Evaluating the Role of Ketamine/Esketamine in the Management of Major Depressive Disorder with Suicide Risk

CB1 receptor mediates anesthetic drug ketamine‑induced neuroprotection against glutamate in HT22 cells

The anesthetic drug, ketamine (KTM) has been shown to induce therapeutic effects against major depressive disorder (MDD), however the related underlying mechanisms remain unclear. In the present study, HT22 neuronal cells were treated with glutamate to imitate oxidative stress injury in MDD, and it was hypothesized that the cannabinoid type 1 (CB1) receptor mediates KTM-induced neuroprotection via ameliorating mitochondrial function in glutamate-treated neuronal cells. Compared with the control, glutamate decreased cell viability and intracellular antioxidants, including glutathione (GSH), catalase and superoxide dismutase 2 levels, and inhibited mitochondrial function simultaneously. Moreover, glutamate increased lactate dehydrogenase release, cellular apoptosis level, cleaved caspase-3 expression and intracellular oxidants, such as reactive oxygen species, oxidized GSH and mitochondrial superoxide in the cells. The presence of KTM, however, significantly decreased the glutamate-induced oxidative stress injury, ameliorated the antioxidant/oxidant levels in the cells, enhanced mitochondrial function and upregulated CB1 receptor expression (P<0.05). Co-administration of the CB1 receptor antagonist AM251 markedly abolished the KTM-induced cytoprotective effects and ameliorations of antioxidant/oxidant levels and mitochondrial function, and also reversed CB1 upregulation (P<0.05). These observations indicated that KTM decreases the oxidative stress injury caused by glutamate in HT22 neuronal cells, and the neuroprotective effects may be mediated by the CB1 receptor.

Rapid and sustained antidepressant effects of intravenous ketamine in treatment-resistant major depressive disorder and suicidal ideation: a randomized clinical trial

BACKGROUND

Major depressive disorder (MDD) is the most disabling and burdensome mental disorder, negatively affecting an individual's quality of life and daily functioning. the current study was conducted with the aim of investigating the clinical effects of intravenous ketamine on symptoms of MDD and suicidal ideation.

METHODS

The current randomized clinical trial was carried out on 64 patients diagnosed with treatment-resistant major depressive disorder between April and August 2022. The participants were randomly assigned to two groups: the intervention group received a dose of 0.5 mg/kg of ketamine, while the control group received normal saline. The Montgomery-Asberg Depression Scale and Beck's Suicidal Ideation Scale were utilized to assess depression and suicidal ideation, respectively.

RESULTS

One hour after the administration of ketamine treatment, there was a notable and significant improvement in both depression symptoms (35.16 ± 8.13 vs. 14.90 ± 10.09) and suicidal ideation (6.74 ± 6.67 vs. 0.42 ± 1.52). Moreover, there were statistically significant differences in depression scores between the two groups at one hour, four hours, one day, three days, one week, one month, and two months after the administration of ketamine (p-value < 0.001). However, ketamine recipients frequently experienced side effects such as increased heart rate, headache, dizziness, and dissociative syndrome symptoms.

CONCLUSION

The observed rapid onset of action and sustained effect demonstrate the potential of ketamine to provide relief from depressive symptoms in a shorter timeframe compared to traditional treatment approaches. These findings contribute to the growing body of evidence supporting the use of ketamine as a valuable therapeutic option for patients with treatment-resistant depression.

IRCT REGISTRATION

IRCT registration number: IRCT20210806052096N1; IRCT URL: https://www.irct.ir/trial/62243 ; Ethical code: IR.ZUMS.REC.1400.150; Registration date: 2022-04-09.

Ketamine-assisted psychotherapy, psychedelic methodologies, and the impregnable value of the subjective-a new and evolving approach

Psychiatry is in a growth phase in which several psychedelic medicines have entered its arena with great promise. Of these, presently, ketamine is the only medicine that may be legally prescribed. We hypothesize that at subanesthetic doses, ketamine produces a unique spectrum of altered states, ranging from psychoactive to deep ego-dissolving experiences, that are intrinsic to ketamine's therapeutic effects. When these experiences are embedded in a therapeutic relationship-a setting-that fosters an amplification of the recipient's subjective consciousness, personal growth, inner healing, greater clarity, and better relationships may well ensue. While much of the literature on ketamine labels its dissociative effects as 'side effects', alteration of consciousness is a component and unavoidable 'effect' of its therapeutic impact. From its inception in the clinical trials of the 1960s, ketamine was recognized for producing dissociative, psychedelic effects on consciousness in subjects as they emerged from ketamine-induced anesthesia. Unanticipated and unintegrated, these experiences of 'emergence phenomena' were felt to be disturbing. Accordingly, such experiences have been typically labeled as dissociative side effects. However, in a conducive set and settings, these experiences have been demonstrated to be of positive use in psychiatry and psychotherapy, providing a time-out from usual states of mind to facilitate a reshaping of self-experience along with symptomatic relief. In this way, ketamine-assisted psychotherapy (KAP) offers a new potential in psychiatry and psychotherapy that is powerfully valanced toward recognizing experience, individuality, and imagination. Essential to a successful therapeutic experience and outcome with KAP is close attention to the subjective experience, its expression by the recipient and integration of the ketamine experience as a healing opportunity.

Low-dose ketamine improves animals' locomotor activity and decreases brain oxidative stress and inflammation in ammonia-induced neurotoxicity

Ammonium ion (NH4 + ) is the major suspected molecule responsible for neurological complications of hepatic encephalopathy (HE). No specific pharmacological action for NH4 + -induced brain injury exists so far. Excitotoxicity is a well-known phenomenon in the brain of hyperammonemic cases. The hyperactivation of the N-Methyl- d-aspartate (NMDA) receptors by agents such as glutamate, an NH4 + metabolite, could cause excitotoxicity. Excitotoxicity is connected with events such as oxidative stress and neuroinflammation. Hence, utilizing NMDA receptor antagonists could prevent neurological complications of NH4 + neurotoxicity. In the current study, C57BL6/J mice received acetaminophen (APAP; 800 mg/kg, i.p) to induce HE. Hyperammonemic animals were treated with ketamine (0.25, 0.5, and 1 mg/kg, s.c) as an NMDA receptor antagonist. Animals' brain and plasma levels of NH4 + were dramatically high, and animals' locomotor activities were disturbed. Moreover, several markers of oxidative stress were significantly increased in the brain. A significant increase in brain tissue levels of TNF-α, IL-6, and IL-1β was also detected in hyperammonemic animals. It was found that ketamine significantly normalized animals' locomotor activity, improved biomarkers of oxidative stress, and decreased proinflammatory cytokines. The effects of ketamine on oxidative stress biomarkers and inflammation seem to play a key role in its neuroprotective mechanisms in the current study.

Pharmacologic Approaches to Suicide Prevention

Suicide is a leading cause of death that is often preventable. This article reviews the role of medications in treating suicidal behavior and in preventing suicide. For an acute suicidal crisis, ketamine, and perhaps esketamine, are emerging as important tools. For patients with chronic suicidality, clozapine remains the only U.S. Food and Drug Administration (FDA) approved antisuicidal medication, and its use is predominantly for patients with schizophrenia and schizoaffective disorder. An abundance of literature supports the use of lithium among patients with mood disorders, including those with major depressive disorder. Despite the black box warning regarding antidepressants and suicide risk among children, adolescents, and young adults, antidepressants are widely used and remain helpful in reducing suicidal thoughts and behaviors, primarily among patients with mood disorders. Treatment guidelines focus on the importance of optimizing treatment of the psychiatric conditions known to be associated with suicide risk. For patients with these conditions, the authors recommend focusing on suicide as an independent treatment target and using an enhanced medication management strategy that includes maintaining a supportive, nonjudgmental therapeutic relationship; flexibility; collaboration; measurement-based care; consideration of combining medications with nonpharmacologic, evidence-based strategies; and ongoing safety planning.

Ketamine and esketamine in suicidal thoughts and behaviors: a systematic review

BACKGROUND

More than 2% of the general population experience suicidal ideas each year and a large number of them will attempt suicide. Evidence-based therapeutic options to manage suicidal crisis are currently limited.

OBJECTIVES

The aim of this study was to overview the findings on the use of ketamine and esketamine for the treatment of suicidal ideas and acts.

DESIGN

Systematic review.

DATA SOURCES AND METHODS

PubMed, article references, and Clinicaltrials.gov up to June 30, 2022. Meta-analyses published within the last 2 years were also reviewed.

RESULTS

We identified 12 randomized controlled trials with reduction of suicidal ideation as the primary objective and 14 trials as secondary objectives. Intravenous racemic ketamine was superior to control drugs (placebo or midazolam) within the first 72 h, in spite of large placebo effects. Adverse events were minor and transient. In contrast, intranasal esketamine did not differ from placebo in large-scale studies. Limitations, clinical considerations, and opportunities for future research include the following points: large placebo effects when studying suicidal ideation reduction; small concerns about blinding quality due to dissociative effects; no studies on the risk/prevention of suicidal acts and mortality; lack of studies beyond affective disorders; no studies in adolescents and older people; lack of knowledge of long-term side effects, notably liability for abuse; no robust predictive markers; limited understanding of the mechanisms of ketamine on suicidal ideas; need for improved assessment of suicidal ideation in clinical trials; need for studies in outpatient settings, emergency room, and liaison consultation; need for research on ketamine administration; limited knowledge on the positive and negative effects of concomitant treatments.

CONCLUSION

Overall, there is compelling evidence for a favorable short-term benefit-risk balance with intravenous racemic ketamine but not intranasal esketamine. The place of ketamine will have to be defined within a multimodal care strategy for suicidal patients. Caution remains necessary for clinical use, and pharmacovigilance will be essential.

The higher levels of self-reported satisfaction, the lower risk of depressive symptoms: Evidence from a nationwide cross-sectional study in China

Objectives

This study aimed to investigate the associations between several dimensions of self-reported satisfaction and the risk of depressive symptoms among Chinese middle-aged and older adults.

Methods

The China Health and Retirement Longitudinal Study (CHARLS) conducted a nationwide cross-sectional study of middle-aged and older adults. Depressive status was evaluated using the 10-item center for epidemiological studies depression scale (CESD-10), and self-reported life, health, marital status, parent-child relationship, and air quality satisfaction were adopted using Likert 5-point evaluation methods. A generalized linear model (GLM) was applied to explore the association between satisfaction and depression risk.

Results

A total of 13,978 Chinese people aged over 45 years old were included in this study, and 35.7% of the participants had depressive symptoms. The GLM analysis indicated that all dimensions of satisfaction were negatively associated with the risk of depressive symptoms. For each 1-point increase in life, health, marital status, parent-child relationship, and air quality satisfaction, the incidence of depressive symptoms decreased by 60.8% (odds ratio (OR) = 0.392; 95% confidence interval (CI): 0.370, 0.414), 56.3% (OR = 0.437; 95% CI: 0.418, 0.458), 41.8% (OR = 0.582; 95% CI: 0.555, 0.610), 37.2% (OR = 0.628; 95% CI: 0.596, 0.662), and 25.6% (OR = 0.744; 95% CI: 0.711, 0.778), respectively.

Conclusion

Higher satisfaction levels with life, health, marital status, parent-child relationship, and air quality are associated with a lower risk of depressive symptoms among middle-aged and older adults. Given the aging society and the increasing mental health problems of middle-aged and older adults in China, our study provides a comprehensive perspective for depression prevention and mental health improvement.

Risk factors for suicidal attempt in patients with the melancholic subtype of depressive disorder: Implication for nursing care

The incidence of suicide in patients with depressive order is much higher than other population. We aimed to evaluate the current status and risk of suicidal attempt in patients with the melancholic subtype of depressive disorder, to provide evidence for the clinical management and nursing care of depressive disorder. Patients diagnosed as the melancholic subtype of depressive disorder and treated in our hospital from June 1, 2018 to August 31, 2021 were included. The characteristics of included patients were collected and analyzed. Pearson correlation analysis and logistic regression analysis with odd ratio and 95% confidence interval were conducted to analyze the influencing factors of suicidal attempt in patients with the melancholic subtype of depressive disorder. A total of 446 patients with melancholic subtype of depressive disorder were included, the incidence of suicidal attempt was 18.83%. Pearson correlation analysis indicated that gender (R = 0.611), alcohol drinking (R = 0.719), living situation (R = 0.812), number of previous admission to hospital (R = 0.547), sleep disorder (R = 0.612) and frequent depressive episodes (R = 0.559) were all correlated with the suicidal attempt in patients with melancholic subtype of depressive disorder (all P < 0.05). Logistic regression analysis showed that female (OR 3.115, 95%CI 2.493-3.906), alcohol drinking(OR 1.946, 95%CI 1.684-2.763), living alone (OR 2.401, 95%CI 1.915-3.008), number of previous admission to hospital ≥ 3 (OR 2.342, 95%CI 1.601-2.742), sleep disorder (OR 1.821, 95%CI 1.328-2.215) and frequent depressive episodes (OR 3.128, 95%CI 2.421-3.779) were the independent risk factors of suicidal attempt (all P < 0.05). Suicidal attempt is common in the patients with melancholic subtype of depressive disorder, and there are many related risk factors for suicidal attempt in patients with the melancholic subtype of depressive disorder.

Brain Neural Activity Patterns in an Animal Model of Antidepressant-Induced Manic Episodes

Background: In the treatment of patients with bipolar disorder (BP), antidepressant-induced mania is usually observed. The rate of phase switching (from depressive to manic) in these patients exceeds 22%. The exploration of brain activity patterns during an antidepressant-induced manic phase may aid the development of strategies to reduce the phase-switching rate. The use of a murine model to explore brain activity patterns in depressive and manic phases can help us to understandthe pathological features of BP. The novel object recognition preference ratio is used to assess cognitive ability in such models.

Objective: To investigate brain Ca²⁺ activity and behavioral expression in the depressive and manic phases in the same murine model, to aid understanding of brain activity patterns in phase switching in BP.

Methods: In vivo two-photon imaging was used to observe brain activity alterations in a murine model in which induce depressive-like and manic-like behaviors were induced sequentially. The immobility time was used to assess depressive-like symptoms and the total distance traveled was used to assess manic-like symptoms.

Results: In vivo two-photon imaging revealed significantly reduced brain Ca²⁺ activity in temporal cortex pyramidal neurons in the depressive phase in mice exposed to chronic unpredictable mild stress compared with naïve controls. The brain Ca²⁺ activity correlated negatively with the novel object recognition preference ratio within the immobility time. Significantly increased brain Ca²⁺ activity was observed in the ketamine-induced manic phase. However, this activity did not correlate with the total distance traveled. The novel object recognition preference ratio correlated negatively with the total distance traveled in the manic phase.

Risk of Suicidal Behaviors and Antidepressant Exposure Among Children and Adolescents: A Meta-Analysis of Observational Studies

OBJECTIVES

Although several studies have reviewed the suicidal risk of antidepressants, the conclusions remain inconsistent. We, therefore, performed a meta-analysis of observational studies to address the association between exposure to antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and the risk of suicide and suicide attempt in children and adolescents.

METHODS

MEDLINE and Embase were searched from January 1990 to April 2021. Seventeen cohort and case-control studies were identified that reported suicide or suicide attempt in children and young adults (aged 5-25 years) who were exposed to any antidepressants. We extracted the estimates and corresponding 95% confidence intervals (CIs) from each publication.

RESULTS

The results showed that antidepressant exposure significantly increased the risk of suicide and suicide attempt when compared with no antidepressant usage among children and adolescents. The pooled relative risk (RR) was 1.38 (95% CI: 1.16-1.64; I ² = 83.1%). Among the antidepressants, SSRI use was associated with an increased risk of suicide and suicide attempt, and the pooled RR was 1.28 (95% CI: 1.09-1.51; I ² = 68.8%). In subgroup analysis, the attempted suicidal risk of antidepressant and SSRI was significantly increased (RR = 1.35, 95% CI: 1.13-1.61; I ² = 86.2% for all antidepressants; and RR = 1.26, 95% CI: 1.06-1.48; I ² = 73.8% for SSRIs), while the completed suicidal risk of antidepressant and SSRI was not statistically significant (RR = 2.32, 95% CI: 0.82-6.53; I ² = 6.28% for all antidepressants; and RR = 1.88, 95% CI: 0.74-4.79; I ² = 52.0% for SSRIs). In addition, the risk of suicide and suicide attempt between SSRIs and other antidepressants was similar (RR 1.13, 95% CI: 0.87-1.46, I ² = 32.4%).

CONCLUSION

The main findings of this meta-analysis provide some evidence that antidepressant exposure seems to have an increased suicidal risk among children and young adults. Since untreated depression remains one of the largest risk factors for suicide and the efficacy of antidepressants is proven, clinicians should evaluate carefully their patients and be cautious with patients at risk to have treatment emergence or worsening of suicidal ideation (TESI/TWOSI) when prescribing antidepressants to children and young patients.