiolini A, Lanza G, Mineo L, Natale A, Rapisarda L, Petralia A, Signorelli MS, Aguglia E. Efficacy and safety of ketamine and esketamine for unipolar and bipolar depression: an overview of systematic reviews with meta-analysis. Front Psychiatry 2024; 15:1325399. [PMID: 38362031 PMCID: PMC10867194 DOI: 10.3389/fpsyt.2024.1325399] [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: 10/21/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
Background Unipolar and bipolar depression present treatment challenges, with patients sometimes showing limited or no response to standard medications. Ketamine and its enantiomer, esketamine, offer promising alternative treatments that can quickly relieve suicidal thoughts. This Overview of Reviews (OoR) analyzed and synthesized systematic reviews (SRs) with meta-analysis on randomized clinical trials (RCTs) involving ketamine in various formulations (intravenous, intramuscular, intranasal, subcutaneous) for patients with unipolar or bipolar depression. We evaluated the efficacy and safety of ketamine and esketamine in treating major depressive episodes across various forms, including unipolar, bipolar, treatment-resistant, and non-resistant depression, in patient populations with and without suicidal ideation, aiming to comprehensively assess their therapeutic potential and safety profile. Methods Following PRIOR guidelines, this OoR's protocol was registered on Implasy (ID:202150049). Searches in PubMed, Scopus, Cochrane Library, and Epistemonikos focused on English-language meta-analyses of RCTs of ketamine or esketamine, as monotherapy or add-on, evaluating outcomes like suicide risk, depressive symptoms, relapse, response rates, and side effects. We included studies involving both suicidal and non-suicidal patients; all routes and formulations of administration (intravenous, intramuscular, intranasal) were considered, as well as all available comparisons with control interventions. We excluded meta-analysis in which the intervention was used as anesthesia for electroconvulsive therapy or with a randomized ascending dose design. The selection, data extraction, and quality assessment of studies were carried out by pairs of reviewers in a blinded manner. Data on efficacy, acceptability, and tolerability were extracted. Results Our analysis included 26 SRs and 44 RCTs, with 3,316 subjects. The intervention is effective and well-tolerated, although the quality of the included SRs and original studies is poor, resulting in low certainty of evidence. Limitations This study is limited by poor-quality SRs and original studies, resulting in low certainty of the evidence. Additionally, insufficient available data prevents differentiation between the effects of ketamine and esketamine in unipolar and bipolar depression. Conclusion While ketamine and esketamine show promising therapeutic potential, the current evidence suffers from low study quality. Enhanced methodological rigor in future research will allow for a more informed application of these interventions within the treatment guidelines for unipolar and bipolar depression. Systematic review registration [https://inplasy.com/inplasy-2021-5-0049/], identifier (INPLASY202150049).
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Affiliation(s)
- Alessandro Rodolico
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Pierfelice Cutrufelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Antonio Di Francesco
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gaetano Catania
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
- University of Catania, Catania, Italy
| | - Carmen Concerto
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Alessandro Cuomo
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Troina, Italy
| | - Ludovico Mineo
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Antimo Natale
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
- Department of Psychiatry, Adult Psychiatry Service (SPA), University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Laura Rapisarda
- Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Catania, Italy
| | - Antonino Petralia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Maria Salvina Signorelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
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Terao I, Tsuge T, Endo K, Kodama W. Comparative efficacy, tolerability and acceptability of intravenous racemic ketamine with intranasal esketamine, aripiprazole and lithium as augmentative treatments for treatment-resistant unipolar depression: A systematic review and network meta-analysis. J Affect Disord 2024; 346:49-56. [PMID: 37949235 DOI: 10.1016/j.jad.2023.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Intravenous racemic ketamine is a promising treatment for treatment-resistant depression. However, its clinical utility compared with intranasal esketamine and the other well-studied conventional pharmacological interventions (i.e., aripiprazole and lithium) as augmentative treatments for treatment-resistant unipolar depression in adults remains unclear. Therefore, we aimed to compare the efficacy, tolerability and acceptability of intravenous racemic ketamine with intranasal esketamine, aripiprazole and lithium under such conditions. METHODS The Cochrane Library, PubMed, CINHAL and ClinicalTrials.gov databases were systematically searched from their inception to 10 May 2023. Randomised controlled trials evaluating these drugs were included. A random-effects network meta-analysis was also performed. RESULTS In the primary analysis, all four drugs were significantly more effective than placebo. In addition, intravenous racemic ketamine was significantly more effective and acceptable than intranasal esketamine and aripiprazole. Intravenous racemic ketamine was not significantly different from placebo in tolerability, whereas intranasal esketamine and aripiprazole were significantly less tolerable than placebo. Lithium did not differ significantly from intravenous racemic ketamine in efficacy, tolerability and acceptability. LIMITATIONS The sample size of patients treated with intravenous racemic ketamine was small. CONCLUSIONS Intravenous racemic ketamine may be a better augmentative treatment for treatment-resistant unipolar depression than intranasal esketamine and aripiprazole. Whether intravenous racemic ketamine or lithium is superior is unclear currently. A larger head-to-head trial of intravenous racemic ketamine versus conventional augmentative treatments for treatment-resistant unipolar depression is needed.
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Affiliation(s)
- Itsuki Terao
- Department of Psychiatry, Ikokoro Clinic Nihonbashi, Chuo-ku, Tokyo 103-0012, Japan.
| | - Takahiro Tsuge
- Department of Rehabilitation, Kurashiki Medical Center, Kurashiki, Okayama 710-8522, Japan; Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Shikata-cho, Okayama 700-8558, Japan
| | - Kaori Endo
- National Coalition of independent scholars, 125 Putney Rd, Battleboro, VT, 05301, USA
| | - Wakako Kodama
- Department of Psychiatry, Negishi Hospital, Fuchu-shi, Tokyo 183-0042, Japan
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Ip CT, de Bardeci M, Kronenberg G, Pinborg LH, Seifritz E, Brunovsky M, Olbrich S. EEG-vigilance regulation is associated with and predicts ketamine response in major depressive disorder. Transl Psychiatry 2024; 14:64. [PMID: 38272875 PMCID: PMC10810879 DOI: 10.1038/s41398-024-02761-x] [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: 05/04/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
Ketamine offers promising new therapeutic options for difficult-to-treat depression. The efficacy of treatment response, including ketamine, has been intricately linked to EEG measures of vigilance. This research investigated the interplay between intravenous ketamine and alterations in brain arousal, quantified through EEG vigilance assessments in two distinct cohorts of depressed patients (original dataset: n = 24; testing dataset: n = 24). Clinical response was defined as a decrease from baseline of >33% on the Montgomery-Åsberg Depression Rating Scale (MADRS) 24 h after infusion. EEG recordings were obtained pre-, start-, end- and 24 h post- infusion, and the resting EEG was automatically scored using the Vigilance Algorithm Leipzig (VIGALL). Relative to placebo (sodium chloride 0.9%), ketamine increased the amount of low-vigilance stage B1 at end-infusion. This increase in B1 was positively related to serum concentrations of ketamine, but not to norketamine, and was independent of clinical response. In contrast, treatment responders showed a distinct EEG pattern characterized by a decrease in high-vigilance stage A1 and an increase in low-vigilance B2/3, regardless of whether placebo or ketamine had been given. Furthermore, pretreatment EEG differed between responders and non-responders with responders showing a higher percentage of stage A1 (53% vs. 21%). The logistic regression fitted on the percent of A1 stages was able to predict treatment outcomes in the testing dataset with an area under the ROC curve of 0.7. Ketamine affects EEG vigilance in a distinct pattern observed only in responders. Consequently, the percentage of pretreatment stage A1 shows significant potential as a predictive biomarker of treatment response.Clinical Trials Registration: https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-000952-17/CZ Registration number: EudraCT Number: 2013-000952-17.
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Affiliation(s)
- Cheng-Teng Ip
- Center for Cognitive and Brain Sciences, University of Macau, Taipa, Macau SAR, China
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mateo de Bardeci
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland
| | - Golo Kronenberg
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland
| | - Lars Hageman Pinborg
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
- Epilepsy Clinic, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Erich Seifritz
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland
| | - Martin Brunovsky
- National Institute of Mental Health, Klecany, Czech Republic
- Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Sebastian Olbrich
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland.
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Teo MTL. Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109644. [PMID: 38216330 DOI: 10.1136/jme-2023-109644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.
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Affiliation(s)
- Marcus T L Teo
- Centre for Biomedical Ethics, National University of Singapore, Singapore
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Duan W, Cao D, Wang S, Cheng J. Serotonin 2A Receptor (5-HT 2AR) Agonists: Psychedelics and Non-Hallucinogenic Analogues as Emerging Antidepressants. Chem Rev 2024; 124:124-163. [PMID: 38033123 DOI: 10.1021/acs.chemrev.3c00375] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Psychedelics make up a group of psychoactive compounds that induce hallucinogenic effects by activating the serotonin 2A receptor (5-HT2AR). Clinical trials have demonstrated the traditional psychedelic substances like psilocybin as a class of rapid-acting and long-lasting antidepressants. However, there is a pressing need for rationally designed 5-HT2AR agonists that possess optimal pharmacological profiles in order to fully reveal the therapeutic potential of these agonists and identify safer drug candidates devoid of hallucinogenic effects. This Perspective provides an overview of the structure-activity relationships of existing 5-HT2AR agonists based on their chemical classifications and discusses recent advancements in understanding their molecular pharmacology at a structural level. The encouraging clinical outcomes of psychedelics in depression treatment have sparked drug discovery endeavors aimed at developing novel 5-HT2AR agonists with improved subtype selectivity and signaling bias properties, which could serve as safer and potentially nonhallucinogenic antidepressants. These efforts can be significantly expedited through the utilization of structure-based methods and functional selectivity-directed screening.
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Affiliation(s)
- Wenwen Duan
- iHuman Institute, ShanghaiTech University, 393 Middle Huaxia Road, Shanghai 201210, China
| | - Dongmei Cao
- State Key Laboratory of Molecular Biology, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences; University of Chinese Academy of Sciences, 320 Yueyang Road, Shanghai 200031, China
| | - Sheng Wang
- State Key Laboratory of Molecular Biology, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences; University of Chinese Academy of Sciences, 320 Yueyang Road, Shanghai 200031, China
- Key Laboratory of Systems Health Science of Zhejiang Province, School of Life Science, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou 310024, China
| | - Jianjun Cheng
- iHuman Institute, ShanghaiTech University, 393 Middle Huaxia Road, Shanghai 201210, China
- School of Life Science and Technology, ShanghaiTech University, 393 Middle Huaxia Road, Shanghai 201210, China
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32
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Olivier B, Olivier JDA. Efficacy, Safety, and Tolerability of Psychedelics in Treatment-Resistant Depression (TRD). ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1456:49-66. [PMID: 39261423 DOI: 10.1007/978-981-97-4402-2_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Major depressive disorder (MDD) is a highly prevalent psychiatric disorder, associated with substantial burden and large economical costs. Notwithstanding various conventional antidepressant treatment options, a large portion of depressed people (ca. 30%) fails to respond to first-line treatment, resulting in treatment-resistant depression (TRD). Although non-response to multiple antidepressant interventions is a common outcome, a consensus definition of TRD is not yet available. In practice, TRD is applied when two or more successive treatments with different antidepressants are not working. The last decade's intense research into new medicines for TRD has led to two developments, using typical or serotonergic (psilocybin, ayahuasca) and atypical (glutamatergic) psychedelics (ketamine, esketamine). Both approaches, although via different entrance mechanism, exhibit a fast onset but also long-lasting antidepressant effect far beyond the biological presence of the drug in the body, strongly indicating that downstream mechanisms activated by signaling cascades in the brain are involved. The present chapter describes the clinical development of psilocybin and esketamine for TRD and discusses the problems involved in the use of a proper placebo because of the psychotomimetic (psilocybin) or dissociative (ketamine) effects that interfere with performing "blind" studies. Nevertheless, intranasal esketamine was developed and approved for TRD, whereas psilocybin has shown positive results. Adverse effects and tolerability of both drugs in the dose ranges used are generally acceptable. The emergence of anti-TRD medicines for treatment of a very severe disease is a breakthrough in psychiatry.
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Affiliation(s)
- Berend Olivier
- Department of Psychopharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
| | - Jocelien D A Olivier
- Neurobiology, Groningen Institute of Evolutionary Life Sciences (GELIFES), Rijksuniversiteit Groningen, Groningen, The Netherlands
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Johnston JN, Kadriu B, Kraus C, Henter ID, Zarate CA. Ketamine in neuropsychiatric disorders: an update. Neuropsychopharmacology 2024; 49:23-40. [PMID: 37340091 PMCID: PMC10700638 DOI: 10.1038/s41386-023-01632-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant led to a new era in the development of neuropsychiatric therapeutics, one characterized by an antidepressant response that occurred within hours or days rather than weeks or months. Considerable clinical research supports the use of-or further research with-subanesthetic-dose ketamine and its (S)-enantiomer esketamine in multiple neuropsychiatric disorders including depression, bipolar disorder, anxiety spectrum disorders, substance use disorders, and eating disorders, as well as for the management of chronic pain. In addition, ketamine often effectively targets symptom domains associated with multiple disorders, such as anxiety, anhedonia, and suicidal ideation. This manuscript: 1) reviews the literature on the pharmacology and hypothesized mechanisms of subanesthetic-dose ketamine in clinical research; 2) describes similarities and differences in the mechanism of action and antidepressant efficacy between racemic ketamine, its (S) and (R) enantiomers, and its hydroxynorketamine (HNK) metabolite; 3) discusses the day-to-day use of ketamine in the clinical setting; 4) provides an overview of ketamine use in other psychiatric disorders and depression-related comorbidities (e.g., suicidal ideation); and 5) provides insights into the mechanisms of ketamine and therapeutic response gleaned from the study of other novel therapeutics and neuroimaging modalities.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Translational and Experimental Medicine, Neuroscience at Jazz Pharmaceuticals, San Diego, CA, USA
| | - Christoph Kraus
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Song C, Wang D, Chen B. A systematic review and meta-analysis comparing the efficacy and safety of ketamine versus morphine for the treatment of acute pain. Minerva Anestesiol 2024; 90:77-86. [PMID: 37930103 DOI: 10.23736/s0375-9393.23.17561-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Ketamine is reported as a potent opioid alternative that provides significant reduction in pain with no severe adverse events. However, some studies didn't find its use satisfactory and reported less reduction in pain score with ketamine. The purpose of this study is to compare the efficacy and safety of ketamine versus morphine for the treatment of acute pain in emergency situations. EVIDENCE ACQUISITION The PubMed, MEDLINE, PsycINFO EMBASE, Cochrane Library, PROSPERO registry platform, and ClinicalTrials.gov websites were queried in accordance with the PRISMA guidelines in order to locate relevant studies. According to the predefined PICOS criteria, articles were included and event data pertaining to changes in Visual Analog Scale or Numeric Rating Scale pain scales were extracted. Using RevMan and MedCalc, a meta-analysis was conducted to compare the effects of ketamine and morphine for the treatment of acute pain. EVIDENCE SYNTHESIS Twelve studies met the criteria for inclusion in this meta-analysis. Ketamine was found to be more effective than morphine at reducing pain scores, with an odds ratio of 0.60 (95% CI 0.48 to 0.76). Similarly, no severe adverse events related to ketamine were reported in any study, and it has a low-risk ratio of 0.78 (95% CI 0.70 to 0.87). Egger's Test P values (0.3052) and Begg's Test P values (0.3869) indicate a low risk of bias, and the Bland-Altman plot demonstrates a high degree of concordance. CONCLUSIONS Ketamine is a potent and effective alternative to morphine for the management of acute pain, and it reduces pain score significantly with minimal side effects.
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Affiliation(s)
- Cheng Song
- Department of Anesthesiology, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Dong Wang
- Department of Anesthesiology, First People's Hospital of Yongkang, Yongkang, China
| | - Bin Chen
- Department of Anesthesiology, Hospital of Integrated Traditional Chinese and Western Medicine of Taizhou, Taizhou, China -
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Lan XJ, Cai DB, Liu QM, Qin ZJ, Pridmore S, Zheng W, Xiang YT. Stanford neuromodulation therapy for treatment-resistant depression: a systematic review. Front Psychiatry 2023; 14:1290364. [PMID: 38161728 PMCID: PMC10756664 DOI: 10.3389/fpsyt.2023.1290364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024] Open
Abstract
Objective This systematic review of randomized controlled studies (RCTs) and observational studies evaluated the efficacy and safety of stanford neuromodulation therapy (SNT) for patients with treatment-resistant depression (TRD). Methods A systematic search (up to 25 September, 2023) of RCTs and single-arm prospective studies was conducted. Results One RCT (n = 29) and three single-arm prospective studies (n = 34) met the study entry criteria. In the RCT, compared to sham, active SNT was significantly associated with higher rates of antidepressant response (71.4% versus 13.3%) and remission (57.1% versus 0%). Two out of the three single-arm prospective studies reported the percentage of antidepressant response after completing SNT, ranging from 83.3% (5/6) to 90.5% (19/21). In the three single-arm prospective studies, the antidepressant remission rates ranged from 66.7% (4/6) to 90.5% (19/21). No severe adverse events occurred in all the four studies. Conclusion This systematic review found SNT significantly improved depressive symptoms in patients with TRD within 5 days, without severe adverse events.
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Affiliation(s)
- Xian-Jun Lan
- The Brain Hospital of Guangxi Zhuang Autonomous Region, Liuzhou, China
| | - Dong-Bin Cai
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Qi-Man Liu
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhen-Juan Qin
- The Brain Hospital of Guangxi Zhuang Autonomous Region, Liuzhou, China
| | - Saxby Pridmore
- Discipline of Psychiatry, University of Tasmania, Hobart, TAS, Australia
| | - Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yu-Tao Xiang
- Unit of Psychiatry, Department of Public Health and Medicinal Administration, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau, Macao SAR, China
- Centre for Cognitive and Brain Sciences, University of Macau, Macau, Macao SAR, China
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Gebara MA, Brown PJ, Roose SP. Finally, New Hope for the Treatment of LLTRD. Am J Geriatr Psychiatry 2023; 31:1042-1044. [PMID: 37562991 DOI: 10.1016/j.jagp.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry (MAG), University of Pittsburgh, School of Medicine, Pittsburgh, PA.
| | - Patrick J Brown
- Department of Psychiatry (PJB, SPR), Columbia University College of Physicians and Surgeons, The New York State Psychiatric Institute, New York, NY
| | - Steven P Roose
- Department of Psychiatry (PJB, SPR), Columbia University College of Physicians and Surgeons, The New York State Psychiatric Institute, New York, NY
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Wojtas A. The possible place for psychedelics in pharmacotherapy of mental disorders. Pharmacol Rep 2023; 75:1313-1325. [PMID: 37934320 PMCID: PMC10661751 DOI: 10.1007/s43440-023-00550-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
Since its emergence in the 1960s, the serotonergic theory of depression bore fruit in the discovery of a plethora of antidepressant drugs affecting the lives of millions of patients. While crucial in the history of drug development, recent studies undermine the effectiveness of currently used antidepressant drugs in comparison to placebo, emphasizing the long time it takes to initiate the therapeutic response and numerous adverse effects. Thus, the scope of contemporary pharmacological research shifts from drugs affecting the serotonin system to rapid-acting antidepressant drugs. The prototypical representative of the aforementioned class is ketamine, an NMDA receptor antagonist capable of alleviating the symptoms of depression shortly after the drug administration. This discovery led to a paradigm shift, focusing on amino-acidic neurotransmitters and growth factors. Alas, the drug is not perfect, as its therapeutic effect diminishes circa 2 weeks after administration. Furthermore, it is not devoid of some severe side effects. However, there seems to be another, more efficient, and safer way to target the glutamatergic system. Hallucinogenic agonists of the 5-HT2A receptor, commonly known as psychedelics, are nowadays being reconsidered in clinical practice, shedding their infamous 1970s stigma. More and more clinical studies prove their clinical efficacy and rapid onset after a single administration while bearing fewer side effects. This review focuses on the current state-of-the-art literature and most recent clinical studies concerning the use of psychedelic drugs in the treatment of mental disorders. Specifically, the antidepressant potential of LSD, psilocybin, DMT, and 5-MeO-DMT will be discussed, together with a brief summary of other possible applications.
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Affiliation(s)
- Adam Wojtas
- Department of Pharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, Smętna 12, 31-343, Kraków, Poland.
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Abstract
This Viewpoint discusses ketamine and its new and experimentally investigated on- and off-label indications that span different medical disciplines.
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Affiliation(s)
- Chittaranjan Andrade
- Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore, India
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Guilloux JP, Nguyen TML, Gardier AM. [Ketamine: a neuropsychotropic drug with an innovative mechanism of action]. Biol Aujourdhui 2023; 217:133-144. [PMID: 38018940 DOI: 10.1051/jbio/2023026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Indexed: 11/30/2023]
Abstract
Ketamine, a non-competitive antagonist of the N-methyl-D-aspartate-glutamate receptor (R-NMDA), has a rapid (from 24 h post-dose) and prolonged (up to one week) antidepressant effect in treatment resistant depression and in rodent models of anxiety/depression. Arguments regarding its cellular and molecular mechanisms underlying its antidepressant activity mainly come from animal studies. However, debates still persist on the structural remodeling of frontocortical/hippocampal neurons and the role of excitatory/inhibitory neurotransmitters involved in its behavioral effect. Neurochemical and behavioral changes are maintained 24 h after administration of ketamine, well beyond its plasma elimination half-life. The glutamatergic pyramidal cells of the medial prefrontal cortex are primarily implicated in the therapeutic effects of ketamine. Advances in knowledge of the consequences of R-NMDA blockade allowed to specify the underlying mechanisms involving the activation of AMPA glutamate receptors, which triggers a cascade of intracellular events dependent on the mechanistic target of rapamycin, brain-derived neurotrophic factor, and synaptic protein synthesis facilitating synaptic plasticity (number of dendritic spines, synaptogenesis). This review focuses on abnormalities of neurotransmitter systems involved in major depressive disorders, their potential impact on neural circuitry and beneficial effects of ketamine. Recent preclinical data pave the way for future studies to better clarify the mechanism of action of fast-acting antidepressant drugs for the development of novel, more effective therapies.
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Affiliation(s)
- Jean-Philippe Guilloux
- Laboratoire de Neuropharmacologie, Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, Équipe MOODS, F-91400 Orsay, France
| | - Thi Mai Loan Nguyen
- Laboratoire de Neuropharmacologie, Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, Équipe MOODS, F-91400 Orsay, France
| | - Alain M Gardier
- Laboratoire de Neuropharmacologie, Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, Équipe MOODS, F-91400 Orsay, France
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Lii TR, Smith AE, Flohr JR, Okada RL, Nyongesa CA, Cianfichi LJ, Hack LM, Schatzberg AF, Heifets BD. Randomized trial of ketamine masked by surgical anesthesia in patients with depression. NATURE MENTAL HEALTH 2023; 1:876-886. [PMID: 38188539 PMCID: PMC10769130 DOI: 10.1038/s44220-023-00140-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/14/2023] [Indexed: 01/09/2024]
Abstract
Ketamine may have antidepressant properties, but its acute psychoactive effects complicate successful masking in placebo-controlled trials. We present a single-center, parallel-arm, triple-masked, randomized, placebo-controlled trial assessing the antidepressant efficacy of intravenous ketamine masked by surgical anesthesia (ClinicalTrials.gov, NCT03861988). Forty adult patients with major depressive disorder who were scheduled for routine surgery were randomized to a single infusion of ketamine (0.5 mg/kg) or placebo (saline) during usual anesthesia. All participants, investigators, and direct patient care staff were masked to treatment allocation. The primary outcome was depression severity measured by the Montgomery-Åsberg Depression Rating Scale (MADRS) at 1, 2, and 3 days post-infusion. After all follow-up visits, participants were asked to guess which intervention they received. A mixed-effects model showed no evidence of effect of treatment assignment on the primary outcome (-5.82, 95% CI -13.3 to 1.64, p=0.13). 36.8% of participants guessed their treatment assignment correctly; both groups allocated their guesses in similar proportions. In conclusion, a single dose of intravenous ketamine delivered during surgical anesthesia had no greater effect than placebo in acutely reducing the severity of depressive symptoms in adults with major depressive disorder. This trial successfully masked treatment allocation in moderate-to-severely depressed patients using surgical anesthesia. Although this masking strategy is impractical for most placebo-controlled trials, future studies of novel antidepressants with acute psychoactive effects should make efforts to fully mask treatment assignment in order to minimize subject-expectancy bias.
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Affiliation(s)
- Theresa R Lii
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ashleigh E Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Josephine R Flohr
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Robin L Okada
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Cynthia A Nyongesa
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa J Cianfichi
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Laura M Hack
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alan F Schatzberg
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Boris D Heifets
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Evanoff AB, Baig M, Taylor JB, Beach SR. Ketamine: A Practical Review for the Consultation-Liaison Psychiatrist. J Acad Consult Liaison Psychiatry 2023; 64:521-532. [PMID: 37301324 DOI: 10.1016/j.jaclp.2023.06.001] [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: 01/04/2023] [Revised: 04/15/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Ketamine is a noncompetitive N-methyl-D-aspartate-receptor antagonist often used for sedation and management of acute agitation in general hospital settings. Many hospitals now include ketamine as part of their standard agitation protocol, and consultation-liaison psychiatrists frequently find themselves treating patients who have received ketamine, despite lack of clear recommendations for management. OBJECTIVE Conduct a nonsystematic narrative review regarding the use of ketamine for agitation and continuous sedation, including benefits and adverse psychiatric effects. Compare ketamine to more traditional agents of agitation control. Provide consultation-liaison psychiatrists with a summary of available knowledge and recommendations for managing patients receiving ketamine. METHODS A literature review was performed using PubMed, querying published articles from inception to March 2023 for articles related to use of ketamine for agitation or continuous sedation and side effects including psychosis and catatonia. RESULTS A total of 37 articles were included. Ketamine was found to have multiple benefits, including shorter time to adequate sedation for agitated patients when compared to haloperidol ± benzodiazepines and unique advantages for continuous sedation. However, ketamine carries significant medical risks including high rates of intubation. Ketamine appears to induce a syndrome that mimics schizophrenia in healthy controls, and such effects are more pronounced and longer-lasting in patients with schizophrenia. Evidence regarding rates of delirium with ketamine for continuous sedation is mixed and requires further investigation before the agent is widely adopted for this purpose. Finally, the diagnosis of "excited delirium syndrome" and use of ketamine to treat this controversial syndrome warrants critical evaluation. CONCLUSIONS Ketamine carries many potential benefits and can be an appropriate medication for patients with profound undifferentiated agitation. However, intubation rates remain high, and ketamine may worsen underlying psychotic disorders. It is essential that consultation-liaison psychiatrists understand the advantages, disadvantages, biased administration, and areas of limited knowledge regarding ketamine.
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Affiliation(s)
- Anastasia B Evanoff
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA.
| | - Mirza Baig
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA
| | - John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Coffelt CB, Gibson K, VanLandingham J. Ketamine for Traumatic Assault-Induced Depression: A Case Report. J Trauma Nurs 2023; 30:353-356. [PMID: 37937877 DOI: 10.1097/jtn.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND This case report describes the use of ketamine as a rapid, effective treatment of depression in a 68-year-old female patient with no significant medical history of psychiatric disorders. Patients who experience intentional or unintentional traumas are at an increased risk for developing depression or posttraumatic stress disorder, and emerging evidence has supported the use of ketamine as an alternative treatment of depression. CASE PRESENTATION This is the case of a 68-year-old female patient who was assaulted, resulting in multiple stab wounds to both hands and the right upper quadrant. She underwent placement of a chest tube and surgical repair of the liver and was subsequently admitted to the intensive care unit. These events led to the development of severe depression symptoms, as evidenced by a Montgomery-Asberg Depression Rating Scale (MADRS) score of 37. As treatment of her acute depression, the patient received a single intravenous dose of ketamine (0.5 mg/kg) infused over 40 min and was monitored for side effects. The MADRS is a 10-item depression screening tool that assesses symptoms and changes over time. Within 4 hr of receiving ketamine, the patient reported a significant improvement in her mood and her MADRS score decreased to 16, classifying this patient as experiencing mild depression. The patient continued to improve, and 24 hr after receiving ketamine, her MADRS score was 4, indicating remission of her depression symptoms. CONCLUSION This case report aims to provide an account of the potential benefits of ketamine as a rapid treatment of depression in an adult trauma patient.
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Affiliation(s)
- Caitlyn B Coffelt
- University of Georgia College of Pharmacy, Athens, Georgia (Dr Coffelt); and Northeast Georgia Medical Center, Gainesville, Georgia (Ms Gibson and Dr VanLandingham)
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Dębowska W, Więdłocha M, Dębowska M, Kownacka Z, Marcinowicz P, Szulc A. Transcranial magnetic stimulation and ketamine: implications for combined treatment in depression. Front Neurosci 2023; 17:1267647. [PMID: 37954877 PMCID: PMC10637948 DOI: 10.3389/fnins.2023.1267647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Drug-resistant mental disorders, particularly treatment-resistant depression, pose a significant medical and social problem. To address this challenge, modern psychiatry is constantly exploring the use of novel treatment methods, including biological treatments, such as transcranial magnetic stimulation (TMS), and novel rapid-acting antidepressants, such as ketamine. While both TMS and ketamine demonstrate high effectiveness in reducing the severity of depressive symptoms, some patients still do not achieve the desired improvement. Recent literature suggests that combining these two methods may yield even stronger and longer-lasting results. This review aims to consolidate knowledge in this area and elucidate the potential mechanisms of action underlying the increased efficacy of combined treatment, which would provide a foundation for the development and optimization of future treatment protocols.
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Affiliation(s)
- Weronika Dębowska
- Department of Psychiatry, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
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Reissmann S, Hartmann M, Kist A, Liechti ME, Stocker K. Case report: Maintaining altered states of consciousness over repeated ketamine infusions may be key to facilitate long-lasting antidepressant effects: some initial lessons from a personalized-dosing single-case study. Front Psychiatry 2023; 14:1197697. [PMID: 37953937 PMCID: PMC10634239 DOI: 10.3389/fpsyt.2023.1197697] [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: 03/31/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Background The interest in psychoactive agents for treating mental disorders has gathered a growing body of scientific interest. However, research on the relationship between altered states of consciousness (ASCs) and ketamine's antidepressant properties is still limited. Likewise, approaches to sustain early treatment success for the long-term are needed. Taking both aspects into account, the question arises whether the persistence of recurrent ASCs during the subsequent infusion sessions is crucial for the preservation of antidepressant effects during prolonged continued ketamine therapy. Aim In this case study we explored whether recurrent ASC experiences across a large number of infusions are associated with improved antidepressant effects in a single case study. Methods A 62-year-old patient with treatment-resistant depression, who has been suffering from depressive episodes for over 20 years, was observed for 12 consecutive infusions across 16 weeks. ASCs during ketamine sessions were measured with the 5D-ASC, and pre/post-infusion depression scores with the BDI-II questionnaire. To emphasize psychoactive experiences a personalized antidepressant dose regimen was used. Results We found a strong correlation between the experienced ASCs during ketamine infusions and the antidepressant effect: the stronger the ASCs overall, the stronger the resulting antidepressant effect. This correlation was consistently observed throughout the infusion series, independent of the number of ketamine sessions completed before. However, despite a personalized dose regimen, neither peri-infusion ASCs nor antidepressant effects could be established on a regular basis, leading overall to no improvement in treatment outcome. Conclusion Maintaining psychoactive effects over repeated ketamine infusions may be key to facilitate long-lasting antidepressant effects. However, for some depressed individuals maintenance of antidepressant effects and/or peri-infusion ASCs might not be achieved, even when personalized dosing is used.
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Affiliation(s)
| | | | - Andreas Kist
- Medical Office for Anesthesiology Zelenka and Colleagues, Villingen-Schwenningen, Germany
| | - Matthias E. Liechti
- Psychopharmacology Research, Division of Clinical Pharmacology and Toxicology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Kurt Stocker
- Department of Psychology, University of Zurich, Zurich, Switzerland
- Faculty of Psychology – UniDistance Suisse, Brig, Switzerland
- Psychopharmacology Research, Division of Clinical Pharmacology and Toxicology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Chair of Cognitive Science, Department of Humanities, Social and Political Sciences, ETH Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
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Schwartz OS, Amminger P, Baune BT, Bedi G, Berk M, Cotton SM, Daglas-Georgiou R, Glozier N, Harrison B, Hermens DF, Jennings E, Lagopoulos J, Loo C, Mallawaarachchi S, Martin D, Phelan B, Read N, Rodgers A, Schmaal L, Somogyi AA, Thurston L, Weller A, Davey CG. The Study of Ketamine for Youth Depression (SKY-D): study protocol for a randomised controlled trial of low-dose ketamine for young people with major depressive disorder. Trials 2023; 24:686. [PMID: 37875938 PMCID: PMC10594918 DOI: 10.1186/s13063-023-07631-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Existing treatments for young people with severe depression have limited effectiveness. The aim of the Study of Ketamine for Youth Depression (SKY-D) trial is to determine whether a 4-week course of low-dose subcutaneous ketamine is an effective adjunct to treatment-as-usual in young people with major depressive disorder (MDD). METHODS SKY-D is a double-masked, randomised controlled trial funded by the Australian Government's National Health and Medical Research Council (NHMRC). Participants aged between 16 and 25 years (inclusive) with moderate-to-severe MDD will be randomised to receive either low-dose ketamine (intervention) or midazolam (active control) via subcutaneous injection once per week for 4 weeks. The primary outcome is change in depressive symptoms on the Montgomery-Åsberg Depression Rating Scale (MADRS) after 4 weeks of treatment. Further follow-up assessment will occur at 8 and 26 weeks from treatment commencement to determine whether treatment effects are sustained and to investigate safety outcomes. DISCUSSION Results from this trial will be important in determining whether low-dose subcutaneous ketamine is an effective treatment for young people with moderate-to-severe MDD. This will be the largest randomised trial to investigate the effects of ketamine to treat depression in young people. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ID: ACTRN12619000683134. Registered on May 7, 2019. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377513 .
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Affiliation(s)
- Orli S Schwartz
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.
- Orygen, Melbourne, Australia.
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
| | - Paul Amminger
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Bernard T Baune
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Department of Psychiatry, University of Münster, Münster, Germany
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Gillinder Bedi
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Michael Berk
- Orygen, Melbourne, Australia
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong, Australia
| | - Sue M Cotton
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Rothanthi Daglas-Georgiou
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Nick Glozier
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Australian Research Council Centre of Excellence for Children and Families Over the Life Course, Sydney, Australia
- Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ben Harrison
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Daniel F Hermens
- Thompson Institute, University of the Sunshine Coast, Sunshine Coast, Australia
| | - Emma Jennings
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Jim Lagopoulos
- Thompson Institute, University of the Sunshine Coast, Sunshine Coast, Australia
- Thompson Brain and Mind Healthcare, Sunshine Coast, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
| | - Sumudu Mallawaarachchi
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Donel Martin
- Black Dog Institute, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Bethany Phelan
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Nikki Read
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lianne Schmaal
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Andrew A Somogyi
- School of Biomedicine, University of Adelaide, Adelaide, Australia
| | - Lily Thurston
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Amber Weller
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
- Victorian Department of Health, Melbourne, Australia
| | - Christopher G Davey
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
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Zavaliangos-Petropulu A, McClintock SM, Joshi SH, Taraku B, Al-Sharif NB, Espinoza RT, Narr KL. Hippocampal subfield volumes in treatment resistant depression and serial ketamine treatment. Front Psychiatry 2023; 14:1227879. [PMID: 37876623 PMCID: PMC10590913 DOI: 10.3389/fpsyt.2023.1227879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Subanesthetic ketamine is a rapidly acting antidepressant that has also been found to improve neurocognitive performance in adult patients with treatment resistant depression (TRD). Provisional evidence suggests that ketamine may induce change in hippocampal volume and that larger pre-treatment volumes might be related to positive clinical outcomes. Here, we examine the effects of serial ketamine treatment on hippocampal subfield volumes and relationships between pre-treatment subfield volumes and changes in depressive symptoms and neurocognitive performance. Methods Patients with TRD (N = 66; 31M/35F; age = 39.5 ± 11.1 years) received four ketamine infusions (0.5 mg/kg) over 2 weeks. Structural MRI scans, the National Institutes of Health Toolbox (NIHT) Cognition Battery, and Hamilton Depression Rating Scale (HDRS) were collected at baseline, 24 h after the first and fourth ketamine infusion, and 5 weeks post-treatment. The same data was collected for 32 age and sex matched healthy controls (HC; 17M/15F; age = 35.03 ± 12.2 years) at one timepoint. Subfield (CA1/CA3/CA4/subiculum/molecular layer/GC-ML-DG) volumes corrected for whole hippocampal volume were compared across time, between treatment remitters/non-remitters, and patients and HCs using linear regression models. Relationships between pre-treatment subfield volumes and clinical and cognitive outcomes were also tested. All analyses included Bonferroni correction. Results Patients had smaller pre-treatment left CA4 (p = 0.004) and GC.ML.DG (p = 0.004) volumes compared to HC, but subfield volumes remained stable following ketamine treatment (all p > 0.05). Pre-treatment or change in hippocampal subfield volumes over time showed no variation by remission status nor correlated with depressive symptoms (p > 0.05). Pre-treatment left CA4 was negatively correlated with improved processing speed after single (p = 0.0003) and serial ketamine infusion (p = 0.005). Left GC.ML.DG also negatively correlated with improved processing speed after single infusion (p = 0.001). Right pre-treatment CA3 positively correlated with changes in list sorting working memory at follow-up (p = 0.0007). Discussion These results provide new evidence to suggest that hippocampal subfield volumes at baseline may present a biomarker for neurocognitive improvement following ketamine treatment in TRD. In contrast, pre-treatment subfield volumes and changes in subfield volumes showed negligible relationships with ketamine-related improvements in depressive symptoms.
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Affiliation(s)
- Artemis Zavaliangos-Petropulu
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Shawn M. McClintock
- Division of Psychology, Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, United States
| | - Shantanu H. Joshi
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Brandon Taraku
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Noor B. Al-Sharif
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Randall T. Espinoza
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Katherine L. Narr
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
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Palanca BJA, Conway CR, Zeffiro T, Gott BM, Nguyen T, Janski A, Jain N, Komen H, Burke BA, Zorumski CF, Nagele P. Persistent Brain Connectivity Changes in Healthy Volunteers Following Nitrous Oxide Inhalation. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2023; 3:698-704. [PMID: 37881568 PMCID: PMC10593877 DOI: 10.1016/j.bpsgos.2023.01.006] [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: 01/09/2022] [Revised: 01/15/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Background Nitrous oxide holds promise in the treatment of major depressive disorder. Its psychotropic effects and NMDA receptor antagonism have led to comparisons with ketamine. Despite longstanding use, persistent effects of nitrous oxide on the brain have not been characterized. Methods Sixteen healthy volunteers were recruited in a double-blind crossover study. In randomized order, individuals underwent a 1-hour inhalation of either 50% nitrous oxide/oxygen or air/oxygen mixtures. At least two 7.5-minute echo-planar resting-state functional magnetic resonance imaging scans were obtained before and at 2 and 24 hours after each inhalation (average 130 min/participant). Using the time series of preprocessed, motion artifact-scrubbed, and nuisance covariate-regressed imaging data, interregional signal correlations were measured and converted to T scores. Hierarchical clustering and linear mixed-effects models were employed. Results Nitrous oxide inhalation produced changes in global brain connectivity that persisted in the occipital cortex at 2 and 24 hours postinhalation (p < .05, false discovery rate-corrected). Analysis of resting-state networks demonstrated robust strengthening of connectivity between regions of the visual network and those of the dorsal attention network, across 2 and 24 hours after inhalation (p < .05, false discovery rate-corrected). Weaker changes in connectivity were found between the visual cortex and regions of the frontoparietal and default mode networks. Parallel analyses following air/oxygen inhalation yielded no significant changes in functional connectivity. Conclusions Nitrous oxide inhalation in healthy volunteers revealed persistent increases in global connectivity between regions of primary visual cortex and dorsal attention network. These findings suggest that nitrous oxide inhalation induces neurophysiological cortical changes that persist for at least 24 hours.
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Affiliation(s)
- Ben Julian A. Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
- Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charles R. Conway
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Thomas Zeffiro
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Britt M. Gott
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Thomas Nguyen
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alvin Janski
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Nisha Jain
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois
| | - Helga Komen
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Broc A. Burke
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Charles F. Zorumski
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois
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Akbar D, Rhee TG, Ceban F, Ho R, Teopiz KM, Cao B, Subramaniapillai M, Kwan ATH, Rosenblat JD, McIntyre RS. Dextromethorphan-Bupropion for the Treatment of Depression: A Systematic Review of Efficacy and Safety in Clinical Trials. CNS Drugs 2023; 37:867-881. [PMID: 37792265 DOI: 10.1007/s40263-023-01032-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND A significant proportion of adults with major depressive disorder (MDD) do not respond to treatments which are currently used in clinical practice such as first-generation monoamine-based antidepressants. OBJECTIVES The objective of this systematic review was to assess the efficacy, safety, and mechanisms of action of AXS-05, a combination of the NMDA-receptor antagonist dextromethorphan with bupropion, in adults with MDD. METHODS We searched PubMed, Embase, Google Scholar, and ClinicalTrials.gov for current studies reporting on efficacy and/or safety of AXS-05 in patients with MDD. The search terms included: "AXS-05" OR "dextromethorphan and bupropion" AND "depression". Studies from database inception to January 2023 were evaluated. Risk of bias was assessed using the Cochrane Risk of Bias tool. RESULTS The search yielded 54 studies of which 5 were included. All studies had low risk of bias. Depression severity, measured with the Montgomery-Åsberg Depression Rating Scale (MADRS) significantly decreased as early as 1-week post-treatment from baseline when compared to a placebo-controlled group (LS mean difference 2.2; 95% CI 0.6-3.9; p = 0.007) and at 2 weeks compared to an active control group (LS mean difference 4.7; 95% CI 0.6-8.8; p = 0.024). Treatment efficacy could be maintained for up to 12 months with mean MADRS score reduction of 23 points from baseline. Clinical remission and response rates also improved at week 1 and were maintained for 12 months. The treatment was well-tolerated, with some transient adverse events reported. CONCLUSION Current evidence suggests that the combination of dextromethorphan and bupropion is a well-tolerated, rapid-acting treatment option for adults with MDD. Initial success with AXS-05 supports the mechanistic role of glutamatergeric and sigma 1 signaling in the pathophysiology of MDD.
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Affiliation(s)
- Dania Akbar
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Felicia Ceban
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, 400715, People's Republic of China
| | - Mehala Subramaniapillai
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
| | - Angela T H Kwan
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation (BCDF), 77 Bloor St W Suite 617, Toronto, ON, M5S 1M2, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
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Kalkman HO. Activation of σ1-Receptors by R-Ketamine May Enhance the Antidepressant Effect of S-Ketamine. Biomedicines 2023; 11:2664. [PMID: 37893038 PMCID: PMC10604479 DOI: 10.3390/biomedicines11102664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/29/2023] Open
Abstract
Ketamine is a racemic mixture composed of two enantiomers, S-ketamine and R-ketamine. In preclinical studies, both enantiomers have exhibited antidepressant effects, but these effects are attributed to distinct pharmacological activities. The S-enantiomer acts as an NMDA-channel blocker and as an opioid μ-receptor agonist, whereas the R-enantiomer binds to σ1-receptors and is believed to act as an agonist. As racemate, ketamine potentially triggers four biochemical pathways involving the AGC-kinases, PKA, Akt (PKB), PKC and RSK that ultimately lead to inhibitory phosphorylation of GSK3β in microglia. In patients with major depressive disorder, S-ketamine administered as a nasal spray has shown clear antidepressant activity. However, when compared to intravenously infused racemic ketamine, the response rate, duration of action and anti-suicidal activity of S-ketamine appear to be less pronounced. The σ1-protein interacts with μ-opioid and TrkB-receptors, whereas in preclinical experiments σ1-agonists reduce μ-receptor desensitization and improve TrkB signal transduction. TrkB activation occurs as a response to NMDA blockade. So, the σ1-activity of R-ketamine may not only enhance two pathways via which S-ketamine produces an antidepressant response, but it furthermore provides an antidepressant activity in its own right. These two factors could explain the apparently superior antidepressant effect observed with racemic ketamine compared to S-ketamine alone.
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Affiliation(s)
- Hans O Kalkman
- Retired Pharmacologist, Gänsbühlgartenweg 7, 4132 Muttenz, Switzerland
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van Elk M, Fried EI. History repeating: guidelines to address common problems in psychedelic science. Ther Adv Psychopharmacol 2023; 13:20451253231198466. [PMID: 37766730 PMCID: PMC10521293 DOI: 10.1177/20451253231198466] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/11/2023] [Indexed: 09/29/2023] Open
Abstract
Research in the last decade has expressed considerable optimism about the clinical potential of psychedelics for the treatment of mental disorders. This optimism is reflected in an increase in research papers, investments by pharmaceutical companies, patents, media coverage, as well as political and legislative changes. However, psychedelic science is facing serious challenges that threaten the validity of core findings and raise doubt regarding clinical efficacy and safety. In this paper, we introduce the 10 most pressing challenges, grouped into easy, moderate, and hard problems. We show how these problems threaten internal validity (treatment effects are due to factors unrelated to the treatment), external validity (lack of generalizability), construct validity (unclear working mechanism), or statistical conclusion validity (conclusions do not follow from the data and methods). These problems tend to co-occur in psychedelic studies, limiting conclusions that can be drawn about the safety and efficacy of psychedelic therapy. We provide a roadmap for tackling these challenges and share a checklist that researchers, journalists, funders, policymakers, and other stakeholders can use to assess the quality of psychedelic science. Addressing today's problems is necessary to find out whether the optimism regarding the therapeutic potential of psychedelics has been warranted and to avoid history repeating itself.
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Affiliation(s)
- Michiel van Elk
- Cognitive Psychology Unit, Institute of Psychology, Leiden University, PO Box 9555, Leiden 2300 RB, The Netherlands
| | - Eiko I. Fried
- Clinical Psychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
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