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Seshadri A, Prokop LJ, Singh B. Efficacy of intravenous ketamine and intranasal esketamine with dose escalation for Major depression: A systematic review and meta-analysis. J Affect Disord 2024; 356:379-384. [PMID: 38537759 DOI: 10.1016/j.jad.2024.03.137] [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: 11/10/2023] [Revised: 03/09/2024] [Accepted: 03/24/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Intravenous (IV) racemic ketamine and intranasal (IN) esketamine have demonstrated rapid antidepressant effects in treatment-resistant depression (TRD). This systematic review aims to evaluate the efficacy and safety of ketamine and esketamine at various dosages for depression. METHODS We included randomized controlled trials (RCTs) with parallel group dose comparison of ketamine and esketamine for depression/TRD. Ovid Medline, Embase, PsycINFO, Scopus and Cochrane databases were searched. Standardized mean differences were calculated using Hedges'-g to complete random effects meta-analysis. The efficacy outcomes were changes in depression outcomes for IV ketamine and IN esketamine respectively. Safety was assessed by reported adverse effects. RESULTS A random effects meta-analysis of studies (n = 12) showed efficacy in reducing depression symptoms with IV ketamine (Hedges'g = 1.52 [0.98-2.22], Z = 4.23, p < 0.001) and IN esketamine (Hedges' g = 0.31 [0.18-0.44], Z = 4.53, P < 0.001) compared to control/placebo. Treatment response was observed at IV ketamine doses ≤0.2 mg/kg, >0.2-0.5 mg/kg and > 0.5 mg/kg. Higher IV ketamine doses (>0.5 mg/kg) did not lead to greater treatment response. Esketamine doses of 56-84 mg were superior to 28 mg dose. LIMITATIONS Overall quality of evidence was low and limited by small number of studies. Publication bias was high. CONCLUSIONS This meta-analysis suggests that IV ketamine may be efficacious at doses as low as 0.2 mg/kg, with increasing dose response at 0.5 mg/kg, without demonstrable increased benefit at 1 mg/kg, based on a small number of studies. Efficacy for IN esketamine increases with doses above 28 mg with best response being found between 56 and 84 mg for reducing depressive symptoms.
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Affiliation(s)
- Ashok Seshadri
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA.
| | - Larry J Prokop
- Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Balwinder Singh
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
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Danyeli LV, Sen ZD, Colic L, Opel N, Refisch A, Blekic N, Macharadze T, Kretzschmar M, Munk MJ, Gaser C, Speck O, Walter M, Li M. Cortical thickness of the posterior cingulate cortex is associated with the ketamine-induced altered sense of self: An ultra-high field MRI study. J Psychiatr Res 2024; 172:136-143. [PMID: 38382237 DOI: 10.1016/j.jpsychires.2024.02.019] [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: 08/14/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Subanesthetic doses of ketamine induce an antidepressant effect within hours in individuals with treatment-resistant depression while it furthermore induces immediate but transient psychotomimetic effects. Among these psychotomimetic effects, an altered sense of self has specifically been associated with the antidepressant response to ketamine as well as psychedelics. However, there is plenty of variation in the extent of the drug-induced altered sense of self experience that might be explained by differences in basal morphological characteristics, such as cortical thickness. Regions that have been previously associated with a psychedelics-induced sense of self and with ketamine's mechanism of action, are the posterior cingulate cortex (PCC) and the pregenual anterior cingulate cortex (pgACC). In this randomized, placebo-controlled, double-blind cross-over magnetic resonance imaging study, thirty-five healthy male participants (mean age ± standard deviation (SD) = 25.1 ± 4.2 years) were scanned at 7 T. We investigated whether the cortical thickness of two DMN regions, the PCC and the pgACC, are associated with disembodiment and experience of unity scores, which were used to index the ketamine-induced altered sense of self. We observed a negative correlation between the PCC cortical thickness and the disembodiment scores (R = -0.54, p < 0.001). In contrast, no significant association was found between the pgACC cortical thickness and the ketamine-induced altered sense of self. In the context of the existing literature, our findings highlight the importance of the PCC as a structure involved in the mechanism of ketamine-induced altered sense of self that seems to be shared with different antidepressant agents with psychotomimetic effects operating on different classes of transmitter systems.
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Affiliation(s)
- Lena Vera Danyeli
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany
| | - Zümrüt Duygu Sen
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany
| | - Lejla Colic
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany
| | - Nils Opel
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany
| | - Alexander Refisch
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany
| | - Nikolai Blekic
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany
| | - Tamar Macharadze
- Department of Anesthesiology and Intensive Care Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany; Department Systems Physiology of Learning, Leibniz Institute for Neurobiology, Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany; Department of Behavioral Neurology, Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - Moritz Kretzschmar
- Department of Anesthesiology and Intensive Care Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - MatthiasH J Munk
- Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany; Systems Neurophysiology, Department of Biology, Darmstadt University of Technology, Darmstadt, Germany
| | - Christian Gaser
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany; Department of Neurology, Jena University Hospital, Jena, Germany
| | - Oliver Speck
- Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany; Department of Behavioral Neurology, Leibniz Institute for Neurobiology, Magdeburg, Germany; Department of Biomedical Magnetic Resonance, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany; Department of Behavioral Neurology, Leibniz Institute for Neurobiology, Magdeburg, Germany.
| | - Meng Li
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany.
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Sajid S, Galfalvy HC, Keilp JG, Burke AK, Mann JJ, Grunebaum MF. Acute Dissociation and Ketamine's Antidepressant and Anti-Suicidal Ideation Effects in a Midazolam-Controlled Trial. Int J Neuropsychopharmacol 2024; 27:pyae017. [PMID: 38573154 PMCID: PMC11053360 DOI: 10.1093/ijnp/pyae017] [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: 01/02/2024] [Accepted: 04/03/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE We sought to explore relationships of acute dissociative effects of intravenous ketamine with change in depression and suicidal ideation and with plasma metabolite levels in a randomized, midazolam-controlled trial. METHODS Data from a completed trial in suicidal, depressed participants (n = 40) randomly assigned to ketamine was used to examine relationships between ketamine treatment-emergent dissociative and psychotomimetic symptoms with pre/post-infusion changes in suicidal ideation and depression severity. Nonparametric correlational statistics were used. These methods were also used to explore associations between dissociative or psychotomimetic symptoms and blood levels of ketamine and metabolites in a subset of participants (n = 28) who provided blood samples immediately post-infusion. RESULTS Neither acute dissociative nor psychotomimetic effects of ketamine were associated with changes in suicidal ideation or depressive symptoms from pre- to post-infusion. Norketamine had a trend-level, moderate inverse correlation with dissociative symptoms on Day 1 post-injection (P = .064; P =.013 removing 1 outlier). Dehydronorketamine correlated with Clinician-Administered Dissociative States Scale scores at 40 minutes (P = .034), 230 minutes (P = .014), and Day 1 (P = .012). CONCLUSION We did not find evidence that ketamine's acute, transient dissociative, or psychotomimetic effects are associated with its antidepressant or anti-suicidal ideation actions. The correlation of higher plasma norketamine with lower dissociative symptoms on Day 1 post-treatment suggests dissociation may be more an effect of the parent drug.
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Affiliation(s)
- Sumra Sajid
- New York State Psychiatric Institute, New York, New York, USA
| | - Hanga C Galfalvy
- Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, New York, USA
| | - John G Keilp
- Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, New York, USA
| | - Ainsley K Burke
- Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, New York, USA
| | - J John Mann
- Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, New York, USA
| | - Michael F Grunebaum
- Columbia University Irving Medical Center and New York State Psychiatric Institute, New York, New York, USA
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Matsingos A, Wilhelm M, Noor L, Yildiz C, Rief W, Hofmann SG, Falkenberg I, Kircher T. Hype or hope? High placebo response in major depression treatment with ketamine and esketamine: a systematic review and meta-analysis. Front Psychiatry 2024; 15:1346697. [PMID: 38525254 PMCID: PMC10957753 DOI: 10.3389/fpsyt.2024.1346697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/13/2024] [Indexed: 03/26/2024] Open
Abstract
Background Ketamine and esketamine offer a novel approach in the pharmacological treatment of major depressive disorder (MDD). This meta-analysis aimed to investigate the placebo response in double-blind, randomized controlled studies (RCTs) on patients with MDD receiving ketamine or esketamine. Methods For this systematic review and meta-analysis Medline (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), PsycInfo and Embase databases were systematically searched for citations published up to March 17, 2023. A total number of 5017 abstracts was identified. Quality of the included trials was assessed with the Cochrane risk-of-bias tool. The meta-analysis was performed using a restricted maximum likelihood model. This study is registered with PROSPERO, number CRD42022377591. Results A total number of 14 studies and 1100 participants (593 in the medication group and 507 in the placebo group) meeting the inclusion criteria were selected. We estimated the pooled effect sizes of the overall placebo (d pl = -1.85 [CI 95%: -2.9 to -0.79] and overall treatment (dtr = -2.57; [CI 95% -3.36 to -1.78]) response. The overall placebo response accounts for up to 72% of the overall treatment response. Furthermore, we performed subgroup analysis of 8 studies for the for the 7 days post-intervention timepoint. Seven days post-intervention the placebo response (d pl 7d = -1.98 [CI 95%: -3.26 to -0.69]) accounts for 66% of the treatment response (d tr 7d = - 3.01 [CI 95%, -4.28 to -1.74]). Conclusion Ketamine and esketamine show large antidepressant effects. However, our findings suggest that the placebo response plays a significant role in the antidepressant response and should be used for the benefit of the patients in clinical practice. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022377591.
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Affiliation(s)
- Alexandros Matsingos
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Marcel Wilhelm
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Laila Noor
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Cüneyt Yildiz
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Stefan G. Hofmann
- Translational Clinical Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Irina Falkenberg
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
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Elmeseiny OSA, Müller HK. A molecular perspective on mGluR5 regulation in the antidepressant effect of ketamine. Pharmacol Res 2024; 200:107081. [PMID: 38278430 DOI: 10.1016/j.phrs.2024.107081] [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: 10/30/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 01/28/2024]
Abstract
Ketamine, a non-competitive N-methyl-D-aspartate receptor (NMDAR) antagonist, has received much attention for its rapid antidepressant effects. A single administration of ketamine elicits rapid and sustained antidepressant effects in both humans and animals. Current efforts are focused on uncovering molecular mechanisms responsible for ketamine's antidepressant activity. Ketamine primarily acts via the glutamatergic pathway, and increasing evidence suggests that ketamine induces synaptic and structural plasticity through increased translation and release of neurotrophic factors, activation of mammalian target of rapamycin (mTOR), and α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor (AMPAR)-mediated synaptic potentiation. However, the initial events triggering activation of intracellular signaling cascades and the mechanisms responsible for the sustained antidepressant effects of ketamine remain poorly understood. Over the last few years, it has become apparent that in addition to the fast actions of the ligand-gated AMPARs and NMDARs, metabotropic glutamate receptors (mGluRs), and particularly mGluR5, may also play a role in the antidepressant action of ketamine. Although research on mGluR5 in relation to the beneficial actions of ketamine is still in its infancy, a careful evaluation of the existing literature can identify converging trends and provide new interpretations. Here, we review the current literature on mGluR5 regulation in response to ketamine from a molecular perspective and propose a possible mechanism linking NMDAR inhibition to mGluR5 modulation.
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Affiliation(s)
- Ola Sobhy A Elmeseiny
- Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Heidi Kaastrup Müller
- Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Guhathakurta D, Petrušková A, Akdaş EY, Perelló-Amorós B, Frischknecht R, Anni D, Weiss EM, Walter M, Fejtová A. Hydroxynorketamine, but not ketamine, acts via α7 nicotinic acetylcholine receptor to control presynaptic function and gene expression. Transl Psychiatry 2024; 14:47. [PMID: 38253622 PMCID: PMC10803733 DOI: 10.1038/s41398-024-02744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 12/21/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Ketamine is clinically used fast-acting antidepressant. Its metabolite hydroxynorketamine (HNK) shows a robust antidepressant effect in animal studies. It is unclear, how these chemically distinct compounds converge on similar neuronal effects. While KET acts mostly as N-methyl-d-aspartate receptor (NMDAR) antagonist, the molecular target of HNK remains enigmatic. Here, we show that KET and HNK converge on rapid inhibition of glutamate release by reducing the release competence of synaptic vesicles and induce nuclear translocation of pCREB that controls expression of neuroplasticity genes connected to KET- and HNK-mediated antidepressant action. Ro25-6981, a selective antagonist of GluN2B, mimics effect of KET indicating that GluN2B-containing NMDAR might mediate the presynaptic effect of KET. Selective antagonist of α7 nicotinic acetylcholine receptors (α7nAChRs) or genetic deletion of Chrna7, its pore-forming subunit, fully abolishes HNK-induced synaptic and nuclear regulations, but leaves KET-dependent cellular effects unaffected. Thus, KET or HNK-induced modulation of synaptic transmission and nuclear translocation of pCREB can be mediated by selective signaling via NMDAR or α7nAChRs, respectively. Due to the rapid metabolism of KET to HNK, it is conceivable that subsequent modulation of glutamatergic and cholinergic neurotransmission affects circuits in a cell-type-specific manner and contributes to the therapeutic potency of KET. This finding promotes further exploration of new combined medications for mood disorders.
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Affiliation(s)
- Debarpan Guhathakurta
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Aneta Petrušková
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- National Institute of Mental Health, Klecany, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Enes Yağız Akdaş
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Bartomeu Perelló-Amorós
- Department of Biology, Animal Physiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Renato Frischknecht
- Department of Biology, Animal Physiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Daniela Anni
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Eva-Maria Weiss
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Jena, Jena, Germany
| | - Anna Fejtová
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
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Medeiros GC, Matheson M, Demo I, Reid MJ, Matheson S, Twose C, Smith GS, Gould TD, Zarate CA, Barrett FS, Goes FS. Brain-based correlates of antidepressant response to ketamine: a comprehensive systematic review of neuroimaging studies. Lancet Psychiatry 2023; 10:790-800. [PMID: 37625426 DOI: 10.1016/s2215-0366(23)00183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 08/27/2023]
Abstract
Ketamine is an effective antidepressant, but there is substantial variability in patient response and the precise mechanism of action is unclear. Neuroimaging can provide predictive and mechanistic insights, but findings are limited by small sample sizes. This systematic review covers neuroimaging studies investigating baseline (pre-treatment) and longitudinal (post-treatment) biomarkers of responses to ketamine. All modalities were included. We performed searches of five electronic databases (from inception to April 26, 2022). 69 studies were included (with 1751 participants). There was substantial methodological heterogeneity and no well replicated biomarker. However, we found convergence across some significant results, particularly in longitudinal biomarkers. Response to ketamine was associated with post-treatment increases in gamma power in frontoparietal regions in electrophysiological studies, post-treatment increases in functional connectivity within the prefrontal cortex, and post-treatment increases in the functional activation of the striatum. Although a well replicated neuroimaging biomarker of ketamine response was not identified, there are biomarkers that warrant further investigation.
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Affiliation(s)
- Gustavo C Medeiros
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Malcolm Matheson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isabella Demo
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Reid
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Claire Twose
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gwenn S Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA; Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, NIMH-NIH, Bethesda, MD, USA
| | - Frederick S Barrett
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neuroscience, Department of Psychological and Brain Sciences, and Center for Psychedelic and Consciousness Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fernando S Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Nikolin S, Rodgers A, Schwaab A, Bahji A, Zarate C, Vazquez G, Loo C. Ketamine for the treatment of major depression: a systematic review and meta-analysis. EClinicalMedicine 2023; 62:102127. [PMID: 37593223 PMCID: PMC10430179 DOI: 10.1016/j.eclinm.2023.102127] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background Intranasal esketamine has received regulatory approvals for the treatment of depression. Recently a large trial of repeated dose racemic ketamine also demonstrated efficacy in severe depression. However, uncertainties remain regarding comparative efficacy, dosage, and the time course of response. Methods In this systematic review and meta-analysis, we searched Embase, Medline, Pubmed, PsycINFO, and CENTRAL up to April 13, 2023, for randomised controlled trials (RCTs) investigating ketamine for depression. Two investigators independently assessed study eligibility and risk of bias and extracted the data on depression severity scores, response and remission rates, and all-cause dropouts. Multivariable mixed-effects meta-regressions incorporated drug formulation (racemic (Rac) or esketamine (Esket)) and dose (Low or High) as covariates. Treatment effects were assessed: immediately following the first dose, during further repeated dosing, and follow-up after the final dose of a treatment course. This study is registered with PROSPERO (CRD42021221157). Findings The systematic review identified 687 articles, of which 49 RCTs were eligible for analysis, comprising 3299 participants. Standardised mean differences (95% confidence intervals) immediately following the first/single treatment were moderate-high for all conditions (Rac-High: -0.73, -0.91 to -0.56; Esket-High: -0.48, -0.75 to -0.20; Rac-Low: -0.33, -0.54 to -0.12; Esket-Low: -0.55, -0.87 to -0.24). Ongoing effects during repeated dosing were significantly greater than the control for Rac-High (-0.61; -1.02 to -0.20) and Rac-Low (-0.55, -1.09 to -0.00), but not Esket-Low (-0.15, -0.49 to 0.19) or Esket-High (-0.22, -0.54 to 0.10). At follow-up effects remained significant for racemic ketamine (-0.65; -1.23 to -0.07) but not esketamine (-0.33; -0.96 to 0.31). All-cause dropout was similar between experiment and control conditions for both formulations combined (Odds Ratio = 1.18, 0.85-1.64). Overall heterogeneity varied from 5.7% to 87.6. Interpretation Our findings suggested that effect sizes for depression severity, as well as response and remission rates, were numerically greater for racemic ketamine than esketamine. Higher doses were more effective than low doses. Differences were evident in initial effects, ongoing treatment, and lasting effects after the final dose. Funding None.
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Affiliation(s)
- Stevan Nikolin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Anees Bahji
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carlos Zarate
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1282, Building 10CRC, Room 7-5342, Bethesda, MD 20892, USA
| | - Gustavo Vazquez
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1282, Building 10CRC, Room 7-5342, Bethesda, MD 20892, USA
| | - Colleen Loo
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Yavorsky C, Ballard E, Opler M, Sedway J, Targum SD, Lenderking W. Recommendations for selection and adaptation of rating scales for clinical studies of rapid-acting antidepressants. Front Psychiatry 2023; 14:1135828. [PMID: 37333908 PMCID: PMC10272853 DOI: 10.3389/fpsyt.2023.1135828] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023] Open
Abstract
The novel mechanisms of action (MOA) derived from some recently introduced molecular targets have led to regulatory approvals for rapid acting antidepressants (RAADs) that can generate responses within hours or days, rather than weeks or months. These novel targets include the N-methyl-D-glutamate receptor antagonist ketamine, along with its enantiomers and various derivatives, and the allosteric modulators of gamma-aminobutyric acid (GABA) receptors. There has also been a strong resurgence in interest in psychedelic compounds that impact a range of receptor sites including D1, 5-HT7, KOR, 5-HT5A, Sigma-1, NMDA, and BDNF. The RAADs developed from these novel targets have enabled successful treatment for difficult to treat depressed individuals and has generated a new wave of innovation in research and treatment. Despite the advances in the neurobiology and clinical treatment of mood disorders, we are still using rating instruments that were created decades ago for drugs from a different era (e.g., The Hamilton and Montgomery-Åsberg depression rating scales, HDRS, and MADRS) continue to be used. These rating instruments were designed to assess mood symptoms over a 7-day time frame. Consequently, the use of these rating instruments often requires modifications to address items that cannot be assessed in short time frames, such as the sleep and appetite items. This review describes the adaptative approaches that have been made with the existing scales to meet this need and examines additional domains such as daily activities, side effects, suicidal ideation and behavior, and role functioning. Recommendations for future studies are described, including the challenges related to implementation of these adapted measures and approaches to mitigation.
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Affiliation(s)
| | | | - Mark Opler
- WIRB Copernicus Group (WCG) Clinical Endpoint Solutions, Princeton, NJ, United States
| | - Jan Sedway
- WIRB Copernicus Group (WCG) Clinical Endpoint Solutions, Princeton, NJ, United States
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10
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Association of the delayed changes in glutamate levels and functional connectivity with the immediate network effects of S-ketamine. Transl Psychiatry 2023; 13:60. [PMID: 36797238 PMCID: PMC9935558 DOI: 10.1038/s41398-023-02346-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Ketamine shows rapid antidepressant effects peaking 24 h after administration. The antidepressant effects may occur through changes in glutamatergic metabolite levels and resting-state functional connectivity (rsFC) within the default mode network (DMN). A multistage drug effect of ketamine has been suggested, inducing acute effects on dysfunctional network configuration and delayed effects on homeostatic synaptic plasticity. Whether the DMN-centered delayed antidepressant-related changes are associated with the immediate changes remains unknown. Thirty-five healthy male participants (25.1 ± 4.2 years) underwent 7 T magnetic resonance spectroscopy (MRS) and resting-state functional magnetic resonance imaging (rsfMRI) before, during, and 24 h after a single S-ketamine or placebo infusion. Changes in glutamatergic measures and rsFC in the DMN node pregenual anterior cingulate cortex (pgACC) were examined. A delayed rsFC decrease of the pgACC to inferior parietal lobe (family-wise error corrected p (pFWEc) = 0.018) and dorsolateral prefrontal cortex (PFC; pFWEc = 0.002) was detected that was preceded by an immediate rsFC increase of the pgACC to medial PFC (pFWEc < 0.001) and dorsomedial PFC (pFWEc = 0.005). Additionally, the immediate rsFC reconfigurations correlated with the delayed pgACC glutamate (Glu) level increase (p = 0.024) after 24 h at trend level (p = 0.067). Baseline measures of rsFC and MRS were furthermore associated with the magnitude of the respective delayed changes (p's < 0.05). In contrast, the delayed changes were not associated with acute psychotomimetic side effects or plasma concentrations of ketamine and its metabolites. This multimodal study suggests an association between immediate S-ketamine-induced network effects and delayed brain changes at a time point relevant in its clinical context.
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11
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Mann JJ. Is psilocybin an effective antidepressant and what is its Mechanism of action? Cell Rep Med 2023; 4:100906. [PMID: 36652915 PMCID: PMC9873942 DOI: 10.1016/j.xcrm.2022.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Goodwin et al.1 report a single 25 mg dose of psilocybin has an antidepressant effect short-term in medication-resistant depression. Unanswered questions include drug blood level as a guide to dose, psychedelic effects relationship to antidepressant benefit, and potential suicide risk of psilocybin.
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Affiliation(s)
- J. John Mann
- Departments of Psychiatry and Radiology, Columbia University/New York State Psychiatric Institute, New York, NY 10032, USA,Corresponding author
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12
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Wieser M, Beckmann KM, Kutter APN, Mauri N, Richter H, Zölch N, Bektas RN. Ketamine administration in idiopathic epileptic and healthy control dogs: Can we detect differences in brain metabolite response with spectroscopy? Front Vet Sci 2023; 9:1093267. [PMID: 36686158 PMCID: PMC9853535 DOI: 10.3389/fvets.2022.1093267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction In recent years ketamine has increasingly become the focus of multimodal emergency management for epileptic seizures. However, little is known about the effect of ketamine on brain metabolites in epileptic patients. Magnetic resonance spectroscopy (MRS) is a non-invasive technique to estimate brain metabolites in vivo. Our aim was to measure the effect of ketamine on thalamic metabolites in idiopathic epileptic (IE) dogs using 3 Tesla MRS. We hypothesized that ketamine would increase the glutamine-glutamate (GLX)/creatine ratio in epileptic dogs with and without antiseizure drug treatment, but not in control dogs. Furthermore, we hypothesized that no different responses after ketamine administration in other measured brain metabolite ratios between the different groups would be detected. Methods In this controlled prospective experimental trial IE dogs with or without antiseizure drug treatment and healthy client-owned relatives of the breeds Border Collie and Greater Swiss Mountain Dog, were included. After sedation with butorphanol, induction with propofol and maintenance with sevoflurane in oxygen and air, a single voxel MRS at the level of the thalamus was performed before and 2 min after intravenous administration of 1 mg/kg ketamine. An automated data processing spectral fitting linear combination model algorithm was used to estimate all commonly measured metabolite ratios. A mixed ANOVA with the independent variables ketamine administration and group allocation was performed for all measured metabolites. A p < 0.05 was considered statistically significant. Results Twelve healthy control dogs, 10 untreated IE and 12 treated IE dogs were included. No significant effects for GLX/creatine were found. However, increased glucose/creatine ratios were found (p < 0.001) with no effect of group allocation. Furthermore, increases in the GABA/creatine ratio were found in IEU dogs. Discussion MRS was able to detect changes in metabolite/creatine ratios after intravenous administration of 1 mg/kg ketamine in dogs and no evidence was found that excitatory effects are induced in the thalamus. Although it is beyond the scope of this study to investigate the antiseizure potential of ketamine in dogs, results of this research suggest that the effect of ketamine on the brain metabolites could be dependent on the concentrations of brain metabolites before administration.
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Affiliation(s)
- Manuela Wieser
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland,*Correspondence: Manuela Wieser ✉
| | | | - Annette P. N. Kutter
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
| | - Nico Mauri
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland,Vetimage Diagnostik AG, Oberentfelden, Switzerland
| | - Henning Richter
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland
| | - Niklaus Zölch
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Rima Nadine Bektas
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
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13
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Abstract
Anorexia nervosa is a disorder associated with serious adverse health outcomes, for which there is currently considerable treatment ineffectiveness. Characterised by restrictive eating behaviours, distorted body image perceptions and excessive physical activity, there is growing recognition anorexia nervosa is associated with underlying dysfunction in excitatory and inhibitory neurometabolite metabolism and signalling. This narrative review critically explores the role of N-methyl-D-aspartate receptor-mediated excitatory and inhibitory neurometabolite dysfunction in anorexia nervosa and its associated biomarkers. The existing magnetic resonance spectroscopy literature in anorexia nervosa is reviewed and we outline the brain region-specific neurometabolite changes that have been reported and their connection to anorexia nervosa psychopathology. Considering the proposed role of dysfunctional neurotransmission in anorexia nervosa, the potential utility of zinc supplementation and sub-anaesthetic doses of ketamine in normalising this is discussed with reference to previous research in anorexia nervosa and other neuropsychiatric conditions. The rationale for future research to investigate the combined use of low-dose ketamine and zinc supplementation to potentially extend the therapeutic benefits in anorexia nervosa is subsequently explored and promising biological markers for assessing and potentially predicting treatment response are outlined.
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14
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Zavaliangos-Petropulu A, Al-Sharif NB, Taraku B, Leaver AM, Sahib AK, Espinoza RT, Narr KL. Neuroimaging-Derived Biomarkers of the Antidepressant Effects of Ketamine. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2022; 8:361-386. [PMID: 36775711 DOI: 10.1016/j.bpsc.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
Major depressive disorder is a highly prevalent psychiatric disorder. Despite an extensive range of treatment options, about a third of patients still struggle to respond to available therapies. In the last 20 years, ketamine has gained considerable attention in the psychiatric field as a promising treatment of depression, particularly in patients who are treatment resistant or at high risk for suicide. At a subanesthetic dose, ketamine produces a rapid and pronounced reduction in depressive symptoms and suicidal ideation, and serial treatment appears to produce a greater and more sustained therapeutic response. However, the mechanism driving ketamine's antidepressant effects is not yet well understood. Biomarker discovery may advance knowledge of ketamine's antidepressant action, which could in turn translate to more personalized and effective treatment strategies. At the brain systems level, neuroimaging can be used to identify functional pathways and networks contributing to ketamine's therapeutic effects by studying how it alters brain structure, function, connectivity, and metabolism. In this review, we summarize and appraise recent work in this area, including 51 articles that use resting-state and task-based functional magnetic resonance imaging, arterial spin labeling, positron emission tomography, structural magnetic resonance imaging, diffusion magnetic resonance imaging, or magnetic resonance spectroscopy to study brain and clinical changes 24 hours or longer after ketamine treatment in populations with unipolar or bipolar depression. Though individual studies have included relatively small samples, used different methodological approaches, and reported disparate regional findings, converging evidence supports that ketamine leads to neuroplasticity in structural and functional brain networks that contribute to or are relevant to its antidepressant effects.
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Affiliation(s)
- Artemis Zavaliangos-Petropulu
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| | - Noor B Al-Sharif
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Brandon Taraku
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Amber M Leaver
- Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ashish K Sahib
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Randall T Espinoza
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Katherine L Narr
- Ahmanson-Lovelace Brain Mapping Center, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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15
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Medeiros GC, Gould TD, Prueitt WL, Nanavati J, Grunebaum MF, Farber NB, Singh B, Selvaraj S, Machado-Vieira R, Achtyes ED, Parikh SV, Frye MA, Zarate CA, Goes FS. Blood-based biomarkers of antidepressant response to ketamine and esketamine: A systematic review and meta-analysis. Mol Psychiatry 2022; 27:3658-3669. [PMID: 35760879 PMCID: PMC9933928 DOI: 10.1038/s41380-022-01652-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/17/2022] [Accepted: 05/31/2022] [Indexed: 02/08/2023]
Abstract
(R,S)-ketamine (ketamine) and its enantiomer (S)-ketamine (esketamine) can produce rapid and substantial antidepressant effects. However, individual response to ketamine/esketamine is variable, and there are no well-accepted methods to differentiate persons who are more likely to benefit. Numerous potential peripheral biomarkers have been reported, but their current utility is unclear. We conducted a systematic review/meta-analysis examining the association between baseline levels and longitudinal changes in blood-based biomarkers, and response to ketamine/esketamine. Of the 5611 citations identified, 56 manuscripts were included (N = 2801 participants), and 26 were compatible with meta-analytical calculations. Random-effect models were used, and effect sizes were reported as standardized mean differences (SMD). Our assessments revealed that more than 460 individual biomarkers were examined. Frequently studied groups included neurotrophic factors (n = 15), levels of ketamine and ketamine metabolites (n = 13), and inflammatory markers (n = 12). There were no consistent associations between baseline levels of blood-based biomarkers, and response to ketamine. However, in a longitudinal analysis, ketamine responders had statistically significant increases in brain-derived neurotrophic factor (BDNF) when compared to pre-treatment levels (SMD [95% CI] = 0.26 [0.03, 0.48], p = 0.02), whereas non-responders showed no significant changes in BDNF levels (SMD [95% CI] = 0.05 [-0.19, 0.28], p = 0.70). There was no consistent evidence to support any additional longitudinal biomarkers. Findings were inconclusive for esketamine due to the small number of studies (n = 2). Despite a diverse and substantial literature, there is limited evidence that blood-based biomarkers are associated with response to ketamine, and no current evidence of clinical utility.
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Affiliation(s)
- Gustavo C. Medeiros
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Todd D. Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.,Departments of Pharmacology and Anatomy & Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA.,Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | | | - Julie Nanavati
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael F. Grunebaum
- Columbia University Irving Medical Center and New York State Psychiatric Institute, New York City, NY, USA
| | - Nuri B. Farber
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA
| | - Balwinder Singh
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Sudhakar Selvaraj
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Rodrigo Machado-Vieira
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Eric D. Achtyes
- Division of Psychiatry and Behavioral Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.,Pine Rest Christian Mental Health Services, Grand Rapids, MI, USA
| | - Sagar V. Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mark A. Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Carlos A. Zarate
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
| | - Fernando S. Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Correspondence and requests for materials should be addressed to Fernando S. Goes.,
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16
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Weigand A, Gärtner M, Scheidegger M, Wyss PO, Henning A, Seifritz E, Stippl A, Herrera-Melendez A, Bajbouj M, Aust S, Grimm S. Predicting Antidepressant Effects of Ketamine: the Role of the Pregenual Anterior Cingulate Cortex as a Multimodal Neuroimaging Biomarker. Int J Neuropsychopharmacol 2022; 25:1003-1013. [PMID: 35948274 PMCID: PMC9743970 DOI: 10.1093/ijnp/pyac049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/15/2022] [Accepted: 08/10/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Growing evidence underscores the utility of ketamine as an effective and rapid-acting treatment option for major depressive disorder (MDD). However, clinical outcomes vary between patients. Predicting successful response may enable personalized treatment decisions and increase clinical efficacy. METHODS We here explored the potential of pregenual anterior cingulate cortex (pgACC) activity to predict antidepressant effects of ketamine in relation to ketamine-induced changes in glutamatergic metabolism. Prior to a single i.v. infusion of ketamine, 24 patients with MDD underwent functional magnetic resonance imaging during an emotional picture-viewing task and magnetic resonance spectroscopy. Changes in depressive symptoms were evaluated using the Beck Depression Inventory measured 24 hours pre- and post-intervention. A subsample of 17 patients underwent a follow-up magnetic resonance spectroscopy scan. RESULTS Antidepressant efficacy of ketamine was predicted by pgACC activity during emotional stimulation. In addition, pgACC activity was associated with glutamate increase 24 hours after the ketamine infusion, which was in turn related to better clinical outcome. CONCLUSIONS Our results add to the growing literature implicating a key role of the pgACC in mediating antidepressant effects and highlighting its potential as a multimodal neuroimaging biomarker of early treatment response to ketamine.
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Affiliation(s)
| | | | - Milan Scheidegger
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, University of Zurich, Switzerland
| | - Patrik O Wyss
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Anke Henning
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, University of Zurich, Switzerland
| | - Anna Stippl
- Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ana Herrera-Melendez
- Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Malek Bajbouj
- Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Sabine Aust
- Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Simone Grimm
- Correspondence: Simone Grimm, PhD, MSB Medical School Berlin, Rüdesheimer Straße 50, 14197 Berlin, Germany ()
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17
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Wu Q, Tang J, Qi C, Xie A, Liu J, O’Neill J, Liu T, Hao W, Liao Y. Higher glutamatergic activity in the medial prefrontal cortex in chronic ketamine users. J Psychiatry Neurosci 2022; 47:E263-E271. [PMID: 35882477 PMCID: PMC9343127 DOI: 10.1503/jpn.210179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/13/2022] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The medial prefrontal cortex (mPFC) plays an important role in depression and addiction. Previous studies have shown alterations in glutamatergic activity in the mPFC following the administration of ketamine in patients with depression and healthy controls. However, it remains unclear whether chronic, nonmedical use of ketamine affects metabolites in the mPFC. METHODS Using proton magnetic resonance spectroscopy, we measured metabolites (glutamate and glutamine [Glx]; phosphocreatine and creatine [PCr+Cr]; myo-inositol; N-acetyl-aspartate; and glycerophosphocholine and phosphocholine [GPC+PC]) in the mPFC of chronic ketamine users (n = 20) and healthy controls (n = 43). Among ketamine users, 60% consumed ketamine once per day or more, 10% consumed it every 2 days and 30% consumed it every 3 or more days. Using analysis of covariance, we evaluated between-group differences in the ratios of Glx:PCr+Cr, myo-inositol:PCr+Cr, N-acetyl-aspartate:PCr+Cr and GPC+PC:PCr+Cr. RESULTS Chronic ketamine users showed significantly higher Glx:PCr+Cr ratios than healthy controls (median 1.05 v. 0.95, p = 0.008). We found no significant differences in myoinositol:PCr+Cr, N-acetyl-aspartate:PCr+Cr or GPC+PC:PCr+Cr ratios between the 2 groups. We found a positive relationship between N-acetyl-aspartate:PCr+Cr and Glx:PCr+Cr ratios in the healthy control group (R = 0.345, p = 0.023), but the ketamine use group failed to show such an association (ρ = 0.197, p = 0.40). LIMITATIONS The cross-sectional design of this study did not permit causal inferences related to higher Glx:PCr+Cr ratios and chronic ketamine use. CONCLUSION This study provides the first evidence that chronic ketamine users have higher glutamatergic activity in the mPFC than healthy controls; this finding may provide new insights relevant to the treatment of depression with ketamine.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yanhui Liao
- From the Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China (Wu, Tang, Liao); the Department of Psychiatry and National Clinical Research Centre for Mental Disorders, Second Xiangya Hospital of Central South University, Changsha, Hunan, P.R. China (Wu, T. Liu, Hao); the Department of Psychiatry, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P.R. China (Qi); the Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, P.R. China (Xie, J. Liu); the Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, Calif., USA (O'Neill)
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18
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Abstract
Depression is an episodic form of mental illness characterized by mood state transitions with poorly understood neurobiological mechanisms. Antidepressants reverse the effects of stress and depression on synapse function, enhancing neurotransmission, increasing plasticity, and generating new synapses in stress-sensitive brain regions. These properties are shared to varying degrees by all known antidepressants, suggesting that synaptic remodeling could play a key role in depression pathophysiology and antidepressant function. Still, it is unclear whether and precisely how synaptogenesis contributes to mood state transitions. Here, we review evidence supporting an emerging model in which depression is defined by a distinct brain state distributed across multiple stress-sensitive circuits, with neurons assuming altered functional properties, synapse configurations, and, importantly, a reduced capacity for plasticity and adaptation. Antidepressants act initially by facilitating plasticity and enabling a functional reconfiguration of this brain state. Subsequently, synaptogenesis plays a specific role in sustaining these changes over time.
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Affiliation(s)
- Puja K Parekh
- Department of Psychiatry and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA;
| | - Shane B Johnson
- Department of Psychiatry and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA;
| | - Conor Liston
- Department of Psychiatry and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA;
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19
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Dong Z, Milak MS, Mann JJ. Proton magnetic resonance spectroscopy thermometry: Impact of separately acquired full water or partially suppressed water data on quantification and measurement error. NMR IN BIOMEDICINE 2022; 35:e4681. [PMID: 34961997 DOI: 10.1002/nbm.4681] [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: 08/23/2021] [Revised: 11/02/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
In proton magnetic resonance spectroscopy (1 H MRS) thermometry, separately acquired full water and partially suppressed water are commonly used for measuring temperature. This paper compares these two approaches. Single-voxel 1 H MRS data were collected on a 3-T GE scanner from 26 human subjects. Every subject underwent five continuous MRS sessions, each separated by a 2-min phase. Each MRS session lasted 13 min and consisted of two free induction decays (FIDs) without water suppression (with full water [FW or w]) and 64 FIDs with partial water suppression (with partially suppressed water [PW or w']). Frequency differences between the two FWs, the first two PWs, the second FW and the first PW (FW2 , PW1 ), or between averaged water ( wav' ) and N-acetylaspartate (NAA), were measured. Intrasubject and intersubject variations of the frequency differences were used as a metric for the error in temperature measurement. The intrasubject variations of frequency differences between FW2 and PW1fw2-fw1' , calculated from the five MRS sessions for each subject, were larger than those between the two FWs or between the first two PWs (p = 1.54 x 10-4 and p = 1.72 x 10-4 , respectively). The mean values of intrasubject variations of fw2-fw1' for all subjects were 4.7 and 4.5 times those of fw2-fw1 and fw2'-fw1' , respectively. The intrasubject variations of the temperatures based on frequency differences, fw2-fNAA or ( fw1'-fNAA ), were about 2.5 times greater than those based on averaged water and NAA frequencies (fwav'-fNAA ). The mean temperature measured from (fwav'-fNAA ) (n = 26) was 0.29°C lower than that measured from fw2-fNAA and was 0.83°C higher than that from ( fw1'-fNAA ). It was concluded that the use of separately acquired unsuppressed or partially suppressed water signals may result in large errors in frequency and, consequently, temperature measurement.
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Affiliation(s)
- Zhengchao Dong
- Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, New York, USA
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, New York, USA
| | - Matthew S Milak
- Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, New York, USA
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, New York, USA
| | - J John Mann
- Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, New York, USA
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, New York, USA
- Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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20
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Repetitive Transcranial Magnetic Stimulation-Associated Changes in Neocortical Metabolites in Major Depression: A Systematic Review. Neuroimage Clin 2022; 35:103049. [PMID: 35738081 PMCID: PMC9233277 DOI: 10.1016/j.nicl.2022.103049] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/01/2022] [Accepted: 05/12/2022] [Indexed: 11/23/2022]
Abstract
We reviewed 12 studies that measured metabolites pre and post rTMS in MDD. Frontal lobe Glu, Gln, NAA, and GABA increased after rTMS. Increases in metabolites were often associated with MDD symptom improvement. We propose novel intracellular mechanisms by which metabolites are altered by rTMS.
Introduction Repetitive Transcranial magnetic stimulation (rTMS) is an FDA approved treatment for major depressive disorder (MDD). However, neural mechanisms contributing to rTMS effects on depressive symptoms, cognition, and behavior are unclear. Proton magnetic resonance spectroscopy (MRS), a noninvasive neuroimaging technique measuring concentrations of biochemical compounds within the brain in vivo, may provide mechanistic insights. Methods This systematic review summarized published MRS findings from rTMS treatment trials to address potential neurometabolic mechanisms of its antidepressant action. Using PubMed, Google Scholar, Web of Science, and JSTOR, we identified twelve empirical studies that evaluated changes in MRS metabolites in a within-subjects, pre- vs. post-rTMS treatment design in patients with MDD. Results rTMS protocols ranged from four days to eight weeks duration, were applied at high frequency to the left dorsolateral prefrontal cortex (DLPFC) in most studies, and were conducted in patients aged 13-to-70. Most studies utilized MRS point resolved spectroscopy acquisitions at 3 Tesla in the bilateral anterior cingulate cortex and DLPFC. Symptom improvements were correlated with rTMS-related increases in the concentration of glutamatergic compounds (glutamate, Glu, and glutamine, Gln), GABA, and N-acetylated compounds (NAA), with some results trend-level. Conclusions This is the first in-depth systematic review of metabolic effects of rTMS in individuals with MDD. The extant literature suggests rTMS stimulation does not produce changes in neurometabolites independent of clinical response; increases in frontal lobe glutamatergic compounds, N-acetylated compounds and GABA following high frequency left DLPFC rTMS therapy were generally associated with clinical improvement. Glu, Gln, GABA, and NAA may mediate rTMS treatment effects on MDD symptomatology through intracellular mechanisms.
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21
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Lengvenyte A, Strumila R, Olié E, Courtet P. Ketamine and esketamine for crisis management in patients with depression: Why, whom, and how? Eur Neuropsychopharmacol 2022; 57:88-104. [PMID: 35219097 DOI: 10.1016/j.euroneuro.2022.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
Currently, only a limited number of interventions can rapidly relieve depressive symptomatology in patients with major depressive disorder or bipolar disorder experiencing extreme distress. Such crises, especially when suicide attempt or ideation is involved, are a major risk factor of suicide. Ketamine, a N-methyl-d-aspartate glutamate receptor antagonist, and its enantiomer esketamine rapidly reduce depressive symptoms in depressed patients with current suicidal ideation. Recently, esketamine has been approved for use in patients with depression at risk of suicide and for psychiatric emergency by major medical agencies in the United States and Europe, whereas ketamine is increasingly used off-label. However, there is currently limited guidance on why, when, and how to use these drugs in patients with depression to treat a crisis. In this review article, we provide a succinct overview of the cellular and molecular mechanisms of action of ketamine and esketamine, and of the functional brain changes following their administration. We also summarize the major clinical studies on ketamine and esketamine efficacy in patients experiencing a crisis (generally, suicidal ideation), and propose a profile of patients who can benefit most from such drugs, on the basis of neurobiological and clinical observations. Finally, we describe the administration mode, the efficacy and tolerability profiles, the side effect management, possible concomitant treatments and the issue of deprescribing.
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Affiliation(s)
- Aiste Lengvenyte
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France; Psychiatric Clinic, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Robertas Strumila
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France; Psychiatric Clinic, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
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22
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Hochschild A, Keilp JG, Madden SP, Burke AK, Mann JJ, Grunebaum MF. Ketamine vs midazolam: Mood improvement reduces suicidal ideation in depression. J Affect Disord 2022; 300:10-16. [PMID: 34953926 PMCID: PMC8828686 DOI: 10.1016/j.jad.2021.12.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/30/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Studies demonstrate rapid antidepressant and anti-suicidal ideation effects of subanesthetic ketamine. The specific subcomponents of depression that are most closely tied to reduction of suicidal ideation with ketamine treatment are less explored. METHODS Exploratory, post hoc analysis of data from a randomized clinical trial of ketamine vs midazolam in patients with major depressive disorder (MDD) and clinically significant suicidal ideation examined changes in factor analysis-derived symptom clusters from standard measures of depression (Hamilton Depression Rating Scale, HDRS; Beck Depression Inventory, BDI) and mood disturbance (Profile of Mood States, POMS), and their relationship to severity of suicidal ideation (Beck Scale for Suicidal Ideation; SSI). Ratings obtained before and one day after blinded intravenous infusion were decomposed into component factors or published subscales. Treatment effects on factors/subscales were compared between drugs, correlations with changes in suicidal ideation were tested, and stepwise regression was used to derive predictors of change in SSI. RESULTS Factor scores for HDRS Psychic Depression, HDRS Anxiety, BDI Subjective Depression, POMS Depression and POMS Fatigue improved more with ketamine than midazolam. Stepwise regression showed across both drugs that improvement in HDRS Psychic Depression, POMS Depression, and HDRS Anxiety predicted 51.6% of the variance in reduction of suicidal ideation. LIMITATIONS Secondary analysis of clinical trial data. CONCLUSIONS Ketamine's rapid effects on suicidal ideation appear to be mostly a function of its effects on core mood and anxiety symptoms of MDD, with comparatively little contribution from neurovegetative symptoms with the potential exception of vigor/fatigue. TRIAL REGISTRATION Data used in this secondary analysis came from ClinicalTrials.gov identifier: NCT01700829.
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Affiliation(s)
| | - John G. Keilp
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - Sean P. Madden
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - Ainsley K. Burke
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - J. John Mann
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - Michael F. Grunebaum
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
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23
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Gärtner M, Weigand A, Scheidegger M, Lehmann M, Wyss PO, Wunder A, Henning A, Grimm S. Acute effects of ketamine on the pregenual anterior cingulate: linking spontaneous activation, functional connectivity, and glutamate metabolism. Eur Arch Psychiatry Clin Neurosci 2022; 272:703-714. [PMID: 35020021 PMCID: PMC9095553 DOI: 10.1007/s00406-021-01377-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Abstract
Ketamine exerts its rapid antidepressant effects via modulation of the glutamatergic system. While numerous imaging studies have investigated the effects of ketamine on a functional macroscopic brain level, it remains unclear how altered glutamate metabolism and changes in brain function are linked. To shed light on this topic we here conducted a multimodal imaging study in healthy volunteers (N = 23) using resting state fMRI and proton (1H) magnetic resonance spectroscopy (MRS) to investigate linkage between metabolic and functional brain changes induced by ketamine. Subjects were investigated before and during an intravenous ketamine infusion. The MRS voxel was placed in the pregenual anterior cingulate cortex (pgACC), as this region has been repeatedly shown to be involved in ketamine's effects. Our results showed functional connectivity changes from the pgACC to the right frontal pole and anterior mid cingulate cortex (aMCC). Absolute glutamate and glutamine concentrations in the pgACC did not differ significantly from baseline. However, we found that stronger pgACC activation during ketamine was linked to lower glutamine concentration in this region. Furthermore, reduced functional connectivity between pgACC and aMCC was related to increased pgACC activation and reduced glutamine. Our results thereby demonstrate how multimodal investigations in a single brain region could help to advance our understanding of the association between metabolic and functional changes.
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Affiliation(s)
- Matti Gärtner
- MSB Medical School Berlin, Rüdesheimer Straße 50, 14197, Berlin, Germany. .,Department of Psychiatry and Psychotherapy, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Anne Weigand
- grid.466457.20000 0004 1794 7698MSB Medical School Berlin, Rüdesheimer Straße 50, 14197 Berlin, Germany
| | - Milan Scheidegger
- grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Mick Lehmann
- grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Patrik O. Wyss
- grid.419769.40000 0004 0627 6016Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Andreas Wunder
- grid.420061.10000 0001 2171 7500Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, 88397 Biberach an der Riss, Germany
| | - Anke Henning
- grid.267313.20000 0000 9482 7121Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX USA
| | - Simone Grimm
- grid.466457.20000 0004 1794 7698MSB Medical School Berlin, Rüdesheimer Straße 50, 14197 Berlin, Germany ,grid.6363.00000 0001 2218 4662Department of Psychiatry and Psychotherapy, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203 Berlin, Germany ,grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
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24
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Yip R, Swainson J, Khullar A, McIntyre RS, Skoblenick K. Intravenous ketamine for depression: A clinical discussion reconsidering best practices in acute hypertension management. Front Psychiatry 2022; 13:1017504. [PMID: 36245888 PMCID: PMC9556663 DOI: 10.3389/fpsyt.2022.1017504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Ketamine is a versatile medication with an emerging role for the treatment of numerous psychiatric conditions, including treatment resistant depression. Current psychiatry guidelines for its intravenous administration to treat depression recommend regular blood pressure monitoring and an aggressive approach to potential transient hypertensive episodes induced by ketamine infusions. While this approach is aimed at ensuring patient safety, it should be updated to align with best practice guidelines in the management of hypertension. This review defines and summarizes the currently recommended approach to the hypertensive emergency, the asymptomatic hypertensive urgency, and discusses their relevance to intravenous ketamine therapy. With an updated protocol informed by these best practice guidelines, ketamine treatment for depression may be more accessible to facilitate psychiatric treatment.
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Affiliation(s)
- Ryan Yip
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.,Misericordia Community Hospital, Edmonton, AB, Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.,Northern Alberta Sleep Clinic, Edmonton, AB, Canada.,Grey Nuns Community Hospital, Edmonton, AB, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.,Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Kevin Skoblenick
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.,Royal Alexandra Hospital, Edmonton, AB, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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25
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Lin J, Ling F, Huang P, Chen M, Song M, Lu K, Wang W. The Development of GABAergic Network in Depression in Recent 17 Years: A Visual Analysis Based on CiteSpace and VOSviewer. Front Psychiatry 2022; 13:874137. [PMID: 35664493 PMCID: PMC9157549 DOI: 10.3389/fpsyt.2022.874137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/27/2022] [Indexed: 11/21/2022] Open
Abstract
In this study, we analyzed the status and research trends of the GABAergic system in depression from 2004 to 2020 to provide a reference for further research. The Web of Science database was used as the data source and 1,658 publishments were included. Using two visualization analysis software, CiteSpace and VOSviewer, we analyzed the publishing years, countries, institutions, authors, journals, categories, keywords, and research frontiers in depression. The publishments revealed an upward trend from 2004 to 2020; the most prolific country and institutions were the United States and INSERM, respectively. The journal of Neuroscience was the most published and cited journal. The most relevant category was neurosciences. The hot topics in this field were GABAergic research in Gaba(a) receptor; the research frontier was depressive model. These analysis results provide a new perspective for researchers to conduct studies on related topics in the future and guidance for scientists to identify potential collaborators and research cooperation institutions.
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Affiliation(s)
- Jieping Lin
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fa Ling
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ping Huang
- Laboratory Animal Management Center, Southern Medical University, Guangzhou, China
| | - Min Chen
- College of Medical Examination and Biotechnology, Southern Medical University, Guangzhou, China
| | - Min Song
- Southern Medical University Library, Guangzhou, China
| | - Kangrong Lu
- NMPA Key Laboratory for Safety Evaluation of Cosmetics, Southern Medical University, Guangzhou, China
| | - Wanshan Wang
- Laboratory Animal Management Center, Southern Medical University, Guangzhou, China.,Guangzhou Southern Medical Laboratory Animal Sci. and Tech. Co., Ltd., Guangzhou, China
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26
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Kang MJY, Hawken E, Vazquez GH. The Mechanisms Behind Rapid Antidepressant Effects of Ketamine: A Systematic Review With a Focus on Molecular Neuroplasticity. Front Psychiatry 2022; 13:860882. [PMID: 35546951 PMCID: PMC9082546 DOI: 10.3389/fpsyt.2022.860882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/18/2022] [Indexed: 12/25/2022] Open
Abstract
The mechanism of action underlying ketamine's rapid antidepressant effects in patients with depression, both suffering from major depressive disorder (MDD) and bipolar disorder (BD), including treatment resistant depression (TRD), remains unclear. Of the many speculated routes that ketamine may act through, restoring deficits in neuroplasticity may be the most parsimonious mechanism in both human patients and preclinical models of depression. Here, we conducted a literature search using PubMed for any reports of ketamine inducing neuroplasticity relevant to depression, to identify cellular and molecular events, relevant to neuroplasticity, immediately observed with rapid mood improvements in humans or antidepressant-like effects in animals. After screening reports using our inclusion/exclusion criteria, 139 publications with data from cell cultures, animal models, and patients with BD or MDD were included (registered on PROSPERO, ID: CRD42019123346). We found accumulating evidence to support that ketamine induces an increase in molecules involved in modulating neuroplasticity, and that these changes are paired with rapid antidepressant effects. Molecules or complexes of high interest include glutamate, AMPA receptors (AMPAR), mTOR, BDNF/TrkB, VGF, eEF2K, p70S6K, GSK-3, IGF2, Erk, and microRNAs. In summary, these studies suggest a robust relationship between improvements in mood, and ketamine-induced increases in molecular neuroplasticity, particularly regarding intracellular signaling molecules.
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Affiliation(s)
- Melody J Y Kang
- Center of Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada
| | - Emily Hawken
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada.,Providence Care Hospital, Kingston, ON, Canada
| | - Gustavo Hector Vazquez
- Center of Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada.,Providence Care Hospital, Kingston, ON, Canada
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27
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Hochschild A, Grunebaum MF, Mann JJ. The rapid anti-suicidal ideation effect of ketamine: A systematic review. Prev Med 2021; 152:106524. [PMID: 34538369 DOI: 10.1016/j.ypmed.2021.106524] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 11/19/2022]
Abstract
In many countries suicide rates have been trending upwards for close to twenty years-presenting a public health crisis. Most suicide attempts and deaths are associated with psychiatric illness, usually a depressive disorder. Subanesthetic ketamine is the only FDA-approved antidepressant that works in hours not weeks-thus potentially transforming treatment of suicidal patients. We reviewed all randomized controlled trials of the effect of ketamine on suicidal ideation to determine if ketamine rapidly reduces suicidal ideation [SI] in depressed patients and how long the benefit persists after one dose and if the route of administration or dose affects the outcome. A systematic review was conducted as per PRISMA [preferred reporting items for systematic reviews and meta-analyses] criteria. PubMed search inclusive of "ketamine" and "suicide" yielded 358 results. Papers (N = 354) were then read by at least two authors, identifying 12 meeting eligibility requirements and eleven RCTs examining whether ketamine treatment ameliorated SI. Four of five RCTs examined racemic ketamine (0.5 mg/kg) given intravenously and found an advantage for ketamine over control for rapid reduction in SI in acutely depressed patients. Two studies examined intranasal esketamine in depressed suicidal patients and found no advantage over saline. One study examined outcome six weeks after a single intravenous dose of ketamine and found benefit for SI sustained relative to 24 h post-dose. Further research is warranted into: optimal dosing strategy, including number and frequency; and long-term efficacy and safety. Ultimately, it remains to be shown that ketamine's benefit for SI translates into prevention of suicidal behavior.
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Affiliation(s)
- Annabella Hochschild
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Michael F Grunebaum
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States of America
| | - J John Mann
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States of America.
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28
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Kantrowitz JT, Dong Z, Milak MS, Rashid R, Kegeles LS, Javitt DC, Lieberman JA, John Mann J. Ventromedial prefrontal cortex/anterior cingulate cortex Glx, glutamate, and GABA levels in medication-free major depressive disorder. Transl Psychiatry 2021; 11:419. [PMID: 34354048 PMCID: PMC8342485 DOI: 10.1038/s41398-021-01541-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/12/2021] [Accepted: 07/23/2021] [Indexed: 02/07/2023] Open
Abstract
Glutamate (Glu) and gamma-aminobutyric acid (GABA) are implicated in the pathophysiology of major depressive disorder (MDD). GABA levels or GABAergic interneuron numbers are generally low in MDD, potentially disinhibiting Glu release. It is unclear whether Glu release or turnover is increased in depression. Conversely, a meta-analysis of prefrontal proton magnetic resonance spectroscopy (1H MRS) studies in MDD finds low Glx (combination of glutamate and glutamine) in medicated MDD. We hypothesize that elevated Glx or Glu may be a marker of more severe, untreated MDD. We examined ventromedial prefrontal cortex/anterior cingulate cortex (vmPFC/ACC) Glx and glutamate levels using 1H MRS in 34 medication-free, symptomatic, chronically ill MDD patients and 32 healthy volunteers, and GABA levels in a subsample. Elevated Glx and Glu were observed in MDD compared with healthy volunteers, with the highest levels seen in males with MDD. vmPFC/ACC GABA was low in MDD. Higher Glx levels correlated with more severe depression and lower GABA. MDD severity and diagnosis were both linked to higher Glx in vmPFC/ACC. Low GABA in a subset of these patients is consistent with our hypothesized model of low GABA leading to glutamate disinhibition in MDD. This finding and model are consistent with our previously reported findings that the NMDAR-antagonist antidepressant effect is proportional to the reduction of vmPFC/ACC Glx or Glu levels.
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Affiliation(s)
- Joshua T. Kantrowitz
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.250263.00000 0001 2189 4777Nathan Kline Institute, 140 Old Orangeburg Road, Orangeburg, NY USA
| | - Zhengchao Dong
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - Matthew S. Milak
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - Rain Rashid
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - Lawrence S. Kegeles
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY USA
| | - Daniel C. Javitt
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.250263.00000 0001 2189 4777Nathan Kline Institute, 140 Old Orangeburg Road, Orangeburg, NY USA
| | - Jeffrey A. Lieberman
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - J. John Mann
- grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY USA
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29
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Watts D, Garcia FD, Lacerda ALT, Mari JDJ, Quarantini LC, Kapczinski F. Intranasal esketamine and the dawn of precision psychiatry. BRAZILIAN JOURNAL OF PSYCHIATRY 2021; 44:117-118. [PMID: 34320126 PMCID: PMC9041972 DOI: 10.1590/1516-4446-2021-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Devon Watts
- St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.,Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Frederico D Garcia
- Departamento de Saúde Mental, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Acioly L T Lacerda
- Programa deTranstornos Afetivos (PRODAF), Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Laboratório Interdisciplinar de Neurociências Clínicas (LiNC), UNIFESP, São Paulo, SP, Brazil.,Instituto Nacional de Ciência e Tecnologia Translacional em Medicina (INCT-TM), Brazil.,CNS Unit, BR Trials, São Paulo, SP, Brazil
| | - Jair de J Mari
- Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Lucas C Quarantini
- Laborato´ rio de Neuropsicofarmacologia, Servic¸o de Psiquiatria, Hospital Universita´ rio Professor Edgard Santos, Universidade Federal da Bahia (UFBA), Salvador, BA, Brazil.,Departamento de Neurociências e Saúde Mental, Faculdade de Medicina da Bahia, UFBA, Salvador, BA, Brazil
| | - Flávio Kapczinski
- St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.,Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada.,CNS Unit, BR Trials, São Paulo, SP, Brazil.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
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30
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A preliminary study of the association of increased anterior cingulate gamma-aminobutyric acid with remission of depression after ketamine administration. Psychiatry Res 2021; 301:113953. [PMID: 33933839 DOI: 10.1016/j.psychres.2021.113953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/14/2021] [Indexed: 11/23/2022]
Abstract
Gamma-aminobutyric acid (GABA) and glutamate neurotransmission have been implicated in the pathophysiology of depression and mechanistically linked to ketamine's antidepressant response. Seven patients with treatment-resistant depression enrolled in an open-label, feasibility trial of a single IV 40-min ketamine infusion during a functional MR spectroscopy (fMRS) scan utilizing a novel frequency adjusting MEGA-PRESS sequence. Next-day treatment remission and reduction in the MADRS scores correlated with anterior cingulate cortex peak GABA levels. These novel findings provide further insights into the underlying neurobiological mechanisms of ketamine and, if confirmed in larger studies, would be encouraging for further development of GABAergic biomarker associated with ketamine response.
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Derakhshanian S, Zhou M, Rath A, Barlow R, Bertrand S, DeGraw C, Lee C, Hasoon J, Kaye AD. Role of Ketamine in the Treatment of Psychiatric Disorders. Health Psychol Res 2021; 9:25091. [PMID: 35106397 PMCID: PMC8801551 DOI: 10.52965/001c.25091] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/17/2021] [Indexed: 09/02/2023] Open
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature regarding the use of ketamine as a treatment for treatment-resistant depression (TRD). It covers the epidemiology, risk factors, pathophysiology, and current treatment modalities regarding Major Depressive Disorder (MDD) and TRD. It provides background on the mechanism of action of ketamine, its history, current approved and off-label indications in the field of psychiatry, and then provides an overview of the existing evidence for the use of ketamine in the treatment of TRD. RECENT FINDINGS MDD is a mental illness that puts an enormous strain on the affected and a high socio-economic burden on society. The illness is complex and combines genetic, pathophysiologic, and environmental factors that combine to negatively affect neurotransmitter balance in the brain. Additional evidence suggests dysregulation of the hypothalamic-pituitary (HPA) axis, brain-derived neurotrophic factor (BDNF), vitamin D levels, and involvement of pro-inflammatory markers. Core symptoms include depressed mood or anhedonia, combined with neurovegetative symptoms such as sleep impairment, changes in appetite, feelings of worthlessness and guilt, and psychomotor retardation. Current first-line treatment options are antidepressants of the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) class. Failure to respond to two adequate trials of treatment meets the criteria for TRD. Esketamine (Spravato) is an NMDA-receptor antagonist with additional AMPA-receptor agonist properties, which the FDA approved in 2019 to treat adult TRD in conjunction with an oral antidepressant. It can be administered intranasally, providing a rapid response and proven effective and safe. Additional research suggests that oral ketamine might be effective for PTSD and anxiety disorders. Intravenous administration of ketamine has also shown benefits for acute suicidal ideation and depression and substance use to reduce relapse rates. SUMMARY TRD is associated with huge costs on individual and societal levels. Underlying disease processes are multifactorial and not well understood. Adjunctive therapies for TRD with proven benefits exist, but acutely depressed and suicidal patients often require prolonged inpatient stabilization. Intranasal esketamine is a new FDA-approved alternative with rapid benefit for TRD, which has also shown a rapid reduction in suicidal ideation while maintaining a favorable side-effect profile. Additional potential off-label uses for ketamine in psychiatric disorders have been studied, including PTSD, anxiety disorders, bipolar depression, and substance use disorders.
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Affiliation(s)
| | - Maxine Zhou
- Department of Psychiatry, Louisiana State University Shreveport, LA
| | - Alexander Rath
- Department of Psychiatry, Louisiana State University Shreveport, LA
| | - Rachel Barlow
- Louisiana State University Health Sciences Center Shreveport School of Medicine, LA
| | - Sarah Bertrand
- Louisiana State University Health Sciences Center Shreveport School of Medicine, LA
| | - Caroline DeGraw
- Louisiana State University Health Sciences Center Shreveport School of Medicine, LA
| | - Christopher Lee
- Department of Internal Medicine, Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, AZ
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, LA
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Artin H, Zisook S, Ramanathan D. How do serotonergic psychedelics treat depression: The potential role of neuroplasticity. World J Psychiatry 2021; 11:201-214. [PMID: 34168967 PMCID: PMC8209538 DOI: 10.5498/wjp.v11.i6.201] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/07/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Depression is a common mental disorder and one of the leading causes of disability around the world. Monoaminergic antidepressants often take weeks to months to work and are not effective for all patients. This has led to a search for a better understanding of the pathogenesis of depression as well as to the development of novel antidepressants. One such novel antidepressant is ketamine, which has demonstrated both clinically promising results and contributed to new explanatory models of depression, including the potential role of neuroplasticity in depression. Early clinical trials are now showing promising results of serotonergic psychedelics for depression; however, their mechanism of action remains poorly understood. This paper seeks to review the effect of depression, classic antidepressants, ketamine, and serotonergic psychedelics on markers of neuroplasticity at a cellular, molecular, electrophysiological, functional, structural, and psychological level to explore the potential role that neuroplasticity plays in the treatment response of serotonergic psychedelics.
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Affiliation(s)
- Hewa Artin
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, United States
| | - Sidney Zisook
- Department of Psychiatry, UC San Diego, San Diego, CA 92093, United States
| | - Dhakshin Ramanathan
- Department of Psychiatry, VA San Diego Healthcare System, San Diego, CA 92161, United States
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Dong Z, Grunebaum MF, Lan MJ, Wagner V, Choo TH, Milak MS, Sobeih T, Mann JJ, Kantrowitz JT. Relationship of Brain Glutamate Response to D-Cycloserine and Lurasidone to Antidepressant Response in Bipolar Depression: A Pilot Study. Front Psychiatry 2021; 12:653026. [PMID: 34149476 PMCID: PMC8208505 DOI: 10.3389/fpsyt.2021.653026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/10/2021] [Indexed: 12/17/2022] Open
Abstract
N-methyl-D-aspartate glutamate-receptor (NMDAR) antagonists such as ketamine have demonstrated efficacy in both major depressive disorder (MDD) and bipolar disorder depression (BP-D). We have previously reported that reduction in Glx (glutamate + glutamine) in the ventromedial prefrontal cortex/anterior cingulate cortex (vmPFC/ACC), measured by proton magnetic resonance spectroscopy (1H MRS) at 3T during a ketamine infusion, mediates the relationship of ketamine dose and blood level to improvement in depression. In the present study, we assessed the impact of D-cycloserine (DCS), an oral NMDAR antagonist combined with lurasidone in BP-D on both glutamate and Glx. Subjects with DSM-V BP-D-I/II and a Montgomery-Asberg Depression Rating Scale (MADRS) score>17, underwent up to three 1H MRS scans. During Scan 1, subjects were randomized to receive double-blind lurasidone 66 mg or placebo. During Scan 2, all subjects received single-blind DCS 950 mg + lurasidone 66 mg, followed by 4 weeks of open label phase of DCS+lurasidone and an optional Scan 3. Five subjects received lurasidone alone and three subjects received placebo for Scan 1. Six subjects received DCS+lurasidone during Scan 2. There was no significant baseline or between treatment-group differences in acute depression improvement or glutamate response. In Scan 2, after a dose of DCS+lurasidone, peak change in glutamate correlated negatively with improvement from baseline MADRS (r = -0.83, p = 0.04). There were no unexpected adverse events. These preliminary pilot results require replication but provide further support for a link between antidepressant effect and a decrease in glutamate by the NMDAR antagonist class of antidepressants.
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Affiliation(s)
- Zhengchao Dong
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, United States
| | - Michael F. Grunebaum
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, United States
| | - Martin J. Lan
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, United States
| | - Vashti Wagner
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, United States
| | - Tse-Hwei Choo
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Mental Health Data Science, New York State Psychiatric Institute, New York, NY, United States
| | - Matthew S. Milak
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, United States
| | - Tarek Sobeih
- Information Sciences, Nathan Kline Institute, Orangeburg, NY, United States
| | - J. John Mann
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, United States
- Department of Radiology, College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Joshua T. Kantrowitz
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Psychotic Disorders, New York State Psychiatric Institute, New York, NY, United States
- Information Sciences, Nathan Kline Institute, Orangeburg, NY, United States
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Abstract
The efficacy of standard antidepressants is limited for many patients with mood disorders such as major depressive disorder (MDD) and bipolar depression, underscoring the urgent need to develop novel therapeutics. Both clinical and preclinical studies have implicated glutamatergic system dysfunction in the pathophysiology of mood disorders. In particular, rapid reductions in depressive symptoms have been observed in response to subanesthetic doses of the glutamatergic modulator racemic (R,S)-ketamine in individuals with mood disorders. These results have prompted investigation into other glutamatergic modulators for depression, both as monotherapy and adjunctively. Several glutamate receptor-modulating agents have been tested in proof-of-concept studies for mood disorders. This manuscript gives a brief overview of the glutamate system and its relevance to rapid antidepressant response and discusses the existing clinical evidence for glutamate receptor-modulating agents, including (1) broad glutamatergic modulators ((R,S)-ketamine, esketamine, (R)-ketamine, (2R,6R)-hydroxynorketamine [HNK], dextromethorphan, Nuedexta [a combination of dextromethorphan and quinidine], deudextromethorphan [AVP-786], axsome [AXS-05], dextromethadone [REL-1017], nitrous oxide, AZD6765, CLE100, AGN-241751); (2) glycine site modulators (D-cycloserine [DCS], NRX-101, rapastinel [GLYX-13], apimostinel [NRX-1074], sarcosine, 4-chlorokynurenine [4-Cl-KYN/AV-101]); (3) subunit (NR2B)-specific N-methyl-D-aspartate (NMDA) receptor antagonists (eliprodil [EVT-101], traxoprodil [CP-101,606], rislenemdaz [MK-0657/CERC-301]); (4) metabotropic glutamate receptor (mGluR) modulators (basimglurant, AZD2066, RG1578, TS-161); and (5) mammalian target of rapamycin complex 1 (mTORC1) activators (NV-5138). Many of these agents are still in the preliminary stages of development. Furthermore, to date, most have demonstrated relatively modest effects compared with (R,S)-ketamine and esketamine, though some have shown more favorable characteristics. Of these novel agents, the most promising, and the ones for which the most evidence exists, appear to be those targeting ionotropic glutamate receptors.
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Lazarevic V, Yang Y, Flais I, Svenningsson P. Ketamine decreases neuronally released glutamate via retrograde stimulation of presynaptic adenosine A1 receptors. Mol Psychiatry 2021; 26:7425-7435. [PMID: 34376822 PMCID: PMC8872981 DOI: 10.1038/s41380-021-01246-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/09/2021] [Accepted: 07/21/2021] [Indexed: 12/27/2022]
Abstract
Ketamine produces a rapid antidepressant response in patients with major depressive disorder (MDD), but the underlying mechanisms appear multifaceted. One hypothesis, proposes that by antagonizing NMDA receptors on GABAergic interneurons, ketamine disinhibits afferens to glutamatergic principal neurons and increases extracellular glutamate levels. However, ketamine seems also to reduce rapid glutamate release at some synapses. Therefore, clinical studies in MDD patients have stressed the need to identify mechanisms whereby ketamine decreases presynaptic activity and glutamate release. In the present study, the effect of ketamine and its antidepressant metabolite, (2R,6R)-HNK, on neuronally derived glutamate release was examined in rodents. We used FAST methodology to measure depolarization-evoked extracellular glutamate levels in vivo in freely moving or anesthetized animals, synaptosomes to detect synaptic recycling ex vivo and primary cortical neurons to perform functional imaging and to examine intracellular signaling in vitro. In all these versatile approaches, ketamine and (2R,6R)-HNK reduced glutamate release in a manner which could be blocked by AMPA receptor antagonism. Antagonism of adenosine A1 receptors, which are almost exclusively expressed at nerve terminals, also counteracted ketamine's effect on glutamate release and presynaptic activity. Signal transduction studies in primary neuronal cultures demonstrated that ketamine reduced P-T286-CamKII and P-S9-Synapsin, which correlated with decreased synaptic vesicle recycling. Moreover, systemic administration of A1R antagonist counteracted the antidepressant-like actions of ketamine and (2R,6R)-HNK in the forced swim test. To conclude, by studying neuronally released glutamate, we identified a novel retrograde adenosinergic feedback mechanism that mediate inhibitory actions of ketamine on glutamate release that may contribute to its rapid antidepressant action.
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Affiliation(s)
- Vesna Lazarevic
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Yunting Yang
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ivana Flais
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Per Svenningsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Affiliation(s)
- J John Mann
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York (Mann, Rizk); Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York (Mann, Rizk); Department of Radiology, Columbia University Irving Medical Center, New York (Mann)
| | - Mina M Rizk
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York (Mann, Rizk); Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York (Mann, Rizk); Department of Radiology, Columbia University Irving Medical Center, New York (Mann)
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