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Jungwirth J, Bavato F, Quednow BB. [Psychedelic and dissociative agents in psychiatry: challenges in the treatment]. DER NERVENARZT 2024; 95:803-810. [PMID: 39196383 PMCID: PMC11374839 DOI: 10.1007/s00115-024-01727-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/29/2024] [Indexed: 08/29/2024]
Abstract
With the discovery of the antidepressive effects of ketamine and the increasing withdrawal of the pharmaceutical industry from the development of new psychotropic drugs, the psychiatric research into the clinical application of hallucinogens in psychiatry has literally blossomed in the last two decades. Promising results for various treatment approaches with psychedelic agents, such lysergic acid diethylamide (LSD) and psilocybin, and dissociative agents, such as ketamine and esketamine, have raised great hopes among researchers, clinicians and patients in recent years, so that there was already talk of a new era in psychiatry. As one of the first of these substances, in December 2019 intranasal esketamine was approved in the USA and the EU for the treatment of treatment-resistant depression and Switzerland followed in 2020. Recently, psilocybin was approved in Australia, Canada and Switzerland for compassionate use in exceptional cases for the treatment of depression, while large approval studies with various psychedelic agents are currently ongoing worldwide. The medical application of psychedelic agents and ketamine/esketamine is considered to be safe; however, as with all new forms of treatment it is of crucial importance that, in addition to the hopes, the specific challenges of these new treatment approaches must also be carefully considered and assessed. Excessive expectations and an insufficient risk-benefit estimation are detrimental to the patients and the reputation of the treating physician. Although a possible paradigm shift in the care of mental health is already being discussed, this review article consciously concentrates on the possible risks of treatment and the methodological weaknesses of the studies carried out so far.
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Affiliation(s)
- Johannes Jungwirth
- AG Neurophänomenologie des Bewusstseins, Erwachsenenpsychiatrie und Psychotherapie, Psychiatrische Universitätsklinik Zürich, Universität Zürich, Zürich, Schweiz
| | - Francesco Bavato
- AG Experimentelle Pharmakopsychologie und psychologische Suchtforschung, Erwachsenenpsychiatrie und Psychotherapie, Psychiatrische Universitätsklinik Zürich, Universität Zürich, Zürich, Schweiz
| | - Boris B Quednow
- AG Experimentelle Pharmakopsychologie und psychologische Suchtforschung, Erwachsenenpsychiatrie und Psychotherapie, Psychiatrische Universitätsklinik Zürich, Universität Zürich, Zürich, Schweiz.
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Ansari M, Pittman B, Tylee DS, Ostroff R, Wilkinson ST, Nikayin S. Blood pressure changes during ketamine infusion for the treatment of depression. Gen Hosp Psychiatry 2024; 90:62-67. [PMID: 38991311 DOI: 10.1016/j.genhosppsych.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE This study aimed to examine blood pressure changes during ketamine infusion for depression and exploring the factors associated with these changes. METHOD This study is a retrospective chart-review of patients with depression undergoing ketamine infusion at Yale Psychiatry Hospital during a 7-year period. Blood pressure (BP) was recorded every 10 min during the infusion. Surges in systolic and diastolic blood pressure (SBP, DBP), along with severe hypertension events, were analyzed in relation to patient demographics. RESULTS A total of 138 patients received a total of 2342 infusions. SBP and DBP peaked at 40 min after the start of the infusion with a mean change of 16.0 (SD: 11.2) and 11.0 mmHg (SD: 8.45) respectively. Severe hypertension was observed in 17 patients (12.5%) and 23 infusion sessions (0.98%), occuring more frequently during the first three infusions (43.4%). Age (OR = 1.04 [1.02,1.05], p-value <0.001) was significantly associated with a surge in SBP and all patients with a past medical history of hypertension experienced a BP surge during their infusions. CONCLUSION Ketamine infusions can cause significant blood pressure increases, particularly in older and hypertensive patients, highlighting the need for careful cardiovascular monitoring to mitigate risks during treatment.
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Affiliation(s)
- Mina Ansari
- Yale Depression Research Program (YDRP), Yale University, New Haven, CT 06511, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Brian Pittman
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel S Tylee
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Ostroff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Interventional Psychiatry Services, Yale Psychiatry Hospital, New Haven, CT 06519, USA
| | - Samuel T Wilkinson
- Yale Depression Research Program (YDRP), Yale University, New Haven, CT 06511, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Interventional Psychiatry Services, Yale Psychiatry Hospital, New Haven, CT 06519, USA
| | - Sina Nikayin
- Yale Depression Research Program (YDRP), Yale University, New Haven, CT 06511, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Interventional Psychiatry Services, Yale Psychiatry Hospital, New Haven, CT 06519, USA.
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Schlegelmilch M, Plint AC, Barrowman N, Gray C, Bhatt M. Intravenous ketamine for emergency department treatment of suicidal ideation in a paediatric population: protocol for a double-blind, randomised, placebo-controlled, parallel-arm pilot trial (KSI study). BMJ Open 2024; 14:e085681. [PMID: 38969374 PMCID: PMC11227786 DOI: 10.1136/bmjopen-2024-085681] [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: 02/22/2024] [Accepted: 05/20/2024] [Indexed: 07/07/2024] Open
Abstract
INTRODUCTION Suicidal ideation (SI) is a common and severe cause of morbidity in adolescents. Patients frequently present to the emergency department (ED) for care, yet there is no acute therapeutic intervention for SI. A single dose of intravenous ketamine has demonstrated efficacy in rapidly reducing SI in adults; however, ketamine has not been studied in paediatrics. We aim to determine the feasibility of a trial of a single intravenous ketamine dose to reduce SI for patients in the paediatric ED. METHODS AND ANALYSIS This will be a single-centre, double-blind, randomised, placebo-controlled, parallel-arm pilot trial of intravenous ketamine for ED treatment of SI in a paediatric population. INTERVENTION one intravenous dose of 0.5 mg/kg of ketamine (max 50 mg), over 40 min. Placebo: one intravenous dose of 0.5 mL/kg (max 50 mL) of normal saline, over 40 min. Participants will be randomised in a 1:1 ratio. SI severity will be measured at baseline, 40 min, 80 min, 120 min, 24 hours and 7 days. We aim to recruit 20 participants. The primary feasibility outcome is the proportion of eligible patients who complete the study protocol. We will pilot three SI severity tools and explore the efficacy, safety and tolerability of the intervention. ETHICS AND DISSEMINATION This study will be conducted according to Canadian Biomedical Research Tutorial, international standards of Good Clinical Practice and the Health Canada, Food and Drug Act, Part C, Division 5. The study documents have been approved by the CHEO Research Institute Research Ethics Board (CHEO REB (23/02E)). Participants must provide free and informed consent to participate. If incapable due to age, assenting participants with parental/legal guardian consent may participate. On completion, we will endeavour to present results at international conferences, and publish the results in a peer-reviewed journal. Participants will receive a results letter. TRIAL REGISTRATION NUMBER NCT05468840.
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Affiliation(s)
| | - Amy C Plint
- Department of Pediatrics, CHEO, Ottawa, Ontario, Canada
| | | | - Clare Gray
- Department of Psychiatry, CHEO, Ottawa, Ontario, Canada
| | - Maala Bhatt
- Department of Pediatrics, CHEO, Ottawa, Ontario, Canada
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Zhang Z, Zhang WH, Lu YX, Lu BX, Wang YB, Cui LY, Cheng H, Yuan ZY, Zhang J, Gao DP, Gong JF, Ji Q. Intraoperative Low-Dose S-Ketamine Reduces Depressive Symptoms in Patients with Crohn's Disease Undergoing Bowel Resection: A Randomized Controlled Trial. J Clin Med 2023; 12:jcm12031152. [PMID: 36769799 PMCID: PMC9917783 DOI: 10.3390/jcm12031152] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
Background: Patients with Crohn's disease (CD) undergoing bowel resection often suffer from depression and acute pain, which severely impairs their recovery. We aimed to investigate the effects of S-ketamine preconditioning on postoperative depression in patients with CD undergoing a bowel resection with mild to moderate depression and to observe whether it can relieve postoperative pain and anti-inflammation. Methods: A total of 124 adult patients were randomized into one of the two groups. Patients in the S-ketamine group received a 0.25 mg/kg S-ketamine intravenous drip under general anesthesia induction, followed by a continuous infusion of S-ketamine with 0.12 mg/kg/h for more than 30 min through target-controlled infusion. Patients in the placebo group received 0.9% saline at an identical volume and rate. The primary outcome measure was the 17-item Hamilton depression Scale (HAMD-17). The secondary outcomes were scores on the following questionnaires: a nine-item patient health questionnaire (PHQ-9); a quality of recovery (QoR-15) form; and a numeric rating scale (NRS). Additional secondary outcomes included the levels of C-reactive protein (CRP) and interleukin 6 (IL-6) on postoperative days (PODs) 1, 3, and 5, the length of hospital stay, and opioid use throughout the hospital stay. Results: The scores of PHQ-9 and HAMD-17 in the S-ketamine group were lower than those in the placebo group on postoperative days (PODs) 1, 2, and 7 (p < 0.05). The scores of QoR-15 in the S-ketamine group were higher than those in the placebo group on postoperative days (PODs) 3 and 5 (p < 0.05). The NRS scores of PACU, postoperative days 1 and 2 in the S-ketamine group were lower than those in the placebo group (p < 0.05). There was no significant difference in the CRP and IL-6 levels on postoperative days (PODs) 1, 3, and 5, postoperative complications, and hospital stay between the two groups (p > 0.05). Conclusions: The trial indicated that the intraoperative administration of low-dose S-ketamine could alleviate mild-to-moderate depressive symptoms and postoperative pain in patients with Crohn's disease undergoing bowel resection without worsening their safety.
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Affiliation(s)
- Zhen Zhang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Wen-Hao Zhang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Yin-Xiao Lu
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Bo-Xuan Lu
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Yi-Bo Wang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Li-Ying Cui
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Hao Cheng
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Zhen-Yu Yuan
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Jie Zhang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Da-Peng Gao
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Jian-Feng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Qing Ji
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
- Correspondence:
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Bosch OG, Halm S, Seifritz E. Psychedelics in the treatment of unipolar and bipolar depression. Int J Bipolar Disord 2022; 10:18. [PMID: 35788817 PMCID: PMC9256889 DOI: 10.1186/s40345-022-00265-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
This is a narrative review about the role of classic and two atypical psychedelics in the treatment of unipolar and bipolar depression. Since the 1990s, psychedelics experience a renaissance in biomedical research. The so-called classic psychedelics include lysergic acid diethylamide (LSD), psilocybin, mescaline and ayahuasca. Characteristic effects like alterations in sensory perception, as well as emotion- and self-processing are induced by stimulation of serotonin 2A receptors in cortical areas. The new paradigm of psychedelic-assisted psychotherapy suggests a therapeutic framework in which a safely conducted psychedelic experience is integrated into a continuous psychotherapeutic process. First randomized, controlled trials with psilocybin show promising efficacy, tolerability, and adherence in the treatment of unipolar depression. On the other hand, classic psychedelics seem to be associated with the induction of mania, which is an important issue to consider for the design of research and clinical protocols. So called atypical psychedelics are a heterogeneous group with overlapping subjective effects but different neurobiological mechanisms. Two examples of therapeutic value in psychiatry are 3,4-methylenedioxymethamphetamine (MDMA) and ketamine. Since 2020 the ketamine enantiomer esketamine has been granted international approval for treatment-resistant unipolar depression, and also first evidence exists for the therapeutic efficacy of ketamine in bipolar depression. Whether psychedelics will fulfil current expectations and find their way into broader clinical use will depend on future rigorous clinical trials with larger sample sizes. A well-considered therapeutic and legal framework will be crucial for these substances to create new treatment settings and a potential paradigm shift.
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Affiliation(s)
- Oliver G Bosch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, PO Box 1931, 8032, Zurich, Switzerland.
| | - Simon Halm
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, PO Box 1931, 8032, Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, PO Box 1931, 8032, Zurich, Switzerland
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Optimized Clinical Strategies for Treatment-Resistant Depression: Integrating Ketamine Protocols with Trauma- and Attachment-Informed Psychotherapy. PSYCH 2022. [DOI: 10.3390/psych4010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Strategically timed trauma- and attachment-informed psychotherapy to address underlying emotional wounds, paired with ketamine administered in precision-calibrated doses to ensure high-entropy brain states, may be key to improving the quality and duration of ketamine’s therapeutic efficacy for treatment-resistant depression. This approach optimizes the opportunities for change created by ketamine’s known effects as a rapid antidepressant that stimulates synaptogenesis, normalizes neural connectivity and coherence, enhances neuroplasticity, reduces inflammation, and induces high-entropy brain states with associated subjective psychedelic experiences. Ketamine, a non-selective N-methyl-D-aspartate (NMDA) receptor antagonist is a safe, effective, fast-acting dissociative anesthetic that, as a standalone treatment, also exhibits rapid sustained antidepressant effects, even in many patients with treatment-resistant depression. A prior history of developmental trauma and attachment injuries are known primary factors in the etiology of treatment resistance in depression and other mental disorders. Thus, the adjunct of targeted psychotherapy attuned to trauma and attachment injuries may enhance and prolong ketamine efficacy and provide an opportunity for lasting therapeutic change. Psychotherapy engagement during repeated ketamine sessions for patient safety and integration of altered states, paired with separate individualized psychotherapy-only sessions timed 24–48 h post ketamine induction, takes advantage of peak ketamine-induced dendritic spine growth in the prefrontal cortex and limbic system, and normalized network connectivity across brain structures. This strategically timed paired-session approach also exploits the therapeutic potential created by precision-calibrated ketamine-linked high-entropy brain states and associated psychedelic experiences that are posited to disrupt overly rigid maladaptive thoughts, behaviors, and disturbing memories associated with treatment-resistant depression; paired sessions also support integration of the felt sense of happiness and connectivity associated with psychedelic experiences.
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Tamman AJF, Anand A, Mathew SJ. A comparison of the safety, feasibility, and tolerability of ECT and ketamine for treatment-resistant depression. Expert Opin Drug Saf 2022; 21:745-759. [PMID: 35253555 DOI: 10.1080/14740338.2022.2049754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Treatment-resistant depression (TRD) is a problematic and prevalent public health and societal concern. Although electroconvulsive therapy (ECT) is the gold standard TRD intervention, the treatment evokes apprehension due to public perceptions, feasibility, and tolerability. Despite significant medical advancements, few medications have been approved by the U.S. Food and Drug Administration for TRD. In 2019, intranasal esketamine, the S-isomer of racemic ketamine, was approved for TRD, garnering significant excitement about the potential for the drug to act as an alternative treatment to ECT. AREAS COVERED The goal of this narrative review is to compare the safety, efficacy, and tolerability of ketamine and ECT; clarify whether ketamine is a reasonable alternative to ECT; and to facilitate improved treatment assignment for TRD. Empirical quantitative and qualitative studies and national and international guidelines these treatments are reviewed. EXPERT OPINION : The field awaits the results of two ongoing large comparative effectiveness trials of ECT and IV ketamine for TRD, which should help guide clinicians and patients as to the relative risk and benefit of these interventions. Over the next five years we anticipate further innovations in neuromodulation and in drug development which broadly aim to develop more tolerable versions of ECT and ketamine, respectively.
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Affiliation(s)
- Amanda J F Tamman
- Department of Psychology, St. John's University, Queens, NY, USA.,Mood and Anxiety Disorders Program, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Amit Anand
- Department of Psychiatry, Mass General Brigham, Harvard Medical School, Boston, MA, USA
| | - Sanjay J Mathew
- Michael E. Debakey VA Medical Center, Houston, TX, USA.,Mood and Anxiety Disorders Program, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Salvador A, Arnal LH, Vinckier F, Domenech P, Gaillard R, Wyart V. Premature commitment to uncertain decisions during human NMDA receptor hypofunction. Nat Commun 2022; 13:338. [PMID: 35039498 PMCID: PMC8763907 DOI: 10.1038/s41467-021-27876-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/21/2021] [Indexed: 11/15/2022] Open
Abstract
Making accurate decisions based on unreliable sensory evidence requires cognitive inference. Dysfunction of n-methyl-d-aspartate (NMDA) receptors impairs the integration of noisy input in theoretical models of neural circuits, but whether and how this synaptic alteration impairs human inference and confidence during uncertain decisions remains unknown. Here we use placebo-controlled infusions of ketamine to characterize the causal effect of human NMDA receptor hypofunction on cognitive inference and its neural correlates. At the behavioral level, ketamine triggers inference errors and elevated decision uncertainty. At the neural level, ketamine is associated with imbalanced coding of evidence and premature response preparation in electroencephalographic (EEG) activity. Through computational modeling of inference and confidence, we propose that this specific pattern of behavioral and neural impairments reflects an early commitment to inaccurate decisions, which aims at resolving the abnormal uncertainty generated by NMDA receptor hypofunction.
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Affiliation(s)
- Alexandre Salvador
- Laboratoire de Neurosciences Cognitives et Computationnelles, Institut National de la Santé et de la Recherche Médicale, Paris, France
- Département d'Études Cognitives, École Normale Supérieure, Université PSL, Paris, France
- Université de Paris, Paris, France
- Département de Psychiatrie, Service Hospitalo-Universitaire, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | - Luc H Arnal
- Institut de l'Audition, Inserm unit 1120, Institut Pasteur, Paris, France
| | - Fabien Vinckier
- Université de Paris, Paris, France
- Département de Psychiatrie, Service Hospitalo-Universitaire, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Équipe Motivation, Cerveau et Comportement, Institut du Cerveau, Sorbonne Université, Paris, France
| | - Philippe Domenech
- Équipe Neurophysiologie des Comportements Répétitifs, Institut du Cerveau, Sorbonne Université, Paris, France
- Département Médico-Universitaire de Psychiatrie et d'Addictologie, CHU AP-HP Henri Mondor, Université Paris-Est Créteil, Créteil, France
| | - Raphaël Gaillard
- Université de Paris, Paris, France
- Département de Psychiatrie, Service Hospitalo-Universitaire, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Unité de Neuropathologie Expérimentale, Département de Santé Globale, Institut Pasteur, Paris, France
| | - Valentin Wyart
- Laboratoire de Neurosciences Cognitives et Computationnelles, Institut National de la Santé et de la Recherche Médicale, Paris, France.
- Département d'Études Cognitives, École Normale Supérieure, Université PSL, Paris, France.
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Zhou Y, Sun W, Zhang G, Wang A, Lin S, Chan MTV, Peng Y, Wang G, Han R. Ketamine Alleviates Depressive Symptoms in Patients Undergoing Intracranial Tumor Resection: A Randomized Controlled Trial. Anesth Analg 2021; 133:1588-1597. [PMID: 34633992 DOI: 10.1213/ane.0000000000005752] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Depressive symptoms occur in over 40% of neurosurgical patients during the perioperative period. However, no measure has been suggested to have a rapid effect on depressive surgical patients during increasingly shorter stays in the hospital. This study aimed to determine whether ketamine could improve depressive symptoms rapidly and safely during the hospital stay. METHODS This was a randomized, placebo-controlled, and double-blinded trial. Patients with moderate-to-severe depressive symptoms undergoing elective supratentorial brain tumor resection were randomized to intravenously receive either (1) 0.5 mg·kg-1 ketamine for 40 minutes or (2) an identical volume of normal saline. The primary outcome was treatment response on postoperative day 3, defined as a ≥50% reduction from the baseline depressive score. The secondary outcomes included the rate of remission and safety outcomes. The Montgomery-Åsberg Depression Rating Scale was applied by trained psychiatrists to evaluate depressive symptoms. RESULTS A total of 84 neurosurgical patients were enrolled in the trial. The response rate was increased by the administration of ketamine (41.5% [17/41] vs 16.3% [7/43]; relative risk [RR]: 2.51, 95% confidence interval [CI], 1.18-5.50) relative to the administration of placebo at 3 days. Furthermore, the remission rate at discharge (29.3% [12/41] vs 7.0% [3/43]; RR: 4.20, 95% CI, 1.28-13.80) was also improved by ketamine. No psychotic symptoms or adverse events were reported to be substantially higher in the ketamine group. CONCLUSIONS The trial indicates that the intraoperative administration of ketamine could alleviate moderate-to-severe depressive symptoms in neurosurgical patients without worsening safety.
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Affiliation(s)
- Yang Zhou
- From the Department of Anesthesiology, Beijing Tiantan Hospital Capital Medical University, Beijing, People's Republic of China
| | - Wanchen Sun
- From the Department of Anesthesiology, Beijing Tiantan Hospital Capital Medical University, Beijing, People's Republic of China
| | - Guofu Zhang
- China & Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Psychiatry, Capital Medical University, China & Center of Depression, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
| | - Anxin Wang
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Matthew T V Chan
- Department of Anesthesia and Intensive Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, People's Republic of China
| | - Yuming Peng
- From the Department of Anesthesiology, Beijing Tiantan Hospital Capital Medical University, Beijing, People's Republic of China
| | - Gang Wang
- China & Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Psychiatry, Capital Medical University, China & Center of Depression, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
| | - Ruquan Han
- From the Department of Anesthesiology, Beijing Tiantan Hospital Capital Medical University, Beijing, People's Republic of China
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Pai SM, Gries JM. Off-Label Use of Ketamine: A Challenging Drug Treatment Delivery Model With an Inherently Unfavorable Risk-Benefit Profile. J Clin Pharmacol 2021; 62:10-13. [PMID: 34652824 DOI: 10.1002/jcph.1983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/06/2022]
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Abstract
TOPIC Ketamine is beneficial in clinical settings ranging from procedural sedation to the treatment of chronic pain. This article describes the clinical benefits of ketamine for treatment of acute pain and for sedation of patients undergoing mechanical ventilation. CLINICAL RELEVANCE Ketamine causes analgesic and amnestic effects by noncompetitive inhibition of the N-methyl-D-aspartate receptor and activation of the opioid μ and κ receptors. Unlike other sedatives, ketamine provides analgesia and amnesia without causing hypotension or respiratory depression. Several studies have elucidated the clinical benefits of ketamine. The use of ketamine has extended beyond critical care areas such as the operating room and intensive care units. Nurses must be familiar with optimal clinical scenarios, monitoring parameters, and contraindications of ketamine. PURPOSE To highlight the clinical utility and pharmacological properties of ketamine through a literature review. Current studies of ketamine in acute pain and sedation management are summarized. CONTENT COVERED This narrative review describes pharmacological properties, dosing strategies, adminis-tration considerations, and adverse effects of ketamine.
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Affiliation(s)
- Kyle Brown
- Kyle Brown is a critical care pharmacy specialist, Memorial Healthcare System, Pembroke Pines, Florida
| | - Calvin Tucker
- Calvin Tucker is a coordinator, Acute Care Surgery Pharmacy Services, University of Florida Health Shands Hospital, Jacksonville, Florida
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Bednarik P, Spurny B, Silberbauer LR, Svatkova A, Handschuh PA, Reiter B, Konadu ME, Stimpfl T, Spies M, Bogner W, Lanzenberger R. Effect of Ketamine on Human Neurochemistry in Posterior Cingulate Cortex: A Pilot Magnetic Resonance Spectroscopy Study at 3 Tesla. Front Neurosci 2021; 15:609485. [PMID: 33841073 PMCID: PMC8024494 DOI: 10.3389/fnins.2021.609485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/23/2021] [Indexed: 12/28/2022] Open
Abstract
Ketamine is a powerful glutamatergic long-lasting antidepressant, efficient in intractable major depression. Whereas ketamine's immediate psychomimetic side-effects were linked to glutamate changes, proton MRS (1H-MRS) showed an association between the ratio of glutamate and glutamine and delayed antidepressant effect emerging ∼2 h after ketamine administration. While most 1H-MRS studies focused on anterior cingulate, recent functional MRI connectivity studies revealed an association between ketamine's antidepressant effect and disturbed connectivity patterns to the posterior cingulate cortex (PCC), and related PCC dysfunction to rumination and memory impairment involved in depressive pathophysiology. The current study utilized the state-of-the-art single-voxel 3T sLASER 1H-MRS methodology optimized for reproducible measurements. Ketamine's effects on neurochemicals were assessed before and ∼3 h after intravenous ketamine challenge in PCC. Concentrations of 11 neurochemicals, including glutamate (CRLB ∼ 4%) and glutamine (CRLB ∼ 13%), were reliably quantified with the LCModel in 12 healthy young men with between-session coefficients of variation (SD/mean) <8%. Also, ratios of glutamate/glutamine and glutamate/aspartate were assessed as markers of synaptic function and activated glucose metabolism, respectively. Pairwise comparison of metabolite profiles at baseline and 193 ± 4 min after ketamine challenge yielded no differences. Minimal detectable concentration differences estimated with post hoc power analysis (power = 80%, alpha = 0.05) were below 0.5 μmol/g, namely 0.39 μmol/g (∼4%) for glutamate, 0.28 μmol/g (∼10%) for Gln, ∼14% for glutamate/glutamine and ∼8% for glutamate/aspartate. Despite the high sensitivity to detect between-session differences in glutamate and glutamine concentrations, our study did not detect delayed glutamatergic responses to subanesthetic ketamine doses in PCC.
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Affiliation(s)
- Petr Bednarik
- High Field MR Center, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Institute for Clinical Molecular MRI in Musculoskeletal System, Karl Landsteiner Society, Vienna, Austria
| | - Benjamin Spurny
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Leo R. Silberbauer
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Alena Svatkova
- Department of Medicine III, Clinical Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Patricia A. Handschuh
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Melisande E. Konadu
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Stimpfl
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Marie Spies
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Bogner
- High Field MR Center, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Institute for Clinical Molecular MRI in Musculoskeletal System, Karl Landsteiner Society, Vienna, Austria
| | - Rupert Lanzenberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
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Acute Effects of Ketamine Infusion on Postoperative Mood Scores in Patients Undergoing Dilation and Curettage: A Randomized Double-Blind Controlled Study. Anesthesiol Res Pract 2021; 2021:6674658. [PMID: 33859685 PMCID: PMC8009713 DOI: 10.1155/2021/6674658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/26/2021] [Accepted: 03/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Emotional and psychological effects following abortion are more common than physical side effects and can range from mild regret to more serious complications such as depression. In the last decade, it has been suggested that low dose of ketamine is a fast-acting antidepressant. Purpose The aim of this study was to investigate the impact of intraoperative ketamine infusion on postoperative mood score in patients undergoing Dilation and Curettage (D&C) under spinal anesthesia. We hypothesized that a single low-dose administration of ketamine infusion during D&C surgery can improve mood scores in the immediate postoperative period. Methods A prospective, randomized, double-blind, parallel-group, placebo-controlled trial. The study included a total of 60 patients, ≥18 years, physical status ASA II, with up to 12-week gestation undergoing elective D&C surgery. Patients were divided randomly into a ketamine group (group K) and a control group (group C). In group K, 0.4 mg/kg ketamine was given as a continuous infusion over 20 min intraoperatively. Main Outcome Measure. Profile of Mood States (POMS) was recorded preoperatively and 2 hours postoperatively. Results There were no differences in preoperative POMS between the two groups. Mean postoperative POMS of group K was lower than that of group C indicating mood improvement. Ketamine group patients showed higher sedation score and increased, although self-limiting, psychedelic phenomena than the control group. Conclusion Observed data here support an acute effect of ketamine on mood but any further claim will be speculative. Further future studies exploring postoperative mood scores after 24 hours post-infusion are needed. This trial is registered with PACTR201907779292947.
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14
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Song B, Zhu J. A Novel Application of Ketamine for Improving Perioperative Sleep Disturbances. Nat Sci Sleep 2021; 13:2251-2266. [PMID: 34992482 PMCID: PMC8715868 DOI: 10.2147/nss.s341161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/04/2021] [Indexed: 01/20/2023] Open
Abstract
Perioperative sleep disturbances are commonly observed before, during, and after surgery and can be caused by several factors, such as preoperative negative moods, general anesthetics, surgery trauma, and pain. Over the past decade, the fast-acting antidepressant effects of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine represent one of the most attractive discoveries in the field of psychiatry, such as antidepressant and anxiolytic effects. It is also widely used as a short-acting anesthetic and analgesic. Recent research has revealed new possible applications for ketamine, such as for perioperative sleep disorders and circadian rhythm disorders. Here, we summarize the risk factors for perioperative sleep disturbances, outcomes of perioperative sleep disturbances, and mechanism of action of ketamine in improving perioperative sleep quality.
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Affiliation(s)
- Bijia Song
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Junchao Zhu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
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15
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Carrillo P, Petit AC, Gaillard R, Vinckier F. The next psychoactive drugs: From imipramine to ketamine. BULLETIN DE L'ACADEMIE NATIONALE DE MEDECINE 2020; 204:e169-e177. [PMID: 36879561 PMCID: PMC9977542 DOI: 10.1016/j.banm.2020.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Since the 1950s, the therapeutic arsenal against depression has grown considerably. From the discovery of mono-amine oxidase inhibitors (MAOIs) to the antidepressant effect of ketamine, several pharmacological breakthroughs made the history of psychiatry. These discoveries oriented the research about the pathophysiology of depression, which is one of the most disabling diseases worldwide affecting 10 to 20% of general population. In this article, we offer a short historical review of the various therapeutic options developed over the past century and the consequences of these innovations. We then review the discovery of the antidepressant effects of ketamine (and its S-enantiomer, esketamine), the lastest development in depression treatment. Ketamine's effects are spectacular both in terms of their very short onset time, and because they are observed even in treatment-resistant depression. Just as MAOIs and tricyclic antidepressants allowed the "monoaminergic hypothesis of depression" to emerge, unravelling the mechanisms of ketamine's antidepressant effects should highlight the role of glutamatergic system and neuro-inflammation in the neurobiology of depression. Ketamine might also help to refine our understanding of the cognitive pathophysiology of depression and to deeply transform the clinical representations of depressive disorder.
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Affiliation(s)
- Pablo Carrillo
- Département de Psychiatrie, centre hospitalier le-Vinatier, 69678 Bron, France
| | - Anne-Cécile Petit
- Université de Paris, 75006 Paris, France.,Service hospitalo-universitaire, GHU de Paris psychiatrie & neurosciences, 75014 Paris, France.,Unité de neuropathologie expérimentale, département santé globale, institut Pasteur, 75015 Paris, France
| | - Raphaël Gaillard
- Université de Paris, 75006 Paris, France.,Service hospitalo-universitaire, GHU de Paris psychiatrie & neurosciences, 75014 Paris, France.,Unité de neuropathologie expérimentale, département santé globale, institut Pasteur, 75015 Paris, France
| | - Fabien Vinckier
- Université de Paris, 75006 Paris, France.,Service hospitalo-universitaire, GHU de Paris psychiatrie & neurosciences, 75014 Paris, France
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16
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Zheng W, Zhou YL, Wang CY, Lan XF, Zhang B, Yang MZ, Nie S, Ning YP. Neurocognitive effects of six ketamine infusions and the association with antidepressant effects in treatment-resistant bipolar depression: a preliminary study. PeerJ 2020; 8:e10208. [PMID: 33194410 PMCID: PMC7646297 DOI: 10.7717/peerj.10208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/28/2020] [Indexed: 12/27/2022] Open
Abstract
Objective The N-methyl-D-aspartate subtype glutamate receptor antagonist ketamine has rapid antidepressant and antisuicidal effects in treating treatment-resistant bipolar depression (TRBD). The neurocognitive effects of repeated ketamine infusions in TRBD are not known. Methods Six intravenous infusions of ketamine (0.5 mg/kg over 40 min) were administered on a Monday–Wednesday–Friday schedule during a 12-day period on 16 patients with TRBD followed by a 2-week observational period. The assessment of neurocognitive function was conducted using the MATRICS Consensus Cognitive Battery at baseline, 13 and 26 days. Tasks were designed to test speed of processing, working memory, visual learning and verbal learning. Results A significant improvement was found only in scores of speed of processing (F = 9.9, p = 0.001) after a 2-week observational period, which was accounted for by the improvement of depression symptoms. There were no significant changes over time in terms of working memory, visual learning and verbal learning. Pearson correlation analysis showed that the improvement of depression symptoms through six ketamine infusions was greater among TRBD patients with lower working memory at baseline (r = 0.54, p = 0.03). In multiple regression analysis, the significant correlation was still maintained (beta = 0.67, t = 2.2, p = 0.04). Conclusion This preliminary study indicated that six ketamine infusions were not harmful but were slightly beneficial for speed of processing in TRBD. However, this change was mainly accounted for the improvement of depression symptoms over time. Lower baseline working memory appears to be associated with greater antidepressant response after completion of six ketamine infusions in patients with TRBD.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan-Ling Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Cheng-Yu Wang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiao-Feng Lan
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bin Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ming-Zhe Yang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Sha Nie
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China, Guangzhou, China
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17
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[The next psychoactive drugs: From imipramine to ketamine]. BULLETIN DE L ACADEMIE NATIONALE DE MEDECINE 2020; 204:1034-1042. [PMID: 32963409 PMCID: PMC7494514 DOI: 10.1016/j.banm.2020.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 09/10/2020] [Indexed: 12/02/2022]
Abstract
Depuis les années 1950, l’arsenal thérapeutique permettant de lutter contre la dépression s’est considérablement enrichi. De la découverte des inhibiteurs de la monoamine oxydase (IMAO) à celle de la kétamine, ces percées pharmacologiques ont marqué l’histoire de la psychiatrie et guidé la recherche sur la physiopathologie de la dépression, cette pathologie dévastatrice affectant entre 10 et 20 % de la population mondiale. Nous proposons dans cet article une courte revue historique des différentes options thérapeutiques développées au cours du siècle passé et des conséquences qu’ont eu ces innovations. Nous réalisons ensuite un état des lieux de la plus récente de ces découvertes, celle des effets antidépresseurs de la kétamine (et de son énantiomère S, l’eskétamine), spectaculaires de par leur délai d’apparition et leur efficacité même dans les formes les plus résistantes de dépression. De même que la découverte des IMAO et des tricycliques a permis de concevoir une théorie monoaminergique de la dépression, l’étude des mécanismes d’actions de la kétamine pourrait permettre de comprendre le rôle de la transmission glutamatergique ou de la neuro-inflammation dans la neurobiologie de cette pathologie, d’affiner nos connaissances sur sa physiopathologie cognitive ou encore de transformer en profondeur les représentations des cliniciens sur cette maladie.
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18
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Wang J, Wang Y, Xu X, Peng S, Xu F, Liu P. Use of Various Doses of S-Ketamine in Treatment of Depression and Pain in Cervical Carcinoma Patients with Mild/Moderate Depression After Laparoscopic Total Hysterectomy. Med Sci Monit 2020; 26:e922028. [PMID: 32565534 PMCID: PMC7331479 DOI: 10.12659/msm.922028] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background This study investigated the effects of various doses of S-ketamine on depression and pain management of cervical carcinoma patients with mild/moderate depression. Material/Methods This randomized, double-blind, controlled study included 417 cervical carcinoma patients who received laparoscopic modified radical hysterectomy from April 2015 to July 2018 and who also had mild/moderate depression symptoms based on HAMD-17 scores (8~24). All patients were randomized into 4 groups: 1) the control group, 2) the racemic ketamine group, 3) the high-dose S-ketamine group; and 4) the low-dose S-ketamine group. Pain was assessed using the Visual Analogue Score (VAS), and depression was assessed using theHAMD-17 score. Serum levels of BDNF and 5-HT were measured. Results The 4 groups of patients showed no significant differences in operation time, bleeding volume, hospitalization duration, or complications. The high-dose S-ketamine group showed significantly lower VAS and HAMD-17 scores than all other groups at 1 day and 3 days postoperatively, but no differences were observed in the low-dose S-ketamine group and the racemic ketamine group. The high-dose S-ketamine group showed significantly higher serum BDNF and 5-HT levels at 1 day and 3 days after surgery. However, 1 week after surgery, no difference was observed in any of the treatment groups. Conclusions At subanesthetic dose, both 0.5 mg/kg and 0.25 mg/kg S-ketamine improved short-term depression and pain for cervical carcinoma patients after surgery, and the effects were better than with the same dose of racemic ketamine.
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Affiliation(s)
- Jie Wang
- Department of Anesthesiology, Ninth People's Hospital of Suzhou, Suzhou, Jiangsu, China (mainland)
| | - Yajun Wang
- Department of Anesthesiology, Xishan People's Hospital, Wuxi, Jiangsu, China (mainland)
| | - Xudong Xu
- Department of Anesthesiology, Changzhou Traditional Chinese Medicine Hospital, Changzhou, Jiangsu, China (mainland)
| | - Sheng Peng
- Department of Anesthesiology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine (TCM), Shanghai, China (mainland)
| | - Feng Xu
- Department of Medical Oncology, Shanghai Gongli Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Peirong Liu
- Department of Anesthesiology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine (TCM), Shanghai, China (mainland)
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19
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Matveychuk D, Thomas RK, Swainson J, Khullar A, MacKay MA, Baker GB, Dursun SM. Ketamine as an antidepressant: overview of its mechanisms of action and potential predictive biomarkers. Ther Adv Psychopharmacol 2020; 10:2045125320916657. [PMID: 32440333 PMCID: PMC7225830 DOI: 10.1177/2045125320916657] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/02/2020] [Indexed: 12/15/2022] Open
Abstract
Ketamine, a drug introduced in the 1960s as an anesthetic agent and still used for that purpose, has garnered marked interest over the past two decades as an emerging treatment for major depressive disorder. With increasing evidence of its efficacy in treatment-resistant depression and its potential anti-suicidal action, a great deal of investigation has been conducted on elucidating ketamine's effects on the brain. Of particular interest and therapeutic potential is the ability of ketamine to exert rapid antidepressant properties as early as several hours after administration. This is in stark contrast to the delayed effects observed with traditional antidepressants, often requiring several weeks of therapy for a clinical response. Furthermore, ketamine appears to have a unique mechanism of action involving glutamate modulation via actions at the N-methyl-D-aspartate (NMDA) and α -amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, as well as downstream activation of brain-derived neurotrophic factor (BDNF) and mechanistic target of rapamycin (mTOR) signaling pathways to potentiate synaptic plasticity. This paper provides a brief overview of ketamine with regard to pharmacology/pharmacokinetics, toxicology, the current state of clinical trials on depression, postulated antidepressant mechanisms and potential biomarkers (biochemical, inflammatory, metabolic, neuroimaging sleep-related and cognitive) for predicting response to and/or monitoring of therapeutic outcome with ketamine.
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Affiliation(s)
- Dmitriy Matveychuk
- Department of Psychiatry, Neurochemical Research Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Rejish K. Thomas
- Grey Nuns Community Hospital and Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Swainson
- Misericordia Community Hospital and Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Atul Khullar
- Grey Nuns Community Hospital and Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Mary-Anne MacKay
- Department of Psychiatry, Neurochemical Research Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Glen B. Baker
- Department of Psychiatry, Neurochemical Research Unit, University of Alberta, 12-105B Clin Sci Bldg, Edmonton, Alberta T6G 2G3, Canada
| | - Serdar M. Dursun
- Department of Psychiatry, Neurochemical Research Unit, University of Alberta, Edmonton, Alberta, Canada
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada
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20
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Beck K, Hindley G, Borgan F, Ginestet C, McCutcheon R, Brugger S, Driesen N, Ranganathan M, D’Souza DC, Taylor M, Krystal JH, Howes OD. Association of Ketamine With Psychiatric Symptoms and Implications for Its Therapeutic Use and for Understanding Schizophrenia: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e204693. [PMID: 32437573 PMCID: PMC7243091 DOI: 10.1001/jamanetworkopen.2020.4693] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/29/2020] [Indexed: 12/16/2022] Open
Abstract
Importance Ketamine hydrochloride is increasingly used to treat depression and other psychiatric disorders but can induce schizophrenia-like or psychotomimetic symptoms. Despite this risk, the consistency and magnitude of symptoms induced by ketamine or what factors are associated with these symptoms remain unknown. Objective To conduct a meta-analysis of the psychopathological outcomes associated with ketamine in healthy volunteers and patients with schizophrenia and the experimental factors associated with these outcomes. Data Sources MEDLINE, Embase, and PsychINFO databases were searched for within-participant, placebo-controlled studies reporting symptoms using the Brief Psychiatric Rating Scale (BPRS) or the Positive and Negative Syndrome Scale (PANSS) in response to an acute ketamine challenge in healthy participants or patients with schizophrenia. Study Selection Of 8464 citations retrieved, 36 studies involving healthy participants were included. Inclusion criteria were studies (1) including healthy participants; (2) reporting symptoms occurring in response to acute administration of subanesthetic doses of ketamine (racemic ketamine, s-ketamine, r-ketamine) intravenously; (3) containing a placebo condition with a within-subject, crossover design; (4) measuring total positive or negative symptoms using BPRS or PANSS; and (5) providing data allowing the estimation of the mean difference and deviation between the ketamine and placebo condition. Data Extraction and Synthesis Two independent investigators extracted study-level data for a random-effects meta-analysis. Total, positive, and negative BPRS and PANSS scores were extracted. Subgroup analyses were conducted examining the effects of blinding status, ketamine preparation, infusion method, and time between ketamine and placebo conditions. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Main Outcomes and Measures Standardized mean differences (SMDs) were used as effect sizes for individual studies. Standardized mean differences between ketamine and placebo conditions were calculated for total, positive, and negative BPRS and PANSS scores. Results The overall sample included 725 healthy volunteers (mean [SD] age, 28.3 [3.6] years; 533 [73.6%] male) exposed to the ketamine and placebo conditions. Racemic ketamine or S-ketamine was associated with a statistically significant increase in transient psychopathology in healthy participants for total (SMD = 1.50 [95% CI, 1.23-1.77]; P < .001), positive (SMD = 1.55 [95% CI, 1.29-1.81]; P < .001), and negative (SMD = 1.16 [95% CI, 0.96-1.35]; P < .001) symptom ratings relative to the placebo condition. The effect size for this association was significantly greater for positive than negative symptoms of psychosis (estimate, 0.36 [95% CI, 0.12-0.61]; P = .004). There was significant inconsistency in outcomes between studies (I2 range, 77%-83%). Bolus followed by constant infusion increased ketamine's association with positive symptoms relative to infusion alone (effect size, 1.63 [95% CI, 1.36-1.90] vs 0.84 [95% CI, 0.35-1.33]; P = .006). Single-day study design increased ketamine's ability to generate total symptoms (effect size, 2.29 [95% CI, 1.69-2.89] vs 1.39 [95% CI, 1.12-1.66]; P = .007), but age and sex did not moderate outcomes. Insufficient studies were available for meta-analysis of studies in schizophrenia. Of these studies, 2 found a statistically significant increase in symptoms with ketamine administration in total and positive symptoms. Only 1 study found an increase in negative symptom severity with ketamine. Conclusions and Relevance This study found that acute ketamine administration was associated with schizophrenia-like or psychotomimetic symptoms with large effect sizes, but there was a greater increase in positive than negative symptoms and when a bolus was used. These findings suggest that bolus doses should be avoided in the therapeutic use of ketamine to minimize the risk of inducing transient positive (psychotic) symptoms.
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Affiliation(s)
- Katherine Beck
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Psychiatric Imaging Group, MRC (Medical Research Council) London Institute of Medical Sciences, Hammersmith Hospital, London, United Kingdom
- South London and Maudsley NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Guy Hindley
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Faith Borgan
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Cedric Ginestet
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Robert McCutcheon
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Psychiatric Imaging Group, MRC (Medical Research Council) London Institute of Medical Sciences, Hammersmith Hospital, London, United Kingdom
- South London and Maudsley NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Stefan Brugger
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Division of Psychiatry, University College London, London, United Kingdom
- Cardiff University Brain Research Imaging Centre, Cardiff, United Kingdom
| | - Naomi Driesen
- Yale University Medical School, Veterans Affairs Connecticut Health Care System, West Haven
| | - Mohini Ranganathan
- Yale University Medical School, Veterans Affairs Connecticut Health Care System, West Haven
- Department of Psychiatry and National Center for Posttraumatic Stress Disorder (PTSD), Veterans Affairs Connecticut Healthcare System, West Haven
| | - Deepak Cyril D’Souza
- Yale University Medical School, Veterans Affairs Connecticut Health Care System, West Haven
- Department of Psychiatry and National Center for Posttraumatic Stress Disorder (PTSD), Veterans Affairs Connecticut Healthcare System, West Haven
| | - Matthew Taylor
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- University Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom
| | - John H. Krystal
- Yale University Medical School, Veterans Affairs Connecticut Health Care System, West Haven
- Department of Veteran Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, Veterans Affairs Connecticut Healthcare System, West Haven
| | - Oliver D. Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Psychiatric Imaging Group, MRC (Medical Research Council) London Institute of Medical Sciences, Hammersmith Hospital, London, United Kingdom
- South London and Maudsley NHS (National Health Service) Foundation Trust, London, United Kingdom
- Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, United Kingdom
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Zhang GF, Liu WX, Qiu LL, Guo J, Wang XM, Sun HL, Yang JJ, Zhou ZQ. Repeated ketamine administration redeems the time lag for citalopram's antidepressant-like effects. Eur Psychiatry 2020; 30:504-10. [DOI: 10.1016/j.eurpsy.2014.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/16/2014] [Accepted: 11/09/2014] [Indexed: 01/31/2023] Open
Abstract
AbstractCurrent available antidepressants exhibit low remission rate with a long response lag time. Growing evidence has demonstrated acute sub-anesthetic dose of ketamine exerts rapid, robust, and lasting antidepressant effects. However, a long term use of ketamine tends to elicit its adverse reactions. The present study aimed to investigate the antidepressant-like effects of intermittent and consecutive administrations of ketamine on chronic unpredictable mild stress (CUMS) rats, and to determine whether ketamine can redeem the time lag for treatment response of classic antidepressants. The behavioral responses were assessed by the sucrose preference test, forced swimming test, and open field test. In the first stage of experiments, all the four treatment regimens of ketamine (10 mg/kg ip, once daily for 3 or 7 consecutive days, or once every 7 or 3 days, in a total 21 days) showed robust antidepressant-like effects, with no significant influence on locomotor activity and stereotype behavior in the CUMS rats. The intermittent administration regimens produced longer antidepressant-like effects than the consecutive administration regimens and the administration every 7 days presented similar antidepressant-like effects with less administration times compared with the administration every 3 days. In the second stage of experiments, the combination of ketamine (10 mg/kg ip, once every 7 days) and citalopram (20 mg/kg po, once daily) for 21 days caused more rapid and sustained antidepressant-like effects than citalopram administered alone. In summary, repeated sub-anesthestic doses of ketamine can redeem the time lag for the antidepressant-like effects of citalopram, suggesting the combination of ketamine and classic antidepressants is a promising regimen for depression with quick onset time and stable and lasting effects.
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Silberbauer LR, Spurny B, Handschuh P, Klöbl M, Bednarik P, Reiter B, Ritter V, Trost P, Konadu ME, Windpassinger M, Stimpfl T, Bogner W, Lanzenberger R, Spies M. Effect of Ketamine on Limbic GABA and Glutamate: A Human In Vivo Multivoxel Magnetic Resonance Spectroscopy Study. Front Psychiatry 2020; 11:549903. [PMID: 33101078 PMCID: PMC7507577 DOI: 10.3389/fpsyt.2020.549903] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Converging evidence suggests that ketamine elicits antidepressant effects via enhanced neuroplasticity precipitated by a surge of glutamate and modulation of GABA. Magnetic resonance spectroscopic imaging (MRSI) illustrates changes to cerebral glutamate and GABA immediately following ketamine administration during dissociation. However, few studies assess subacute changes in the first hours following application, when ketamine's antidepressant effects emerge. Moreover, ketamine metabolites implicated in its antidepressant effects develop during this timeframe. Thus, this study aimed to investigate subacute changes in cerebral Glx (glutamate + glutamine), GABA and their ratio in seven brain regions central to depressive pathophysiology and treatment. METHODS Twenty-five healthy subjects underwent two multivoxel MRS scans using a spiral encoded, MEGA-edited LASER-localized 3D-MRSI sequence, at baseline and 2 h following intravenous administration of racemic ketamine (0.8 mg/kg bodyweight over 50 min). Ketamine, norketamine and dehydronorketamine plasma levels were determined at routine intervals during and after infusion. Automated region-of-interest (ROI)-based quantification of mean metabolite concentration was used to assess changes in GABA+/total creatine (tCr), Glx/tCr, and GABA+/Glx ratios in the thalamus, hippocampus, insula, putamen, rostral anterior cingulate cortex (ACC), caudal ACC, and posterior cingulate cortex. Effects of ketamine on neurotransmitter levels and association with ketamine- and metabolite plasma levels were tested with repeated measures analyses of variance (rmANOVA) and correlation analyses, respectively. RESULTS For GABA+/tCr rmANOVA revealed a measurement by region interaction effect (puncorr < 0.001) and post hoc pairwise comparisons showed a reduction in hippocampal GABA+/tCr after ketamine (pcorr = 0.02). For Glx/tCr and GABA+/Glx neither main effects of measurement nor measurement by region interactions were observed (all puncorr > 0.05). Furthermore, no statistically significant associations between changes in any of the neurotransmitter ratios and plasma levels of ketamine, norketamine, or dehydronorketamine were observed (pcorr > 0.05). CONCLUSION This study provides evidence for decreased hippocampal GABA+/tCr ratio 2 h following ketamine administration. As MRS methodology measures total levels of intra- and extracellular GABA, results might indicate drug induced alterations in GABA turnover. Our study in healthy humans suggests that changes in GABA levels, particularly in the hippocampus, should be further assessed for their relevance to ketamine´s antidepressant effects.
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Affiliation(s)
- Leo R Silberbauer
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Benjamin Spurny
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Patricia Handschuh
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Manfred Klöbl
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Petr Bednarik
- Department of Biomedical Imaging and Image-guided Therapy, High Field MR Centre, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Vera Ritter
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Patricia Trost
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Melisande E Konadu
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Marita Windpassinger
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Stimpfl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Bogner
- Department of Biomedical Imaging and Image-guided Therapy, High Field MR Centre, Medical University of Vienna, Vienna, Austria
| | - Rupert Lanzenberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Marie Spies
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
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Jalali A, Akbari H, Bahreini M. Post-traumatic stress disorder or emergence phenomena? A case of psychomotor agitation after procedural sedation and analgesia. Drug Metab Pers Ther 2019; 34:/j/dmdi.ahead-of-print/dmpt-2019-0024/dmpt-2019-0024.xml. [PMID: 31874096 DOI: 10.1515/dmpt-2019-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 11/28/2019] [Indexed: 06/10/2023]
Abstract
Background Psychomotor agitation can be problematic in an overcrowded emergency department (ED) during uncontrolled procedural sedation. Although emergence phenomena have been studied, various presentations may exist. Case presentation During procedural sedation, a 58-year-old man was sedated with a dissociative dose of ketamine in conjunction with propofol. His shoulder dislocation was reduced successfully but eventually, an exaggerated agitation occurred resembling a post-traumatic stress disorder (PTSD) flashback of past war scenes He was controlled by physical and chemical restraint with an intramuscular injection of 0.1 mg/kg midazolam. After resolution of sedation in rather stable psychiatric conditions, he left the ED with his relatives insisting for discharge against medical advice. Conclusions A PTSD flashback may occur from ketamine sedation in patients with a past history of military experience and can be a manifestation of psychologic adverse effects of ketamine.
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Affiliation(s)
- Alireza Jalali
- Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamideh Akbari
- Imam-Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Bahreini
- Tehran University of Medical Sciences, Tehran, Iran
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran, Phone: +98-915-1243578, Tel/Fax: +982163121432
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Kryst J, Kawalec P, Pilc A. Efficacy and safety of intranasal esketamine for the treatment of major depressive disorder. Expert Opin Pharmacother 2019; 21:9-20. [PMID: 31663783 DOI: 10.1080/14656566.2019.1683161] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: In March 2019, intranasal esketamine was approved by the Food and Drug Administration (FDA) for the treatment of treatment-resistant depression (TRD) in adults. This review presents the results of clinical trials underlying the FDA approval of intranasal esketamine.Areas covered: Esketamine's efficacy and safety in TRD were assessed in 5 phase III studies: three 4-week, placebo-controlled studies, and two long-term trials. One short-term trial showed statistically significant antidepressant effects of esketamine vs placebo, while a long-term withdrawal study showed that esketamine is significantly beneficial in terms of extending time to relapse, compared to placebo. Two other short-term trials did not meet the prespecified statistical tests for showing efficacy, although improvement in depressive symptoms from baseline to the end of week 4 favors esketamine over placebo.Expert opinion: Intranasal esketamine is a new treatment option for people with TRD. The main benefit of esketamine is rapid onset of antidepressant activity, but the effects of prolonged treatment are still preliminary. The main concerns relate to the safety aspects of prolonged esketamine therapy, when considering its abuse potential. While data for esketamine use over a long period of time is lacking, its use should be carefully monitored.
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Affiliation(s)
- Joanna Kryst
- Laboratory of Pharmacology and Brain Biostructure, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Paweł Kawalec
- Department of Neurobiology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland.,Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Kraków, Poland
| | - Andrzej Pilc
- Department of Neurobiology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland.,Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Kraków, Poland
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25
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Nugent AC, Ballard ED, Gould TD, Park LT, Moaddel R, Brutsche NE, Zarate CA. Ketamine has distinct electrophysiological and behavioral effects in depressed and healthy subjects. Mol Psychiatry 2019; 24:1040-1052. [PMID: 29487402 PMCID: PMC6111001 DOI: 10.1038/s41380-018-0028-2] [Citation(s) in RCA: 150] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 07/13/2017] [Accepted: 11/03/2017] [Indexed: 01/19/2023]
Abstract
Ketamine's mechanism of action was assessed using gamma power from magnetoencephalography (MEG) as a proxy measure for homeostatic balance in 35 unmedicated subjects with major depressive disorder (MDD) and 25 healthy controls enrolled in a double-blind, placebo-controlled, randomized cross-over trial of 0.5 mg/kg ketamine. MDD subjects showed significant improvements in depressive symptoms, and healthy control subjects exhibited modest but significant increases in depressive symptoms for up to 1 day after ketamine administration. Both groups showed increased resting gamma power following ketamine. In MDD subjects, gamma power was not associated with the magnitude of the antidepressant effect. However, baseline gamma power was found to moderate the relationship between post-ketamine gamma power and antidepressant response; specifically, higher post-ketamine gamma power was associated with better response in MDD subjects with lower baseline gamma, with an inverted relationship in MDD subjects with higher baseline gamma. This relationship was observed in multiple regions involved in networks hypothesized to be involved in the pathophysiology of MDD. This finding suggests biological subtypes based on the direction of homeostatic dysregulation and has important implications for inferring ketamine's mechanism of action from studies of healthy controls alone.
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Affiliation(s)
- Allison C Nugent
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Elizabeth D Ballard
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lawrence T Park
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Ruin Moaddel
- Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
| | - Nancy E Brutsche
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Maltbie EA, Gopinath KS, Howell LL. Effects of ketamine treatment on cocaine-induced reinstatement and disruption of functional connectivity in unanesthetized rhesus monkeys. Psychopharmacology (Berl) 2019; 236:2105-2118. [PMID: 30879118 DOI: 10.1007/s00213-019-05204-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/18/2019] [Indexed: 01/28/2023]
Abstract
RATIONALE Substance use disorders are characterized by a loss of executive control over reward-based decision-making, and disruption of fronto-striatal connectivity has been implicated in this process. Sub-anesthetic ketamine has recently been shown to bolster fronto-striatal connectivity in drug-naïve subjects. OBJECTIVES The influence of ketamine treatment was examined on the disruptive effects of cocaine on functional connectivity (FC) and on cocaine-seeking behavior in female rhesus monkeys. METHODS Three female rhesus were trained for unanesthetized MRI scanning. Each received three drug-naïve/abstinent pharmacological MRI scans with acute injections of saline, cocaine (0.3 mg/kg i.v.), and cocaine (0.3 mg/kg i.v.) 48-h after a ketamine treatment (low dose = 0.345 mg/kg bolus + 0.256 mg/kg/h for 1 h; i.v.), and a fourth scan with saline injection following 2 months of daily cocaine self-administration. A separate cohort of five rhesus (4 female), all with extensive histories of cocaine exposure, underwent reinstatement testing 48 h after ketamine (or vehicle) treatment. Two sub-anesthetic doses were tested: low dose and high dose = 0.69 mg/kg + 0.512 mg/kg/h for 1 h. RESULTS Ketamine treatment attenuated the effects of cocaine on both global and fronto-striatal FC in drug-naïve/abstinent subjects. Two months of daily cocaine self-administration led to prolonged disruption of both global and fronto-striatal FC. Cocaine-seeking behavior during reinstatement was reduced following ketamine treatment at the low dose, but not high dose. CONCLUSION These findings illustrate the disruptive effects of cocaine on functional connectivity and provide evidence for the potential efficacy of ketamine as a treatment for stimulant use disorder.
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Affiliation(s)
- Eric A Maltbie
- Yerkes National Primate Research Center, Emory University, 954 Gatewood Rd NE, Atlanta, GA, 30329, USA
| | - Kaundinya S Gopinath
- Yerkes National Primate Research Center, Emory University, 954 Gatewood Rd NE, Atlanta, GA, 30329, USA.,Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, 30329, USA
| | - Leonard L Howell
- Yerkes National Primate Research Center, Emory University, 954 Gatewood Rd NE, Atlanta, GA, 30329, USA. .,Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, 30329, USA.
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27
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Schoepfer KJ, Strong CE, Saland SK, Wright KN, Kabbaj M. Sex- and dose-dependent abuse liability of repeated subanesthetic ketamine in rats. Physiol Behav 2019; 203:60-69. [PMID: 29055748 PMCID: PMC5906213 DOI: 10.1016/j.physbeh.2017.10.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/13/2017] [Accepted: 10/17/2017] [Indexed: 12/21/2022]
Abstract
RATIONALE Subanesthetic ketamine (KET) elicits rapid, robust, but transient antidepressant effects. KET's antidepressant actions can be augmented and maintained for a longer duration when repeatedly delivered. However, KET is recreationally abused, raising long-term treatment safety concerns. Women are more likely than men to seek treatment for depression, escalate from casual to compulsive drug use, and are more sensitive to antidepressants. Similarly, female rodents are more sensitive than males to KET's rapid antidepressant-like behavioral effects; dose-response thresholds in these assays equal 2.5 and 5.0mg/kg (i.p.), respectively. This suggests the utility of preclinical rodent models in optimizing sex-differential KET therapy protocols and minimizing adverse drug reactions. OBJECTIVES Here, we assessed behavioral and biochemical correlates of abuse liability following six serial KET treatments on alternating days at three subanesthetic, antidepressant-like doses (2.5, 5.0, or 10mg/kg, i.p.) in adult male and female rats. A potential role for ΔFosB-mediated transcription in the nucleus accumbens is outlined in the context of KET-mediated locomotor sensitization. RESULTS Antidepressant-like threshold doses (2.5, 5.0mg/kg KET) failed to evoke a conditioned place preference in all animals, but only males positively responded to a higher dose (10mg/kg). Behavioral sensitization to 5.0 or 10mg/kg KET's locomotor-activating effects was established in both sexes, and females' sensitized response to 5.0mg/kg was greater than males'. KET-induced hyperlocomotion positively correlated with ΔFosB protein expression in the nucleus accumbens. rAAV-ΔJunD inhibition of ΔFosB-mediated transcription in the accumbens failed to block locomotor sensitization to 10mg/kg KET. CONCLUSIONS These data suggest that in rats, six alternating-day treatments with 2.5mg/kg KET do not induce apparent behavioral signatures of abuse liability despite accumulation of ΔFosB protein in the accumbens. Additionally, females are more sensitive than males to KET's locomotor-stimulant properties, both acutely and after repeated treatments. More studies are needed to determine brain regions and neural mechanisms responsible for KET-induced behavioral adaptations and to extrapolate these data to inform sex-dependent strategies for long-term KET therapy protocols for depression.
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Affiliation(s)
- Kristin J Schoepfer
- Program in Neuroscience, Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Caroline E Strong
- Program in Neuroscience, Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Samantha K Saland
- Program in Neuroscience, Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Katherine N Wright
- Program in Neuroscience, Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Mohamed Kabbaj
- Program in Neuroscience, Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA; College of Medicine, Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA.
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28
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Zheng W, Zhou YL, Liu WJ, Wang CY, Zhan YN, Li HQ, Chen LJ, Li MD, Ning YP. Neurocognitive performance and repeated-dose intravenous ketamine in major depressive disorder. J Affect Disord 2019; 246:241-247. [PMID: 30590286 DOI: 10.1016/j.jad.2018.12.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/21/2018] [Accepted: 12/08/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Ketamine has demonstrated a rapid antidepressant and antisuicidal effect in patients with major depressive disorder (MDD), but the neurocognitive effects of ketamine are relatively unknown. This study aims to examine the neurocognitive effects of six ketamine infusions and the association of baseline neurocognitive function and the change in severity of depressive symptoms after the last infusions. METHODS Sixty-four patients with MDD completed six intravenous infusions of ketamine (0.5 mg/kg over 40 min) administered over a 12-day period (Monday-Wednesday-Friday), and were followed by a 2-week observational period. Four domains of neurocognitive function (including speed of processing, working memory, visual learning and verbal learning) were assessed using the MATRICS Consensus Cognitive Battery (MCCB) at 0, 13 and 26 days. RESULTS In linear mixed model, significant improvements were found in terms of speed of processing (F = 20.7, p < 0.001) and verbal learning (F = 11.1, p < 0.001). The Sobel test showed the improvement of speed of processing (Sobel test = 2.8, p < 0.001) and verbal learning (Sobel test = 3.6, p < 0.001) were significantly mediated by change in depressive symptoms. Other two neurocognitive domains showed no significant changes over time. Correlation analysis showed no significant association of change in depressive symptoms with neurocognitive function at baseline. CONCLUSION Our findings suggest that six ketamine infusions were associated with the improvement of speed of processing and verbal learning, which were partly accounted for by improvement in the severity of depression symptoms over time.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yan-Ling Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Wei-Jian Liu
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Cheng-Yu Wang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yan-Ni Zhan
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Han-Qiu Li
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Li-Jian Chen
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Ming-D Li
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China; State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
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Efficacy and Safety of a Rapid Intravenous Injection of Ketamine 0.5 mg/kg in Treatment-Resistant Major Depression: An Open 4-Week Longitudinal Study. J Clin Psychopharmacol 2018; 38:590-597. [PMID: 30346333 DOI: 10.1097/jcp.0000000000000960] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ketamine has been documented for its rapid antidepressant effects. However, optimal dose and delivery route have not yet been thoroughly investigated. The objectives of this study were to document the safety and test the antidepressant and antisuicidal effects of a single rapid 1-minute injection of ketamine 0.5 mg/kg in treatment-resistant depression (TRD). METHODS Ten patients with TRD were included in an open, noncontrolled 4-week study and received a rapid intravenous dose of ketamine 0.5 mg/kg. Main outcome measure was the Montgomery-Åsberg Depression Rating Scale and suicidality was assessed using the Scale for Suicide Ideation. RESULTS Rapid injection of ketamine elicited transient increase of blood pressure and altered states of consciousness in all patients and mild psychotomimetic effects in 4 patients, which all resolved without any intervention. Decrease of depression severity was observed from 40-minute postinjection until day 15. Eight patients became responders within 1 day and all were nonresponders after 4 weeks. The decrease of suicidal ideation was significant until day 7. Analysis indicated that higher severity of depression and anxiety at baseline predicted a larger Montgomery-Åsberg Depression Rating Scale decrease after 4 weeks. CONCLUSIONS This study suggests that in well-controlled medical settings with adequate monitoring, a single rapid 1-minute injection of ketamine 0.5 mg/kg can be well tolerated and is efficacious in rapidly reducing depression symptoms and suicidal thoughts in outpatients with TRD. These findings are relevant to the practice of general clinical psychiatry and emergency departments were ketamine can have a place in acute management of TRD. Larger studies are necessary to confirm these results.
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Shen M, Lv D, Liu X, Li S, Chen Y, Zhang Y, Wang Z, Wang C. Essential roles of neuropeptide VGF regulated TrkB/mTOR/BICC1 signaling and phosphorylation of AMPA receptor subunit GluA1 in the rapid antidepressant-like actions of ketamine in mice. Brain Res Bull 2018; 143:58-65. [PMID: 30316917 DOI: 10.1016/j.brainresbull.2018.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/27/2018] [Accepted: 10/09/2018] [Indexed: 12/12/2022]
Abstract
Previous studies have suggested that rapid reductions in depression-like behaviors are observed in response to sub-anesthetic-doses of ketamine, an N-methyl-d-aspartate receptor (NMDAR) antagonist. Neuropeptide VGF (non-acronymic) is a critical effector of depression-like behaviors and is thought to be involved in the antidepressant actions of ketamine that have been demonstrated. However, the mechanism underlying the involvement of VGF in the anti-depressant action of ketamine remains unclear. We found that single dose ketamine treatment reversed CSDS-induced depression-like behaviors and decrease of VGF in the PFC of mice. To investigate the involvement of VGF in the antidepressant-like effects of ketamine, a lentivirus vector for VGF was constructed to knockdown the expression of VGF in the prefrontal cortex (PFC) of mice. The biochemical and behavioral effects of this VGF knockdown were examined, using the open field, forced swim, and sucrose preference tests. Our results show that knockdown of VGF increased the immobility time and decreased the sucrose preference in mice. These effects were not improved by ketamine administration. In addition, we found that knockdown of VGF significantly decreased the expression of phosphorylation of tropomyosin receptor kinase B (TrkB), mammalian target of rapamycin (mTOR), and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor subunit GluA1 Ser845 and increased the expression of bicaudal C homolog 1 (BICC1) in the mouse PFC, and blocked the regulation of TrkB/mTOR/BICC1 signaling and GluA1 phosphorylation by ketamine. Our results indicate that the rapid onset antidepressant-like actions of ketamine require VGF to regulate TrkB/mTOR/BICC1 signaling and AMPA receptor GluA1 phosphorylation.
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Affiliation(s)
- Mengxin Shen
- Ningbo Key Laboratory of Behavioral Neuroscience, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Zhejiang Provincial Key Laboratory of Pathophysiology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Department of Physiology and Pharmacology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China
| | - Dan Lv
- Ningbo Key Laboratory of Behavioral Neuroscience, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Zhejiang Provincial Key Laboratory of Pathophysiology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Department of Physiology and Pharmacology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China
| | - Xu Liu
- Department of Pharmacy, General Hospital of Chinese People's Armed Police Forces, Beijing 100039, PR China
| | - Shuting Li
- Ningbo Key Laboratory of Behavioral Neuroscience, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Zhejiang Provincial Key Laboratory of Pathophysiology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Department of Physiology and Pharmacology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China
| | - Yaping Chen
- Ningbo Key Laboratory of Behavioral Neuroscience, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Zhejiang Provincial Key Laboratory of Pathophysiology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Department of Physiology and Pharmacology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China
| | - Yanhua Zhang
- Ningbo Key Laboratory of Behavioral Neuroscience, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Zhejiang Provincial Key Laboratory of Pathophysiology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Department of Physiology and Pharmacology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China
| | - Zhen Wang
- CAS Key Laboratory for Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China.
| | - Chuang Wang
- Ningbo Key Laboratory of Behavioral Neuroscience, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Zhejiang Provincial Key Laboratory of Pathophysiology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China; Department of Physiology and Pharmacology, Ningbo University School of Medicine, 818 Fenghua Road, Ningbo, Zhejiang 315211, PR China.
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31
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D’Souza DC, Carson RE, Driesen N, Johannesen J, Ranganathan M, Krystal JH. Dose-Related Target Occupancy and Effects on Circuitry, Behavior, and Neuroplasticity of the Glycine Transporter-1 Inhibitor PF-03463275 in Healthy and Schizophrenia Subjects. Biol Psychiatry 2018; 84:413-421. [PMID: 29499855 PMCID: PMC6068006 DOI: 10.1016/j.biopsych.2017.12.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/14/2017] [Accepted: 12/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Glycine transporter-1 (GlyT1) inhibitors may ameliorate cognitive impairments associated with schizophrenia. The dose-related occupancy and target engagement of the GlyT1 inhibitor PF-03463275 were studied to inform optimal dose selection for a clinical trial for cognitive impairments associated with schizophrenia. METHODS In substudy 1, the effects of PF-03463275 (10, 20, and 40 mg twice a day) on occupancy of GlyT1 were tested using positron emission tomography and 18F-MK-6577, and visual long-term potentiation (LTP) in schizophrenia patients (SZs) and healthy control subjects. Furthermore, the capacity of PF-03463275 to attenuate ketamine-induced disruption of working memory-related activation of a "working memory" circuit was tested only in healthy control subjects using functional magnetic resonance imaging. Subsequently, the effects of PF-03463275 (60 mg twice a day) on occupancy of GlyT1 and long-term potentiation were examined only in SZs (substudy 2). RESULTS PF-03463275 at 10, 20, 40, and 60 mg twice a day produced ∼44%, 61%, 76%, and 83% GlyT1 occupancy, respectively, in SZs with higher ligand binding to GlyT1 in subcortical versus cortical regions. PF-03463275 did not attenuate any ketamine-induced effects but did improve working memory accuracy in healthy control subjects. PF-03463275 increased long-term potentiation only in SZs with peak effects at 40 mg twice a day (∼75% GlyT1 occupancy) and with a profile suggestive of an inverted U dose response. PF-03463275 was well-tolerated. CONCLUSIONS The dose-related GlyT1 occupancy of PF-03463275 is linear. While PF-03463275 did not show evidence of facilitating N-methyl-D-aspartate receptor function in the ketamine assay, it enhanced neuroplasticity in SZs. These findings provide support for a clinical trial to test the ability of PF-03463275 to enhance cognitive remediation toward addressing cognitive impairments associated with schizophrenia.
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Affiliation(s)
- Deepak Cyril D’Souza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Mental Health Service Line, VA Connecticut Healthcare System, West Haven, CT, USA,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
| | - Richard E. Carson
- Yale PET Center, New Haven, CT, USA,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Naomi Driesen
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Mental Health Service Line, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Jason Johannesen
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Mental Health Service Line, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Mohini Ranganathan
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Mental Health Service Line, VA Connecticut Healthcare System, West Haven, CT, USA,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
| | - John H. Krystal
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Mental Health Service Line, VA Connecticut Healthcare System, West Haven, CT, USA,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA,Yale-New Haven Hospital, New Haven, CT,Department of Neurobiology, Yale University School of Medicine, New Haven, CT, USA
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Cullen KR, Amatya P, Roback MG, Albott CS, Westlund Schreiner M, Ren Y, Eberly LE, Carstedt P, Samikoglu A, Gunlicks-Stoessel M, Reigstad K, Horek N, Tye S, Lim KO, Klimes-Dougan B. Intravenous Ketamine for Adolescents with Treatment-Resistant Depression: An Open-Label Study. J Child Adolesc Psychopharmacol 2018; 28:437-444. [PMID: 30004254 PMCID: PMC6154760 DOI: 10.1089/cap.2018.0030] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Novel interventions for treatment-resistant depression (TRD) in adolescents are urgently needed. Ketamine has been studied in adults with TRD, but little information is available for adolescents. This study investigated efficacy and tolerability of intravenous ketamine in adolescents with TRD, and explored clinical response predictors. METHODS Adolescents, 12-18 years of age, with TRD (failure to respond to two previous antidepressant trials) were administered six ketamine (0.5 mg/kg) infusions over 2 weeks. Clinical response was defined as a 50% decrease in Children's Depression Rating Scale-Revised (CDRS-R); remission was CDRS-R score ≤28. Tolerability assessment included monitoring vital signs and dissociative symptoms using the Clinician-Administered Dissociative States Scale (CADSS). RESULTS Thirteen participants (mean age 16.9 years, range 14.5-18.8 years, eight biologically male) completed the protocol. Average decrease in CDRS-R was 42.5% (p = 0.0004). Five (38%) adolescents met criteria for clinical response. Three responders showed sustained remission at 6-week follow-up; relapse occurred within 2 weeks for the other two responders. Ketamine infusions were generally well tolerated; dissociative symptoms and hemodynamic symptoms were transient. Higher dose was a significant predictor of treatment response. CONCLUSIONS These results demonstrate the potential role for ketamine in treating adolescents with TRD. Limitations include the open-label design and small sample; future research addressing these issues are needed to confirm these results. Additionally, evidence suggested a dose-response relationship; future studies are needed to optimize dose. Finally, questions remain regarding the long-term safety of ketamine as a depression treatment; more information is needed before broader clinical use.
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Affiliation(s)
- Kathryn R. Cullen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota.,Address correspondence to: Kathryn R. Cullen, MD, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Medical School, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454
| | - Palistha Amatya
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mark G. Roback
- Departments of Pediatrics and Emergency Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Christina Sophia Albott
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Yanan Ren
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lynn E. Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Patricia Carstedt
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Ali Samikoglu
- Hennepin County Medical Center, Minneapolis, Minnesota
| | - Meredith Gunlicks-Stoessel
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kristina Reigstad
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Nathan Horek
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Kelvin O. Lim
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Bonnie Klimes-Dougan
- Psychology Department, College of Liberal Arts, University of Minnesota, Minneapolis, Minnesota
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Zhou Y, Peng Y, Fang J, Sun W, Zhang G, Zhen L, Wang G, Han R. Effect of low-dose ketamine on PerioperAtive depreSsive Symptoms in patients undergoing Intracranial tumOr resectioN (PASSION): study protocol for a randomized controlled trial. Trials 2018; 19:463. [PMID: 30157913 PMCID: PMC6114290 DOI: 10.1186/s13063-018-2831-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perioperative depressive symptoms (PDS) are common mental comorbidities that influence clinical outcomes and prognosis. However, there is no rapid-acting treatment to address these symptoms during a limited hospital stay. METHODS/DESIGN This is a single-center, randomized, placebo-controlled, and double-blind trial. Randomization will be applied and stratified by the severity of PDS (moderate versus severe). Eighty patients who are scheduled for elective supratentorial brain tumor resection with PDS will be randomly allocated to the ketamine or placebo group with a ratio of 1 to 1. Patients in the ketamine group will be administered low-dose ketamine (0.5 mg/kg) intravenously for 40 min while the dural mater is being cut into, whereas patients in the placebo group will receive the same volume of normal saline at the same infusion rate at the same time points. The primary endpoint is the rate of PDS response at 3 days after surgery. Secondary outcomes include efficacy parameters such as the rate of PDS remission and safety outcomes such as the incidence of postoperative delirium, quality of recovery, and psychiatric side effects. DISCUSSION This study aims to determine whether ketamine could improve the depressive symptoms of perioperative patients undergoing supratentorial brain tumor resection. It will also examine the safety of administering ketamine as an intraoperative anti-depressant. TRIAL REGISTRATION ClinicalTrials.gov, NCT03086148 . Registered on 22 March 2017.
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Affiliation(s)
- Yang Zhou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng District, Beijing, 100050, People's Republic of China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng District, Beijing, 100050, People's Republic of China
| | - Jinghan Fang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng District, Beijing, 100050, People's Republic of China
| | - Wanchen Sun
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng District, Beijing, 100050, People's Republic of China
| | - Guofu Zhang
- China and Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Psychiatry, Capital Medical University, China and Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Long Zhen
- China and Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Psychiatry, Capital Medical University, China and Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Gang Wang
- China and Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Psychiatry, Capital Medical University, China and Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng District, Beijing, 100050, People's Republic of China.
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Morrison RL, Fedgchin M, Singh J, Van Gerven J, Zuiker R, Lim KS, van der Ark P, Wajs E, Xi L, Zannikos P, Drevets WC. Effect of intranasal esketamine on cognitive functioning in healthy participants: a randomized, double-blind, placebo-controlled study. Psychopharmacology (Berl) 2018; 235:1107-1119. [PMID: 29392371 PMCID: PMC5869899 DOI: 10.1007/s00213-018-4828-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 01/03/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The effect of intranasal esketamine on cognitive functioning in healthy participants is assessed in this study. METHODS Twenty-four participants (19-49 years) were randomized to one of two treatment sequences in which either esketamine 84 mg or placebo was intranasally administered in a double-blind, two-period crossover design. Primary measures included five tests of Cogstate® computerized test battery assessed at 1 h predose and 40 min, 2, 4, and 6 h postdose. Secondary measures included the Mental Effort Scale, Karolinska Sleepiness Scale (KSS), and safety. RESULTS Esketamine was associated with significant cognitive performance impairment at 40 min postdose for all five Cogstate® tests (Detection p = 0.0011, Identification p = 0.0006, One-Card Learning p = 0.0040, One Back p = 0.0017, and Groton Maze Learning Test p < 0.0001) versus placebo. In contrast, performance on these tests did not differ significantly between esketamine and placebo at 2, 4, or 6 h postdose. Secondary outcomes indicated a significant, transient increase from baseline under esketamine versus placebo at 40 min postdose on the Mental Effort Scale and at 40 min and 2 h postdose on KSS (p < 0.0001 for both); however, no significant difference was observed on these outcomes between esketamine and placebo at later timepoints. The most commonly reported adverse events were dizziness (67%), nausea (37.5%), disturbance in attention (29.2%), and fatigue (29.2%); the majority were considered mild in severity. CONCLUSIONS Esketamine was associated with cognitive performance decline, and greater effort was required to complete the test battery versus placebo at 40 min postdose, which returned to placebo-comparable levels by 2 h postdose. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02094378.
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Affiliation(s)
- Randall L Morrison
- Neuroscience Integrative Solutions, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.
- Janssen Research & Development, LLC, Titusville, NJ, USA.
| | | | - Jaskaran Singh
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | | | - Rob Zuiker
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Kyoung Soo Lim
- Centre for Human Drug Research, Leiden, The Netherlands
- CHA University School of Medicine and CHA Budang Medical Center, Seongnam, South Korea
| | - Peter van der Ark
- Janssen Research & Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Ewa Wajs
- Janssen Research & Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Liwen Xi
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Peter Zannikos
- Janssen Research & Development, LLC, Titusville, NJ, USA
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Dakwar E, Nunes EV, Hart CL, Hu MC, Foltin RW, Levin FR. A sub-set of psychoactive effects may be critical to the behavioral impact of ketamine on cocaine use disorder: Results from a randomized, controlled laboratory study. Neuropharmacology 2018; 142:270-276. [PMID: 29309770 DOI: 10.1016/j.neuropharm.2018.01.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/27/2017] [Accepted: 01/04/2018] [Indexed: 01/01/2023]
Abstract
Efforts to translate sub-anesthetic ketamine infusions into widespread clinical use have centered around developing medications with comparable neurobiological activity, but with attenuated psychoactive effects so as to minimize the risk of behavioral toxicity and abuse liability. Converging lines of research, however, suggest that some of the psychoactive effects of sub-anesthetic ketamine may have therapeutic potential. Here, we assess whether a subset of these effects - the so-called mystical-type experience - mediates the effect of ketamine on craving and cocaine use in cocaine dependent research volunteers. We found that ketamine leads to significantly greater acute mystical-type effects (by Hood Mysticism Scale: HMS), dissociation (by Clinician Administered Dissociative States Scale: CADSS), and near-death experience phenomena (by the Near-Death Experience Scale: NDES), relative to the active control midazolam. HMS score, but not the CADSS or NDES score, was found to mediate the effect of ketamine on global improvement (decreased cocaine use and craving) over the post-infusion period. This is the first controlled study to show that mystical-type phenomena, long considered to have therapeutic potential, may work to impact decision-making and behavior in a sustained manner. These data suggest that an important direction for medication development is the identification of ketamine-like pharmacotherapy that is selectively psychoactive (as opposed to free of experiential effects entirely), so that mystical-type perspectival shifts are more reliably produced and factors lending to abuse or behavioral impairment are minimized. Future research can further clarify the relationship between medication-occasioned mystical-type effects and clinical benefit for different disorders. This article is part of the Special Issue entitled 'Psychedelics: New Doors, Altered Perceptions'.
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Affiliation(s)
- E Dakwar
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, USA.
| | - E V Nunes
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, USA
| | - C L Hart
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, USA; Department of Psychology, Columbia University, USA
| | - M C Hu
- Department of Psychology, Columbia University, USA
| | - R W Foltin
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, USA
| | - F R Levin
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, USA
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Abstract
Low-dose infusion of ketamine may have rapid antisuicide properties. Such a treatment may therefore be useful in the general hospital to prevent suicide in an environment that cannot be made safe enough. We report on the use of ketamine as an efficient, well-tolerated treatment for persistent suicidal ideation in a patient hospitalized in a general hospital after a severe suicide attempt. Based on data in the literature, we suggest that the benefit-risk ratio for ketamine use in such a context is highly favorable.
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37
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Zuckerman H, Pan Z, Park C, Brietzke E, Musial N, Shariq AS, Iacobucci M, Yim SJ, Lui LMW, Rong C, McIntyre RS. Recognition and Treatment of Cognitive Dysfunction in Major Depressive Disorder. Front Psychiatry 2018; 9:655. [PMID: 30564155 PMCID: PMC6288549 DOI: 10.3389/fpsyt.2018.00655] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022] Open
Abstract
Major Depressive Disorder (MDD) is a prevalent, chronic, disabling, and multidimensional mental disorder. Cognitive dysfunction represents a core diagnostic and symptomatic criterion of MDD, and is a principal determinant of functional non-recovery. Cognitive impairment has been observed to persist despite remission of mood symptoms, suggesting dissociability of mood and cognitive symptoms in MDD. Recurrent impairments in several domains including, but not limited to, executive function, learning and memory, processing speed, and attention and concentration, are associated with poor psychosocial and occupational outcomes. Attempts to restore premorbid functioning in individuals with MDD requires regular screenings and assessment of objective and subjective measures of cognition by clinicians. Easily accessible and cost-effective tools such as the THINC-integrated tool (THINC-it) are suitable for use in a busy clinical environment and appear to be promising for routine usage in clinical settings. However, antidepressant treatments targeting specific cognitive domains in MDD have been insufficiently studied. While select antidepressants, e.g., vortioxetine, have been demonstrated to have direct and independent pro-cognitive effects in adults with MDD, research on additional agents remains nascent. A comprehensive clinical approach to cognitive impairments in MDD is required. The current narrative review aims to delineate the importance and relevance of cognitive dysfunction as a symptomatic target for prevention and treatment in the phenomenology of MDD.
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Affiliation(s)
- Hannah Zuckerman
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Zihang Pan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Caroline Park
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Elisa Brietzke
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Natalie Musial
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Aisha S Shariq
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Michelle Iacobucci
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Samantha J Yim
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Carola Rong
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain and Cognition Discovery Foundation, Toronto, ON, Canada
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Attenuation of ketamine-induced impairment in verbal learning and memory in healthy volunteers by the AMPA receptor potentiator PF-04958242. Mol Psychiatry 2017; 22:1633-1640. [PMID: 28242871 DOI: 10.1038/mp.2017.6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/22/2016] [Accepted: 12/19/2016] [Indexed: 01/03/2023]
Abstract
There is a need to develop treatments for cognitive impairment associated with schizophrenia (CIAS). The significant role played by N-methyl-d-aspartate receptors (NMDARs) in both the pathophysiology of schizophrenia and in neuronal plasticity suggests that facilitation of NMDAR function might ameliorate CIAS. One strategy to correct NMDAR hypofunction is to stimulate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPARs) as AMPAR and NMDAR functioning are coupled and interdependent. In rats and nonhuman primates (NHP), AMPAR potentiators reduce spatial working memory deficits caused by the nonselective NMDAR antagonist ketamine. The current study assessed whether the AMPAR potentiator PF-04958242 would attenuate ketamine-induced deficits in verbal learning and memory in humans. Healthy male subjects (n=29) participated in two randomized treatment periods of daily placebo or PF-04958242 for 5 days separated by a washout period. On day 5 of each treatment period, subjects underwent a ketamine infusion for 75 min during which the effects of PF-04958242/placebo were assessed on ketamine-induced: (1) impairments in verbal learning and recall measured by the Hopkins Verbal Learning Test; (2) impairments in working memory on a CogState battery; and (3) psychotomimetic effects measured by the Positive and Negative Syndrome Scale and Clinician-Administered Dissociative Symptoms Scale. PF-04958242 significantly reduced ketamine-induced impairments in immediate recall and the 2-Back and spatial working memory tasks (CogState Battery), without significantly attenuating ketamine-induced psychotomimetic effects. There were no pharmacokinetic interactions between PF-04958242 and ketamine. Furthermore, PF-04958242 was well tolerated. 'High-impact' AMPAR potentiators like PF-04958242 may have a role in the treatment of the cognitive symptoms, but not the positive or negative symptoms, associated with schizophrenia. The excellent concordance between the preclinical (rat, NHP) and human studies with PF-04958242, and in silico modeling of AMPAR-NMDAR interactions in the hippocampus, highlights the translational value of this study.
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Spies M, James GM, Berroterán-Infante N, Ibeschitz H, Kranz GS, Unterholzner J, Godbersen M, Gryglewski G, Hienert M, Jungwirth J, Pichler V, Reiter B, Silberbauer L, Winkler D, Mitterhauser M, Stimpfl T, Hacker M, Kasper S, Lanzenberger R. Assessment of Ketamine Binding of the Serotonin Transporter in Humans with Positron Emission Tomography. Int J Neuropsychopharmacol 2017; 21:145-153. [PMID: 29045739 PMCID: PMC5793827 DOI: 10.1093/ijnp/pyx085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/15/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Comprehensive description of ketamine's molecular binding profile becomes increasingly pressing as use in real-life patient cohorts widens. Animal studies attribute a significant role in the substance's antidepressant effects to the serotonergic system. The serotonin transporter is a highly relevant target in this context, because it is central to depressive pathophysiology and treatment. This is, to our knowledge, the first study investigating ketamine's serotonin transporter binding in vivo in humans. METHODS Twelve healthy subjects were assessed twice using [11C]DASB positron emission tomography. A total of 0.50 mg/kg bodyweight ketamine was administered once i.v. prior to the second positron emission tomography scan. Ketamine plasma levels were determined during positron emission tomography. Serotonin transporter nondisplaceable binding potential was computed using a reference region model, and occupancy was calculated for 4 serotonin transporter-rich regions (caudate, putamen, thalamus, midbrain) and a whole-brain region of interest. RESULTS After administration of the routine antidepressant dose, ketamine showed <10% occupancy of the serotonin transporter, which is within the test-retest variability of [11C]DASB. A positive correlation between ketamine plasma levels and occupancy was shown. CONCLUSIONS Measurable occupancy of the serotonin transporter was not detectable after administration of an antidepressant dose of ketamine. This might suggest that ketamine binding of the serotonin transporter is unlikely to be a primary antidepressant mechanism at routine antidepressant doses, as substances that facilitate antidepressant effects via serotonin transporter binding (e.g., selective serotonin reuptake inhibitors) show 70% to 80% occupancy. Administration of high-dose ketamine is widening. Based on the positive relationship we find between ketamine plasma levels and occupancy, there is a need for investigation of ketamine's serotonin transporter binding at higher doses.
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Affiliation(s)
- Marie Spies
- Department of Psychiatry and Psychotherapy, Vienna, Austria
| | | | - Neydher Berroterán-Infante
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Vienna, Austria
| | - Harald Ibeschitz
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Vienna, Austria
| | - Georg S Kranz
- Department of Psychiatry and Psychotherapy, Vienna, Austria
| | | | | | | | - Marius Hienert
- Department of Psychiatry and Psychotherapy, Vienna, Austria
| | | | - Verena Pichler
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Vienna, Austria
| | | | | | | | - Markus Mitterhauser
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Vienna, Austria,Medical University of Vienna, Vienna, Austria,Ludwig Boltzmann Institute for Applied Diagnostics, Vienna, Austria
| | | | - Marcus Hacker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Vienna, Austria
| | | | - Rupert Lanzenberger
- Department of Psychiatry and Psychotherapy, Vienna, Austria,Correspondence: Rupert Lanzenberger, MD, PD, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Wien ()
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Abstract
PURPOSE The aim of the study was to assess the effectiveness, tolerability, and safety of oral ketamine as an antidepressant treatment in adults with treatment-resistant depression. METHODS We reviewed retrospective data on 22 patients with treatment-resistant depression, who failed at least 3 adequate antidepressant treatment trials and 1 adequate trial of repetitive transcranial magnetic stimulation; subsequently, they received open-label treatment with oral ketamine, commenced at a dose of 50 mg every 3 days, titrated up by 25 mg every 3 days, according to response and tolerability. The primary outcome measure was the Beck Depression Inventory II, which was used to rate subjective mood improvement at baseline and then at each follow-up visit. Data about adverse effects related to ketamine and a self-harm risk assessment were also obtained. FINDINGS Over the course of treatment, 18% of the patients showed greater than 50% reduction in the Beck Depression Inventory II scores, 14% reported partial improvement in mood symptoms, while 45% had no response to ketamine and 23% showed a mild worsening in their depressive symptoms. The most frequent adverse effects were acute dissociation, dizziness, blurred vision, numbness and sedation. Neither serious adverse effects, nor any cases of abuse or dependence were observed. CONCLUSIONS Although this case series found oral ketamine to be safe and well tolerated, the findings also showed rather modest effectiveness of oral ketamine in treatment-resistant depression, with only approximately 30% reporting some benefit and approximately 70% reporting no change or worsening of mood. However, bearing in mind the limitations of this small, open-label case series, further exploration of the effectiveness of oral ketamine is warranted.
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Singh I, Morgan C, Curran V, Nutt D, Schlag A, McShane R. Ketamine treatment for depression: opportunities for clinical innovation and ethical foresight. Lancet Psychiatry 2017; 4:419-426. [PMID: 28395988 DOI: 10.1016/s2215-0366(17)30102-5] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 12/12/2022]
Abstract
We present a review and analysis of the ethical considerations in off-label ketamine use for severe, treatment-resistant depression. The analysis of ethical considerations is contextualised in an overview of the evidence for ketamine use in depression, and a review of the drug's safety profile. We find that, based on current evidence, ketamine use for severe, treatment-resistant depression does not violate ethical principles; however, clinicians and professional bodies must take steps to ensure that guidelines for good practice are enacted, that all experimental and trial data are made available through national registries, and that the risk potential of ketamine treatment continues to be monitored and modelled. We conclude with a set of key recommendations for oversight bodies that would support safe, effective, and ethical use of ketamine in depression.
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Affiliation(s)
- Ilina Singh
- Department of Psychiatry and Oxford Uehiro Centre, University of Oxford, Oxford, UK.
| | - Celia Morgan
- Department of Psychology, University of Exeter, Exeter, UK
| | - Valerie Curran
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - David Nutt
- Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, London, UK
| | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Kose S, Cetin M. Ketamine and electroconvulsive therapy pairing in depression and mood disorders. PSYCHIAT CLIN PSYCH 2017. [DOI: 10.1080/24750573.2017.1332513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Samet Kose
- Assoc. Prof. of Psychiatry, Franklin, TN, USA
| | - Mesut Cetin
- Prof. of Psychiatry, Editor-in-Chief, Psychiatry & Clinical Psychopharmacology and Journal of Mood Disorders, Istanbul, Turkey
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Role of N-Methyl-D-Aspartate Receptors in Action-Based Predictive Coding Deficits in Schizophrenia. Biol Psychiatry 2017; 81:514-524. [PMID: 27647218 PMCID: PMC5203970 DOI: 10.1016/j.biopsych.2016.06.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Recent theoretical models of schizophrenia posit that dysfunction of the neural mechanisms subserving predictive coding contributes to symptoms and cognitive deficits, and this dysfunction is further posited to result from N-methyl-D-aspartate glutamate receptor (NMDAR) hypofunction. Previously, by examining auditory cortical responses to self-generated speech sounds, we demonstrated that predictive coding during vocalization is disrupted in schizophrenia. To test the hypothesized contribution of NMDAR hypofunction to this disruption, we examined the effects of the NMDAR antagonist, ketamine, on predictive coding during vocalization in healthy volunteers and compared them with the effects of schizophrenia. METHODS In two separate studies, the N1 component of the event-related potential elicited by speech sounds during vocalization (talk) and passive playback (listen) were compared to assess the degree of N1 suppression during vocalization, a putative measure of auditory predictive coding. In the crossover study, 31 healthy volunteers completed two randomly ordered test days, a saline day and a ketamine day. Event-related potentials during the talk/listen task were obtained before infusion and during infusion on both days, and N1 amplitudes were compared across days. In the case-control study, N1 amplitudes from 34 schizophrenia patients and 33 healthy control volunteers were compared. RESULTS N1 suppression to self-produced vocalizations was significantly and similarly diminished by ketamine (Cohen's d = 1.14) and schizophrenia (Cohen's d = .85). CONCLUSIONS Disruption of NMDARs causes dysfunction in predictive coding during vocalization in a manner similar to the dysfunction observed in schizophrenia patients, consistent with the theorized contribution of NMDAR hypofunction to predictive coding deficits in schizophrenia.
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Abstract
One of the most fascinating drugs in the anesthesiologist's armament is ketamine, an N-methyl-D-aspartate receptor antagonist with a myriad of uses. The drug is a dissociative anesthetic and has been used more often as an analgesic in numerous hospital units, outpatient pain clinics, and in the prehospital realm. It has been used to treat postoperative pain, chronic pain, complex regional pain syndrome, phantom limb pain, and other neuropathic conditions requiring analgesia. Research has also demonstrated its efficacy as an adjunct in psychotherapy, as a treatment for both depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and neurologic conditions. Ketamine is not without its adverse effects, some of which can be mitigated with certain efforts. Such effects make it necessary for the clinician to use the drug only in situations where it will provide the greatest benefit with the fewest adverse effects. To the best of our knowledge, none of the reviews regarding ketamine have taken a comprehensive look at the drug's uses in all territories of medicine. This review will serve to touch on its chemical data, pharmacokinetics and pharmacodynamics, medical uses, and adverse effects while focusing specifically on the drugs usage in anesthesia and analgesia.
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Morgan C, McAndrew A, Stevens T, Nutt D, Lawn W. Tripping up addiction: the use of psychedelic drugs in the treatment of problematic drug and alcohol use. Curr Opin Behav Sci 2017. [DOI: 10.1016/j.cobeha.2016.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Jaso BA, Niciu MJ, Iadarola ND, Lally N, Richards EM, Park M, Ballard ED, Nugent AC, Machado-Vieira R, Zarate CA. Therapeutic Modulation of Glutamate Receptors in Major Depressive Disorder. Curr Neuropharmacol 2017; 15:57-70. [PMID: 26997505 PMCID: PMC5327449 DOI: 10.2174/1570159x14666160321123221] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/09/2015] [Accepted: 01/30/2016] [Indexed: 12/12/2022] Open
Abstract
Current pharmacotherapies for major depressive disorder (MDD) have a distinct lag of onset that can prolong distress and impairment for patients, and realworld effectiveness trials further suggest that antidepressant efficacy is limited in many patients. All currently approved antidepressant medications for MDD act primarily through monoaminergic mechanisms, e.g., receptor/reuptake agonists or antagonists with varying affinities for serotonin, norepinephrine, or dopamine. Glutamate is the major excitatory neurotransmitter in the central nervous system, and glutamate and its cognate receptors are implicated in the pathophysiology of MDD, as well as in the development of novel therapeutics for this disorder. Since the rapid and robust antidepressant effects of the N-methyl-D-aspartate (NMDA) antagonist ketamine were first observed in 2000, other NMDA receptor antagonists have been studied in MDD. These have been associated with relatively modest antidepressant effects compared to ketamine, but some have shown more favorable characteristics with increased potential in clinical practice (for instance, oral administration, decreased dissociative and/or psychotomimetic effects, and reduced abuse/diversion liability). This article reviews the clinical evidence supporting the use of glutamate receptor modulators with direct affinity for cognate receptors: 1) non-competitive NMDA receptor antagonists (ketamine, memantine, dextromethorphan, AZD6765); 2) subunit (NR2B)-specific NMDA receptor antagonists (CP- 101,606/traxoprodil, MK-0657); 3) NMDA receptor glycine-site partial agonists (D-cycloserine, GLYX- 13); and 4) metabotropic glutamate receptor (mGluR) modulators (AZD2066, RO4917523/basimglurant). Several other theoretical glutamate receptor targets with preclinical antidepressant-like efficacy, but that have yet to be studied clinically, are also briefly discussed; these include α-amino-3-hydroxyl-5-methyl-4- isoxazoleproprionic acid (AMPA) agonists, mGluR2/3 negative allosteric modulators, and mGluR7 agonists.
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Affiliation(s)
- Brittany A. Jaso
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Mark J. Niciu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Nicolas D. Iadarola
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Níall Lally
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Erica M. Richards
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Minkyung Park
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Elizabeth D. Ballard
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Allison C. Nugent
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Rodrigo Machado-Vieira
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
| | - Carlos A. Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, 10 Center Dr., Building 10/CRC, Room 7-5545, Bethesda, MD 20892, USA
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Cocaine self-administration disrupted by the N-methyl-D-aspartate receptor antagonist ketamine: a randomized, crossover trial. Mol Psychiatry 2017; 22:76-81. [PMID: 27090301 PMCID: PMC5435123 DOI: 10.1038/mp.2016.39] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/13/2016] [Accepted: 02/05/2016] [Indexed: 12/21/2022]
Abstract
Repeated drug consumption may progress to problematic use by triggering neuroplastic adaptations that attenuate sensitivity to natural rewards while increasing reactivity to craving and drug cues. Converging evidence suggests a single sub-anesthetic dose of the N-methyl-D-aspartate receptor antagonist ketamine may work to correct these neuroadaptations and restore motivation for non-drug rewards. Using an established laboratory model aimed at evaluating behavioral shifts in the salience of cocaine now vs money later, we found that ketamine, as compared to the control, significantly decreased cocaine self-administration by 67% relative to baseline at greater than 24 h post-infusion, the most robust reduction observed to date in human cocaine users and the first to involve mechanisms other than stimulant or dopamine agonist effects. These findings signal new directions in medication development for substance use disorders.
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Zhu W, Ding Z, Zhang Y, Shi J, Hashimoto K, Lu L. Risks Associated with Misuse of Ketamine as a Rapid-Acting Antidepressant. Neurosci Bull 2016; 32:557-564. [PMID: 27878517 DOI: 10.1007/s12264-016-0081-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 10/26/2016] [Indexed: 12/17/2022] Open
Abstract
Major depression is a serious psychiatric disorder and remains a leading cause of disability worldwide. Conventional antidepressants take at least several weeks to achieve a therapeutic response and this lag period has hindered their ability to attain beneficial effects in depressed individuals at high risk of suicide. The non-competitive N-methyl-D-aspartate glutamate receptor antagonist ketamine has been shown to have rapid antidepressant effects in both rodents and humans. The emergence of ketamine as a fast-acting antidepressant provides promising new insights into the development of a rapid treatment response in patients with clinical depression. However, its safety and toxicity remain a concern. In this review, we focus on the limitations of ketamine, including neurotoxicity, cognitive dysfunction, adverse events associated with mental status, psychotomimetic effects, cardiovascular events, and uropathic effects. Studies have shown that its safety and tolerability profiles are generally good at low doses and with short-term treatment in depressed patients. The adverse events associated with ketamine usually occur with very high doses that are administered for prolonged periods of time and can be relieved by cessation. The antidepressant actions of its two enantiomers, S-ketamine (esketamine) and R-ketamine, are also discussed. R-ketamine has greater antidepressant actions than S-ketamine, without ketamine-related side-effects. Future treatment strategies should consider using R-ketamine for the treatment of depressed patients to decrease the risk of adverse events associated with long-term ketamine use.
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Affiliation(s)
- Weili Zhu
- National Institute on Drug Dependence, Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China
| | - Zengbo Ding
- National Institute on Drug Dependence, Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China
| | - Yinan Zhang
- National Institute on Drug Dependence, Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China
| | - Jie Shi
- National Institute on Drug Dependence, Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China
| | - Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, 260-8670, Japan
| | - Lin Lu
- National Institute on Drug Dependence, Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China. .,Institute of Mental Health/Peking University Sixth Hospital, Key Laboratory of Mental Health, Beijing, 100191, China.
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Betaine enhances antidepressant-like, but blocks psychotomimetic effects of ketamine in mice. Psychopharmacology (Berl) 2016; 233:3223-35. [PMID: 27363702 DOI: 10.1007/s00213-016-4359-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 06/13/2016] [Indexed: 01/26/2023]
Abstract
Ketamine is emerging as a new hope against depression, but ketamine-associated psychotomimetic effects limit its clinical use. An adjunct therapy along with ketamine to alleviate its adverse effects and even potentiate the antidepressant effects might be an alternative strategy. Betaine, a methyl derivative of glycine and a dietary supplement, has been shown to have antidepressant-like effects and to act like a partial agonist at the glycine site of N-methyl-D-aspartate receptors (NMDARs). Accordingly, betaine might have potential to be an adjunct to ketamine treatment for depression. The antidepressant-like effects of ketamine and betaine were evaluated by forced swimming test and novelty suppressed feeding test in mice. Both betaine and ketamine produced antidepressant-like effects. Furthermore, we determined the effects of betaine on ketamine-induced antidepressant-like and psychotomimetic behaviors, motor incoordination, hyperlocomotor activity, and anesthesia. The antidepressant-like responses to betaine combined with ketamine were stronger than their individual effects. In contrast, ketamine-induced impairments in prepulse inhibition, novel object recognition test, social interaction, and rotarod test were remarkably attenuated, whereas ketamine-induced hyperlocomotion and loss of righting reflex were not affected by betaine. These findings revealed that betaine could enhance the antidepressant-like effects, yet block the psychotomimetic effects of ketamine, suggesting that betaine can be considered as an add-on therapy to ketamine for treatment-resistant depression and suitable for the treatment of depressive symptoms in patients with schizophrenia.
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50
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Finnegan M, Ryan K, Shanahan E, Harkin A, Daly L, McLoughlin DM. Ketamine for depression relapse prevention following electroconvulsive therapy: protocol for a randomised pilot trial (the KEEP-WELL trial). Pilot Feasibility Stud 2016; 2:38. [PMID: 27965856 PMCID: PMC5153900 DOI: 10.1186/s40814-016-0080-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/13/2016] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Major depressive disorder is a common debilitating illness that is the second leading contributor to the global burden of disease. Unfortunately, about 30 % of patients do not respond to adequate trials of antidepressants and/or psychotherapies. About 45-60 % of such treatment-resistant patients will remit with electroconvulsive therapy (ECT). However, relapse rates are high following ECT-38 % after 6 months. There is a need for better relapse prevention strategies. One possibility is to use ketamine, a competitive glutamate receptor antagonist used for anaesthesia. A recent paradigm shift in treating depression and understanding its biology has been the finding that ketamine has a robust, rapid-onset, though short-lived, antidepressant effect that is possibly mediated through neuroplastic effects. However, ketamine has not previously been reported on for relapse prevention. METHODS/DESIGN The main objective of this study is to conduct a randomised controlled pilot trial (n = 40) of a 4-week course of once-weekly ketamine infusions for relapse prevention following ECT for depression to assess trial procedures that will inform a future definitive trial. Participants with unipolar depression will be recruited prior to commencing ECT and be assessed weekly during the ECT course using the primary clinical outcome, the 24-item Hamilton Rating Scale for Depression (HRSD-24). Those who meet standard response criteria will be invited, on completing ECT, to be randomised in a 1:1 ratio to a course of four once-weekly infusions of ketamine or an active comparator midazolam, which mimics some of the effects of ketamine and may improve blinding over inactive placebo. Participants will be followed up over 6 months using the HRSD-24 to assess for relapse. DISCUSSION This is the first registered trial (NCT02414932, https://clinicaltrials.gov/ct2/show/NCT02414932) of ketamine for depression relapse prevention, an important possible use of this agent. The primary focus of the pilot trial is on feasibility. However, a 95 % confidence interval will be determined for the difference between ketamine and midazolam groups in 6-month relapse rates to help inform a future definitive trial. TRIAL REGISTRATION https://clinicaltrials.gov/ NCT02414932 Secondary Identifying numbers: EudraCT number: 2014-000339-18 Sponsors' Reference, Sponsor: St. Patrick's Mental Health Services: 05/14 Research Ethics Committee Reference, Joint REC of St James' and Tallaght Hospitals, Dublin: 2014-08-19.
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Affiliation(s)
- Martha Finnegan
- Department of Psychiatry and Trinity College Institute of Neuroscience, St. Patrick’s University Hospital, James’ St., Dublin 8, Ireland
| | - Karen Ryan
- Trinity College Institute of Neuroscience, Trinity College Dublin, College Green, Dublin 2, Ireland
| | - Enda Shanahan
- Department of Psychiatry and Trinity College Institute of Neuroscience, St. Patrick’s University Hospital, James’ St., Dublin 8, Ireland
| | - Andrew Harkin
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, College Green, Dublin 2, Ireland
| | - Leslie Daly
- Centre for Training and Research in Analysis and Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - Declan M. McLoughlin
- Department of Psychiatry and Trinity College Institute of Neuroscience, St. Patrick’s University Hospital, James’ St., Dublin 8, Ireland
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