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Jiang Q, Qi Y, Zhou M, Dong Y, Zheng W, Zhu L, Li Y, Zhou H, Wang L. Effect of esketamine on serum neurotransmitters in patients with postpartum depression: a randomized controlled trial. BMC Anesthesiol 2024; 24:293. [PMID: 39160473 PMCID: PMC11331807 DOI: 10.1186/s12871-024-02681-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 08/14/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND The development of postpartum depression has been linked to fluctuations in the levels of neurotransmitters in the human body, such as 5-hydroxytryptamine (5-HT), dopamine (DA), noradrenaline (Norepinephrine, NE), and brain derived neurotrophic factor (BDNF). Research has indicated that the antidepressant effect of esketamine are mediated by monoamine transmitters and neurotrophic factors. Therefore, we postulate that intravenous administration of esketamine in patients with postpartum depression may alter the serum concentrations of these neurotransmitters. METHODS Three hundred fifteen patients with postpartum depression were selected and divided into two groups based on randomized numerical expression: esketamine (E) group (0. 25 mg/kg esketamine) and control (C) group (a same volume of 0.9% saline), all the drugs were pumped for 40 min. After the end of drug pumping, all patients were continuously observed for 2 h. Changes in serum levels of 5-HT, DA, NE, BDNF were recorded before drug administration and on the 3rd day after drug administration. The scores of Edinburgh Postnatal Depression Scale (EPDS) were calculated before drug administration, and on the 3rd day and on the 30th day after drug administration. Dizziness, headache, nausea, vomiting, drowsiness, and feeling of detachment occurred were recorded within 2 h after drug administration. RESULTS Before drug administration, the serum concentrations of 5-HT,DA,BDNF,NE in Group E and Group C were namely (0. 91 ± 0. 19 vs. 0. 98 ± 0. 21, P = 0. 181), (2. 38 ± 0. 35 vs. 2. 32 ± 0. 32, P = 0. 491), (3. 07 ± 0. 89 vs 3. 02 ± 0. 88, P = 0. 828), (39. 79 ± 7. 78 vs 41. 34 ± 10. 03, P = 0. 506). On the third day post-medication, the serum concentrations of 5-HT,DA,BDNF,NE in Group E and Group C were namely (1. 42 ± 0. 35 vs. 0. 96 ± 0. 24, P < 0. 001), (3. 99 ± 0. 17 vs. 2. 41 ± 0. 28, P < 0. 001),(5. 45 ± 0. 81 vs 3. 22 ± 0. 76, P < 0. 001),(44. 36 ± 9. 98 vs 40. 69 ± 11. 75, P = 0. 198). Before medication, the EPDS scores were (16. 15 ± 3. 02 vs 17. 85 ± 3. 89, P = 0. 064). on the third day after medication, the Group E had significantly reduced scores (12. 98 ± 2. 39 vs 16. 73 ± 3. 52, P < 0. 001). On the 30rd day after medication, EPDS scores between the two groups were (16. 34 ± 3. 43 vs 16. 91 ± 4. 02, p = 0. 203). Within 2 h of medication, the rate of adverse events was similar between the two groups. CONCLUSIONS Small doses of esketamine can increase the serum concentration of 5-HT,DA,BDNF, and in the short term, decrease EPDS scores, and improve postpartum depressive symptoms. TRIAL REGISTRATION Retrospectively registered in the Chinese Clinical Trial Registry (ChiCTR2300078343, 2023/12/05).
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Affiliation(s)
- Qinyu Jiang
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Jiangsu, China
| | - Yu Qi
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Jiangsu, China
| | - Meiyan Zhou
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Jiangsu, China
| | - Yaqi Dong
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China
| | - Wenting Zheng
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China
| | - Lijiao Zhu
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China
| | - Yanyu Li
- Department of Obstetrics and Gynecology, The Xuzhou Clinical College of Xuzhou Medical University, Xuzhou Central Hospital, Jiangsu, China
| | - Hai Zhou
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China.
| | - Liwei Wang
- Department of Anesthesiology, Xuzhou Central Hospital, The Xuzhou Clinical College of Xuzhou Medical University, No. 199, Jiefang South Road, Xuzhou , Jiangsu, 221009, China.
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Pattanaseri K, Lortrakul J, Jaisin K, Srifuengfung M, Sa-Nguanpanich N, Viravan N, Pariwatcharakul P, Makarasara W, Ratta-Apha W. A randomized controlled pilot study of daily intravenous ketamine over three days for treatment-resistant depression. BMC Psychiatry 2024; 24:512. [PMID: 39026266 PMCID: PMC11256507 DOI: 10.1186/s12888-024-05951-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Studies have confirmed the rapid antidepressant action of ketamine in depressive episodes. Nevertheless, a standardized procedure for the delivery of ketamine infusion in individuals suffering from treatment-resistant depression, particularly in terms of infusion frequency and total dosage, remains undetermined. In addition, an efficacious ketamine regimen for persistent pain management involved a continuous 10-day infusion period with no notable adverse effects. Consequently, the primary objective of this study was to evaluate the antidepressant capacity of consecutive ketamine infusions spanning over three successive days, the duration of therapeutic response, and the overall safety profile of the treatment. METHODS In this randomized controlled trial, participants aged 18-64 with treatment-resistant depression were randomized to receive either intravenous ketamine or midazolam (used as an active placebo) for 40 min daily over three consecutive days. Statistical analysis using repeated measures ANOVA was employed to assess the changes in the total score of the Montgomery-Åsberg Depression Rating Scale (MADRS) and the clinical global impression-Severity from the initial assessment to 10 and 31 days post-infusion. Additionally, the duration of response and remission was evaluated using Kaplan-Meier survival analysis. RESULTS Out of 33 randomized participants, 20 underwent the treatment as planned. By day 10th, the ketamine group had a mean reduction in MADRS score of 12.55 (95% CI = 6.70-18.09), whereas the midazolam group had a decrease of 17.22 (95% CI = 11.09-23.36). This pattern continued to day 31, with ketamine showing a mean score decrease of 13.73 (95% CI = 7.54-19.91) and midazolam a fall of 12.44 (95% CI = 5.61-19.28). Both treatments were well tolerated, with dissociative symptoms in the ketamine group being temporary and ceasing by the end of each infusion. CONCLUSION Intravenous ketamine given for three consecutive days did not show a notable antidepressant advantage when compared to the active placebo midazolam, highlighting the need for further research into effective treatments schedules for treatment-resistant depression. TRIAL REGISTRATION NCT05026203, ClinicalTrials.gov, registered on 24/08/2021.
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Affiliation(s)
- Keerati Pattanaseri
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand.
| | - Juthawadee Lortrakul
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Kankamol Jaisin
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Maytinee Srifuengfung
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Naratip Sa-Nguanpanich
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Research Department, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Natee Viravan
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Pornjira Pariwatcharakul
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Wattanan Makarasara
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok Noi, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Siriraj Informatics and Data Innovation Center, Mahidol University, Bangkok Noi, Bangkok, Thailand
| | - Woraphat Ratta-Apha
- Faculty of Medicine Siriraj Hospital, Department of Psychiatry, Mahidol University, Bangkok Noi, Bangkok, Thailand
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Juneja K, Afroze S, Goti Z, Sahu S, Asawa S, Bhuchakra HP, Natarajan B. Beyond therapeutic potential: a systematic investigation of ketamine misuse in patients with depressive disorders. DISCOVER MENTAL HEALTH 2024; 4:23. [PMID: 38951348 PMCID: PMC11217219 DOI: 10.1007/s44192-024-00077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 06/17/2024] [Indexed: 07/03/2024]
Abstract
Ketamine, a pharmacological agent that acts as an antagonist of the N-methyl-D-aspartate (NMDA) receptor, has garnered considerable interest because of its notable and expeditious antidepressant properties observed in individuals diagnosed with major depressive disorder (MDD) who exhibit resistance to conventional therapeutic interventions. A comprehensive and rigorous systematic review was undertaken to evaluate the prevalence of ketamine abuse undergoing ketamine treatment for depressive disorders. A comprehensive search was conducted across the electronic databases to identify pertinent studies published between 2021 and 2023. The present investigation incorporated a comprehensive range of studies encompassing the abuse or misuse of ketamine, including case reports, observational studies, and clinical trials. Data extraction and quality assessment were conducted in accordance with predetermined criteria. The findings of this systematic review demonstrate the importance of monitoring and addressing ketamine abuse in patients receiving ketamine treatment for depressive disorders like MDD. The wide range of reported prevalence rates highlights the need for standardized criteria and measures for defining and assessing ketamine abuse. This study presents a significant contribution to the field by introducing a novel screening questionnaire and assessment algorithm designed to identify and evaluate ketamine misuse among major depressive disorder (MDD) patients undergoing ketamine treatment. This innovative tool holds the potential to enhance clinical practice by providing healthcare professionals with a standardized approach to promptly detect and address ketamine misuse. The integration of this screening tool into routine care protocols can facilitate more effective monitoring and management of ketamine misuse in this population, ultimately leading to improved patient outcomes and safety.
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Affiliation(s)
| | - Sabah Afroze
- Shadan Hospital and Institute of Medical Sciences, Hyderabad, India
| | - Zeel Goti
- Government Medical College, Surat, India
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Chang M, Juruena MF, Young AH. Ketamine cystitis following ketamine therapy for treatment-resistant depression - case report. BMC Psychiatry 2024; 24:9. [PMID: 38166893 PMCID: PMC10763323 DOI: 10.1186/s12888-023-05468-3] [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: 07/04/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Ketamine is a novel and exciting putative antidepressant medication for patients with treatment-resistant depression. A complication commonly seen in frequent and heavy recreational use of ketamine is ulcerative cystitis, which presents with lower urinary tract symptoms (LUTS) and upper renal tract damage and can be seen in over 25% of regular users. Although Ketamine-induced cystitis (KIC) is a recognised complication in recreational use of ketamine, its occurrence in therapeutic use of ketamine in depression has so far not been reported. The exact pathogenesis of KIC is currently unknown, making treatment and prevention advice much more difficult. Early diagnosis of KIC and immediate cessation of ketamine has been shown to improve adverse urinary tract symptoms and prevent further damage. CASE PRESENTATION We present a case of a 28-year-old female who was started on ketamine treatment for depression, and who then developed symptoms of KIC, which was confirmed by urine microscopy, culture and analysis. CONCLUSIONS To our knowledge, this is the first reported case of KIC in a patient receiving treatment-dose ketamine as part of their antidepressant therapy.
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Affiliation(s)
- Minna Chang
- Epsom and St Helier Hospital University and Hospital Trust, Epsom Surrey, KT18 7EG, UK.
| | - Mario F Juruena
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley (SLaM) NHS Foundation Trust, London, UK
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley (SLaM) NHS Foundation Trust, London, UK
- Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
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Zaretsky TG, Jagodnik KM, Barsic R, Antonio JH, Bonanno PA, MacLeod C, Pierce C, Carney H, Morrison MT, Saylor C, Danias G, Lepow L, Yehuda R. The Psychedelic Future of Post-Traumatic Stress Disorder Treatment. Curr Neuropharmacol 2024; 22:636-735. [PMID: 38284341 PMCID: PMC10845102 DOI: 10.2174/1570159x22666231027111147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 01/30/2024] Open
Abstract
Post-traumatic stress disorder (PTSD) is a mental health condition that can occur following exposure to a traumatic experience. An estimated 12 million U.S. adults are presently affected by this disorder. Current treatments include psychological therapies (e.g., exposure-based interventions) and pharmacological treatments (e.g., selective serotonin reuptake inhibitors (SSRIs)). However, a significant proportion of patients receiving standard-of-care therapies for PTSD remain symptomatic, and new approaches for this and other trauma-related mental health conditions are greatly needed. Psychedelic compounds that alter cognition, perception, and mood are currently being examined for their efficacy in treating PTSD despite their current status as Drug Enforcement Administration (DEA)- scheduled substances. Initial clinical trials have demonstrated the potential value of psychedelicassisted therapy to treat PTSD and other psychiatric disorders. In this comprehensive review, we summarize the state of the science of PTSD clinical care, including current treatments and their shortcomings. We review clinical studies of psychedelic interventions to treat PTSD, trauma-related disorders, and common comorbidities. The classic psychedelics psilocybin, lysergic acid diethylamide (LSD), and N,N-dimethyltryptamine (DMT) and DMT-containing ayahuasca, as well as the entactogen 3,4-methylenedioxymethamphetamine (MDMA) and the dissociative anesthetic ketamine, are reviewed. For each drug, we present the history of use, psychological and somatic effects, pharmacology, and safety profile. The rationale and proposed mechanisms for use in treating PTSD and traumarelated disorders are discussed. This review concludes with an in-depth consideration of future directions for the psychiatric applications of psychedelics to maximize therapeutic benefit and minimize risk in individuals and communities impacted by trauma-related conditions.
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Affiliation(s)
- Tamar Glatman Zaretsky
- James J. Peters Veterans Affairs Medical Center, New York, NY, USA
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kathleen M. Jagodnik
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Barsic
- James J. Peters Veterans Affairs Medical Center, New York, NY, USA
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Josimar Hernandez Antonio
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip A. Bonanno
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carolyn MacLeod
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charlotte Pierce
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hunter Carney
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Morgan T. Morrison
- James J. Peters Veterans Affairs Medical Center, New York, NY, USA
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles Saylor
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Danias
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lauren Lepow
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Yehuda
- James J. Peters Veterans Affairs Medical Center, New York, NY, USA
- The Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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S-ketamine: Is it a ride worth taking? Adverse effects associated with S-ketamine use as an adjuvant or single agent drug. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Shoib S, Kotra M, Javed S, Nguyen VS, Malathesh BC. Esketamine-A quick-acting novel antidepressant without the disadvantages of ketamine. Horm Mol Biol Clin Investig 2022; 43:505-511. [PMID: 35851448 DOI: 10.1515/hmbci-2021-0099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/23/2022] [Indexed: 12/24/2022]
Abstract
Esketamine, which is an S-enantiomer of ketamine, is better than conventional antidepressants and even better than R-ketamine. This article discusses the mechanism of action of Esketamine, how different it is from other antidepressants, its side effect profile, indications for use, various routes of administration and the review of existing literature on Esketamine.
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Affiliation(s)
- Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Kashmir, India
| | | | - Sana Javed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | - Vinh-Son Nguyen
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Wang W, Xu H, Ling B, Chen Q, Lv J, Yu W. Effects of esketamine on analgesia and postpartum depression after cesarean section: A randomized, double-blinded controlled trial. Medicine (Baltimore) 2022; 101:e32010. [PMID: 36451452 PMCID: PMC9704928 DOI: 10.1097/md.0000000000032010] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/03/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The aim of this randomized double-blind placebo controlled clinical trial was to investigate the effects of different doses of esketamine combined with sufentanil for postoperative intravenous controlled analgesia after cesarean section and the incidence of postpartum depression. METHODS One hundred and sixty patients undergoing elective cesarean section, with a singleton term pregnancy and American Society of Anesthesiologists physical status II were selected. All patients were treated by a combined epidural with spinal anesthesia. They were randomly divided into 4 groups according to patient controlled intravenous analgesia formula. The consumption of sufentanil, times of effective press and remediate analgesia at 48 hours after cesarean section, incidence of postpartum depression (PPD) at 1 week and 6 weeks after the operation were recorded. RESULTS Comparison of cumulated dosage of sufentanil, times of effective press and rescue analgesia at 48 hours after operation: Group H was significantly lower than Group M, Group L, and Group C (P < .05), Group M significantly lower than group L and Group C (P < .05), and Group L significantly lower than Group C (P < .05). Comparison of the incidence of PPD at 1 week and 6 weeks later: Group H was significantly lower than Group M, Group L, and Group C (P < .01), Group M significantly lower than Group L and Group C (P < .01) and Group L significantly lower than Group C (P < .01). Compared with Group C, the incidence of nausea and vomiting was significantly reduced in Group H, Group M, and Group L (P < .05). CONCLUSION Esketamine combined with sufentanil used for patient controlled intravenous analgesia after elective cesarean section can reduce the consumption of sufentanil, improve postoperative analgesia, decrease the incidence of PPD at 1 week and 6 weeks and postoperative nausea and vomiting.
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Affiliation(s)
- Wei Wang
- Department of Anesthesiology, the Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, China
| | - Hua Xu
- Department of Gynaecology and Obstetrics, the Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, China
| | - Bin Ling
- Department of Anesthesiology, the Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, China
| | - Qing Chen
- Department of Anesthesiology, the Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, China
| | - Jie Lv
- Department of Anesthesiology, the Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, China
| | - Wanyou Yu
- Department of Anesthesiology, the Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, China
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Smith-Apeldoorn SY, Vischjager M, Veraart JK, Kamphuis J, Aan Het Rot M, Schoevers RA. The antidepressant effect and safety of non-intranasal esketamine: A systematic review. J Psychopharmacol 2022; 36:531-544. [PMID: 35546042 PMCID: PMC9112628 DOI: 10.1177/02698811221084055] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The introduction of esketamine into the field of psychiatry comes on the heels of excitement from studies on racemic ketamine. While the intranasal route has been the most studied to date, other modes of administration of esketamine may also be of interest in the management of depression. AIMS To systematically review the literature on non-intranasal esketamine for depression in terms of its antidepressant effect and safety. METHODS We searched PubMed, Embase, the Cochrane Library, and Google Scholar from inception up to February 2021. Search terms included a combination of Medical Subject Headings and text words indicative of esketamine and depression. We selected both controlled and uncontrolled studies examining non-intranasal esketamine for the treatment of depression. RESULTS We identified four randomized controlled trials (RCTs) on intravenous esketamine and 15 open-label studies on intravenous (n = 80), subcutaneous (n = 73), and oral (n = 5) esketamine. We found intravenous, subcutaneous, and possibly oral administration of esketamine to be effective in reducing depressive symptoms in most patients with major depressive disorder, bipolar depression, and (severe) treatment-resistant depression. Clinical response to repeated administration of esketamine persisted over the course of treatment. Esketamine was well tolerated by most patients, but open-label data indicate marked psychotomimetic symptoms in exceptional cases. The overall quality of the controlled studies was considered high, the overall quality of the uncontrolled studies low to moderate. CONCLUSIONS Intravenous, subcutaneous, and possibly oral esketamine may offer an effective and safe addition to the depression treatment armamentarium. However, as most included studies lacked a control group and had small sample sizes, the quality of our results is limited. Different types and formulations of ketamine remain to be compared directly.
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Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maurice Vischjager
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jolien Ke Veraart
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Mood Disorders, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marije Aan Het Rot
- Department of Psychology, University of Groningen, Groningen, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Kritzer MD, Pae CU, Masand PS. Key considerations for the use of ketamine and esketamine for the treatment of depression: focusing on administration, safety, and tolerability. Expert Opin Drug Saf 2022; 21:725-732. [PMID: 35475388 DOI: 10.1080/14740338.2022.2069749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Racemic ketamine, a derivative of phencyclidine, has been used as a dissociative anesthetic since 1970. In 2000, the first randomized controlled trial showed a rapid relief of depressive symptoms. Since then, intravenous ketamine and intranasal S-ketamine have been validated for the treatment of depression and suicidal ideation following dose-response and double-blind placebo-controlled clinical trials. In clinical practice, after dose titration and with repeated treatments, patients may experience approximately 2-3 weeks of symptomatic relief from depression. AREAS COVERED Areas covered in this narrative review include mechanism of action, dosing, safety, and tolerability. Some attention is paid to the possibility of R-ketamine as a future antidepressant. EXPERT OPINION We recommend further investigation into treatment dosing and frequency strategies as well as approaches that prolong the therapeutic effects. The current fixed dosing of esketamine for obese individuals may be insufficient. Additional investigation into co-administration with somatic and neuromodulation treatments needs investigation. Finally, continuing to monitor research subjects and patients long-term for the emergence of adverse effects on cognition or other organ systems is critical.
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Affiliation(s)
- Michael D Kritzer
- Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Prakash S Masand
- CEO, Centers of Psychiatric Excellence (COPE), New York, New York, USA.,Duke-NUS (National University of Singapore), Singapore
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Nikayin S, Murphy E, Krystal JH, Wilkinson ST. Long-term safety of ketamine and esketamine in treatment of depression. Expert Opin Drug Saf 2022; 21:777-787. [PMID: 35416105 DOI: 10.1080/14740338.2022.2066651] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Ketamine is an NMDA receptor antagonist that can produce rapid-acting antidepressant effects. Esketamine (Spravato), the S-enantiomer of racemic ketamine, was approved by the FDA for treatment-resistant depression in 2019. Here we review what is known about the long-term safety of both racemic ketamine and esketamine as therapies for psychiatric disorders. AREAS COVERED In this article, we conducted a safety review of ketamine and esketamine. In looking at ketamine and esketamine long-term safety effects, we considered data available from experimental studies and several phase-three clinical trials. EXPERT OPINION Based on available data, the most common side effects of ketamine/esketamine are generally transient, mild, and self-limited. These include dissociation, nausea, headache, elevated heart rate, and blood pressure. Treatment with esketamine may lead to an increased risk of lower urinary tract symptoms, such as dysuria or urgency. However, severe bladder pathology has not been reported among patients receiving doses of esketamine/ketamine in line with prescribing guidelines for depression. There is considerable data that ketamine at high doses can lead to long-term impairments in cognition. However, the esketamine clinical trials found that cognition generally remains stable or improves over time, suggesting that when used appropriately, there is no increased risk of cognitive impairment.
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Affiliation(s)
- Sina Nikayin
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
| | - Eva Murphy
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
| | - John H Krystal
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
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12
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Zhang X, Zhang N, Liu D, Ding J, Zhang Y, Zhu Z. Research advances in the clinical application of esketamine. IBRAIN 2022; 8:55-67. [PMID: 37786420 PMCID: PMC10528803 DOI: 10.1002/ibra.12019] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/15/2021] [Accepted: 01/10/2022] [Indexed: 10/04/2023]
Abstract
Esketamine is dextrorotatory ketamine, which is an enantiomer of ketamine. Compared with ketamine, it has the advantages of a fast metabolism, fewer side effects, and strong pharmacological effects, so it is more suitable for clinical use. Esketamine has a powerful analgesic effect and has little effect on breathing. It has a wide range of applications in the fields of pediatric anesthesia, conscious sedation anesthesia, and emergency analgesia. In addition, it is also used for pain that is difficult to relieve with conventional drugs and to prevent postoperative pain. Various routes of administration are also suitable for patients who need short-term analgesia and sedation. As a drug, esketamine inevitably brings some side effects when it is used clinically. In this article, by introducing the mechanism of action and pharmacological characteristics of esketamine, its clinical application is reviewed, and it provides a reference for the more reasonable and safe clinical application of esketamine.
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Affiliation(s)
- Xiao‐Xi Zhang
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Nai‐Xin Zhang
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - De‐Xing Liu
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Jun Ding
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Yi‐Nan Zhang
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Zhao‐Qiong Zhu
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
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13
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Findeis H, Ludwig V, Mikolas P, Graff J, Bauer M, Ritter P. [Practical aspects of ketamine treatment-Safety, combination treatment and comorbidities]. DER NERVENARZT 2022; 93:243-253. [PMID: 35171310 DOI: 10.1007/s00115-021-01260-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although multiple studies and meta-analyses have documented the rapid antidepressive efficacy of ketamine, there are numerous questions regarding the practical use in the clinical routine that are still unanswered. OBJECTIVE Based on personal clinical experience, by comparison and supplementation of the current data situation, answers are given to questions regarding the practical use of ketamine for depression that have not yet been satisfactorily clarified. MATERIAL AND METHODS The clinical experiences with antidepressive treatment using ketamine over more than 5 years were evaluated with respect to the questions at hand. This was followed by a qualitative comparison of these results with those of a narrative literature search. RESULTS A total of 72 patients (unipolar depression n = 53, bipolar depression n = 16, schizoaffective depression n = 3) were included in the analysis of this cohort. A statistically significant reduction of depressive symptoms and suicidal ideation after S-ketamine treatment was found. Of the patients 61% suffered from at least one secondary diagnosis. A dose of 0.5 mg/kg body weight of S‑ketamine at a frequency of three times per week was shown to be effective. The treatment appears to be safe with respect to urotoxic side effects, combination treatment with tranylcypromine and in comorbid posttraumatic stress disorder. CONCLUSION Ketamine appears to be a safe and effective option for the treatment of unipolar and bipolar depression.
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Affiliation(s)
- H Findeis
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus An der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - V Ludwig
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus An der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - P Mikolas
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus An der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - J Graff
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus An der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - M Bauer
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus An der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Philipp Ritter
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus An der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
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14
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Swainson J, Klassen LJ, Brennan S, Chokka P, Katzman MA, Tanguay RL, Khullar A. Non-parenteral Ketamine for Depression: A Practical Discussion on Addiction Potential and Recommendations for Judicious Prescribing. CNS Drugs 2022; 36:239-251. [PMID: 35165841 PMCID: PMC8853036 DOI: 10.1007/s40263-022-00897-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada. .,Misericordia Community Hospital, Edmonton, AB, Canada.
| | | | - Stefan Brennan
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK Canada
| | - Pratap Chokka
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Chokka Center for Integrative Health, Edmonton, AB Canada
| | - Martin A. Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, ON Canada ,Department of Psychiatry, Northern Ontario School of Medicine, Thunder Bay, ON Canada ,Department of Psychology, Lakehead University, Thunder Bay, ON Canada ,Department of Psychology, Adler Graduate Professional School, Toronto, ON Canada
| | - Robert L. Tanguay
- Department of Psychiatry and Department of Surgery, University of Calgary, Calgary, AB Canada ,The Newly Institute, Calgary, AB Canada ,Hotchkiss Brain Institute and Mathison Centre for Mental Health, Calgary, AB Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Northern Alberta Sleep Clinic, Edmonton, AB Canada
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15
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Kojic M, Saelens J, Kadriu B, Zarate CA, Kraus C. Ketamine for Depression: Advances in Clinical Treatment, Rapid Antidepressant Mechanisms of Action, and a Contrast with Serotonergic Psychedelics. Curr Top Behav Neurosci 2022; 56:141-167. [PMID: 35312993 PMCID: PMC10500612 DOI: 10.1007/7854_2022_313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The approval of ketamine for treatment-resistant depression has created a model for a novel class of rapid-acting glutamatergic antidepressants. Recent research into other novel rapid-acting antidepressants - most notably serotonergic psychedelics (SPs) - has also proven promising. Presently, the mechanisms of action of these substances are under investigation to improve these novel treatments, which also exhibit considerable side effects such as dissociation. This chapter lays out the historical development of ketamine as an antidepressant, outlines its efficacy and safety profile, reviews the evidence for ketamine's molecular mechanism of action, and compares it to the proposed mechanism of SPs. The evidence suggests that although ketamine and SPs act on distinct primary targets, both may lead to rapid restoration of synaptic deficits and downstream network reconfiguration. In both classes of drugs, a glutamate surge activates α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) throughput and increases in brain-derived neurotrophic factor (BDNF) levels. Taken together, these novel antidepressant mechanisms may serve as a framework to explain the rapid and sustained antidepressant effects of ketamine and may be crucial for developing new rapid-acting antidepressants with an improved side effect profile.
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Affiliation(s)
- Marina Kojic
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Johan Saelens
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Bashkim Kadriu
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, CA, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Christoph Kraus
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria.
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
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16
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Hochschild A, Grunebaum MF, Mann JJ. The rapid anti-suicidal ideation effect of ketamine: A systematic review. Prev Med 2021; 152:106524. [PMID: 34538369 DOI: 10.1016/j.ypmed.2021.106524] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 11/19/2022]
Abstract
In many countries suicide rates have been trending upwards for close to twenty years-presenting a public health crisis. Most suicide attempts and deaths are associated with psychiatric illness, usually a depressive disorder. Subanesthetic ketamine is the only FDA-approved antidepressant that works in hours not weeks-thus potentially transforming treatment of suicidal patients. We reviewed all randomized controlled trials of the effect of ketamine on suicidal ideation to determine if ketamine rapidly reduces suicidal ideation [SI] in depressed patients and how long the benefit persists after one dose and if the route of administration or dose affects the outcome. A systematic review was conducted as per PRISMA [preferred reporting items for systematic reviews and meta-analyses] criteria. PubMed search inclusive of "ketamine" and "suicide" yielded 358 results. Papers (N = 354) were then read by at least two authors, identifying 12 meeting eligibility requirements and eleven RCTs examining whether ketamine treatment ameliorated SI. Four of five RCTs examined racemic ketamine (0.5 mg/kg) given intravenously and found an advantage for ketamine over control for rapid reduction in SI in acutely depressed patients. Two studies examined intranasal esketamine in depressed suicidal patients and found no advantage over saline. One study examined outcome six weeks after a single intravenous dose of ketamine and found benefit for SI sustained relative to 24 h post-dose. Further research is warranted into: optimal dosing strategy, including number and frequency; and long-term efficacy and safety. Ultimately, it remains to be shown that ketamine's benefit for SI translates into prevention of suicidal behavior.
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Affiliation(s)
- Annabella Hochschild
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Michael F Grunebaum
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States of America
| | - J John Mann
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, United States of America.
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17
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Himmelseher S, Kochs EF. Ready for a "breakthrough" with ketamine? A look at recent pharmacological insights! Curr Opin Anaesthesiol 2021; 34:393-401. [PMID: 34052823 DOI: 10.1097/aco.0000000000001017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To update pharmacological insights on ketamine integrating information from different disciplines for developing steps to "breakthrough" approaches in clinical challenges. RECENT FINDINGS Pharmacokinetic/pharmacodynamic (PK/PD) models have incorporated recirculation, ketamine metabolites, drug-drug interaction, and covariates such as age. Ketamine-induced relief from treatment-resistant depression has been explained by "disinhibition" of gamma-aminobutyric acid-ergic interneurons and synaptogenic mechanisms requiring neurotrophic signals. Neuroimaging/electroencephalographic investigations have shown an increase in gamma spectral power in healthy volunteers and patients with depression, but also opposite changes in functional network connectivity after subanesthetic ketamine. Volunteer data may not be transferable to clinical conditions. Altered states of consciousness induced by subanesthetic ketamine have been described by disruption of resisting-state functional networks and frontoparietal connectivity with preservation of multisensory and sensor-motor networks. This has been interpreted as a "disconnected consciousness". SUMMARY More precise PK/PD models may improve the ketamine use regimen. The findings from research on depression are an important discovery because ketamine's impact on neuronal plasticity and synaptogenesis in human brain disease has directly been documented. Psychic adverse effects with subanesthetic ketamine are related to a "disconnected consciousness". Overall, progress has been made, but the "breakthrough" still has to come.
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Affiliation(s)
- Sabine Himmelseher
- Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
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18
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McIntyre RS, Rosenblat JD, Nemeroff CB, Sanacora G, Murrough JW, Berk M, Brietzke E, Dodd S, Gorwood P, Ho R, Iosifescu DV, Jaramillo CL, Kasper S, Kratiuk K, Lee JG, Lee Y, Lui LM, Mansur RB, Papakostas GI, Subramaniapillai M, Thase M, Vieta E, Young AH, Zarate CA, Stahl S. Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation. Am J Psychiatry 2021; 178:383-399. [PMID: 33726522 PMCID: PMC9635017 DOI: 10.1176/appi.ajp.2020.20081251] [Citation(s) in RCA: 299] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Replicated international studies have underscored the human and societal costs associated with major depressive disorder. Despite the proven efficacy of monoamine-based antidepressants in major depression, the majority of treated individuals fail to achieve full syndromal and functional recovery with the index and subsequent pharmacological treatments. Ketamine and esketamine represent pharmacologically novel treatment avenues for adults with treatment-resistant depression. In addition to providing hope to affected persons, these agents represent the first non-monoaminergic agents with proven rapid-onset efficacy in major depressive disorder. Nevertheless, concerns remain about the safety and tolerability of ketamine and esketamine in mood disorders. Moreover, there is uncertainty about the appropriate position of these agents in treatment algorithms, their comparative effectiveness, and the appropriate setting, infrastructure, and personnel required for their competent and safe implementation. In this article, an international group of mood disorder experts provides a synthesis of the literature with respect to the efficacy, safety, and tolerability of ketamine and esketamine in adults with treatment-resistant depression. The authors also provide guidance for the implementation of these agents in clinical practice, with particular attention to practice parameters at point of care. Areas of consensus and future research vistas are discussed.
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Affiliation(s)
- Roger S. McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Department of Psychiatry, University of Toronto, Toronto; Department of Pharmacology, University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto
| | - Joshua D. Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Department of Psychiatry, University of Toronto, Toronto; Canadian Rapid Treatment Center of Excellence, Mississauga, Ontario
| | - Charles B. Nemeroff
- Department of Psychiatry and Behavioral Sciences, Austin Dell Medical School, University of Texas, Austin
| | - Gerard Sanacora
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn
| | - James W. Murrough
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry, and Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York
| | - Michael Berk
- Deakin University, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Orygen, National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Elisa Brietzke
- Department of Psychiatry, Queen’s University School of Medicine, and Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario
| | - Seetal Dodd
- Deakin University, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Centre for Youth Mental Health and Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Philip Gorwood
- Université de Paris, Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, and GHU Paris Psychiatrie et Neurosciences, CMME, Hôpital Sainte-Anne, Paris
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, and Institute of Health Innovation and Technology, National University of Singapore, Singapore
| | - Dan V. Iosifescu
- Department of Psychiatry, NYU School of Medicine, and Clinical Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York
| | | | | | - Kevin Kratiuk
- Canadian Rapid Treatment Center of Excellence, Mississauga, Ontario; Department of Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jung Goo Lee
- Department of Psychiatry, College of Medicine, Haeundae Paik Hospital, Paik Institute for Clinical Research, and Department of Health Science and Technology, Graduate School, Inje University, Busan, Republic of Korea
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Institute of Medical Science, University of Toronto, Toronto
| | - Leanna M.W. Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto
| | - Rodrigo B. Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Department of Psychiatry, University of Toronto, Toronto
| | | | | | - Michael Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona
| | - Allan H. Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London and South London, and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, Kent
| | - Carlos A. Zarate
- Experimental Therapeutics and Pathophysiology Branch and Section on the Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, NIMH, Bethesda, Md
| | - Stephen Stahl
- Department of Psychiatry and Neuroscience, University of California, Riverside, and University of California, San Diego
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19
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Ng J, Lui LMW, Rosenblat JD, Teopiz KM, Lipsitz O, Cha DS, Xiong J, Nasri F, Lee Y, Kratiuk K, Rodrigues NB, Gill H, Subramaniapillai M, Mansur RB, Ho R, Cao B, McIntyre RS. Ketamine-induced urological toxicity: potential mechanisms and translation for adults with mood disorders receiving ketamine treatment. Psychopharmacology (Berl) 2021; 238:917-926. [PMID: 33484298 DOI: 10.1007/s00213-021-05767-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/14/2021] [Indexed: 12/14/2022]
Abstract
Intravenous (IV) ketamine has been shown to have rapid and robust antidepressant effects in adults with treatment-resistant depression (TRD). Urological toxicity has been observed in chronic ketamine abusers as evidenced by dysuria, urgency, and hematuria. The foregoing observation provides the basis for evaluating whether ketamine-induced urological toxicity (KIUT) is associated with sub-anesthetic doses of ketamine (0.5-1.0 mg/kg) in adults with mood disorders. The overarching objective of this article is to identify potential mechanisms of KIUT which appears to be dose and frequency dependent. Available research indicates that high-frequency ketamine is associated with disruption of the urothelial barrier as well as direct ketamine toxicity (i.e., decreased expression of junction proteins) in KIUT of the bladder. Chronic and high-frequency ketamine use is also associated with bladder inflammation mediated via neurogenic and IgE inflammation. Other non-mutually exclusive causes are nerve hyperplasia, hypersensitivity, cell apoptosis, microvascular damage, and overexpression of carcinogenic genes. Notwithstanding the evidence of KIUT in ketamine abusers, there is no evidence that ketamine and/or esketamine treatment in adults with mood disorders is associated with KIUT. However, all patients receiving ketamine/esketamine for mood disorder treatment should be queried about genitourinary symptoms during acute and, where applicable, maintenance dosing.
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Affiliation(s)
- Jason Ng
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Leanna M W Lui
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Kayla M Teopiz
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Orly Lipsitz
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Danielle S Cha
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada.,School of Medicine, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jiaqi Xiong
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Flora Nasri
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Yena Lee
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Kevin Kratiuk
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Nelson B Rodrigues
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Hartej Gill
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Mehala Subramaniapillai
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Rodrigo B Mansur
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Bing Cao
- School of Psychology and Key Laboratory of Cognition and Personality (Ministry of Education), Southwest University, Chongqing, 400715, China.,National Demonstration Center for Experimental Psychology Education, Southwest University, Chongqing, 400715, China
| | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada. .,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada. .,Brain and Cognition Discovery Foundation, Toronto, Canada.
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