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Sicignano DJ, Kurschner R, Weisman N, Sedensky A, Hernandez AV, White CM. The Impact of Ketamine for Treatment of Post-Traumatic Stress Disorder: A Systematic Review With Meta-Analyses. Ann Pharmacother 2024; 58:669-677. [PMID: 37776285 DOI: 10.1177/10600280231199666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Ketamine has been used in anesthesia, pain management, and major depressive disorder. It has recently been studied in patients with post-traumatic stress disorder (PTSD). OBJECTIVE To determine the impact of ketamine on PTSD symptomatology and depression scores. METHODS We conducted a literature search of Medline 1960 to May 20, 2023, and found 6 randomized controlled trials that met our inclusion criteria. We extracted data on the Clinician-Administered PTSD (CAPS), PTSD Checklist (PCL), or Montgomery-Asberg Depression Rating (MADRS) scales. RESULTS The use of ketamine significantly reduced CAPS scores (n = 5, MD: -10.63 [95% CI -14.95 to -6.32]), PCL scores (n = 3, MD: -6.13 [95% CI -8.61 to -3.64]), and MADRS scores (n = 3, MD: -6.33 [95% CI -8.97 to -3.69]) at the maximal follow-up times versus control. Significant benefits were found at day 1 and weeks 1, 2, and 4 for CAPS and PCL scores as well as MADRS scores at day 1, week 1, and week 4 for ketamine versus control. The time to PTSD relapse was prolonged in the patients receiving ketamine versus control (n = 2, 15.74 days [95% CI 3.57 to 29.91 days]). More dry mouth (n = 2, OR 5.85 [95% CI 1.32 to 25.95]), dizziness (n = 2, OR 3.83 [95% CI 1.28 to 11.41]), and blurred vision (n = 2, OR 7.57 [1.00 to 57.10]) occurred with ketamine than control therapy. CONCLUSIONS AND RELEVANCE Ketamine modestly reduced PTSD and depression scores as early as 1 day of therapy, but the longevity of effect needs to be determined. Given similar magnitude of benefit with SSRIs and venlafaxine, ketamine would not supplant these traditional options for chronic use.
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Affiliation(s)
| | - Ryan Kurschner
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Nissen Weisman
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Ava Sedensky
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Adrian V Hernandez
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- Research Administration, Hartford Hospital, Hartford, CT, USA
| | - C Michael White
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- Research Administration, Hartford Hospital, Hartford, CT, USA
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2
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Davis LL, Hamner MB. Post-traumatic stress disorder: the role of the amygdala and potential therapeutic interventions - a review. Front Psychiatry 2024; 15:1356563. [PMID: 38903645 PMCID: PMC11187309 DOI: 10.3389/fpsyt.2024.1356563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/16/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Post-traumatic stress disorder (PTSD) is a psychiatric disorder triggered by exposure to a life-threatening or sexually violent traumatic event, and is characterized by symptoms involving intrusive re-experiencing, persistent avoidance of associated stimuli, emotional and cognitive disturbances, and hyperarousal for long periods after the trauma has occurred. These debilitating symptoms induce occupational and social impairments that contribute to a significant clinical burden for PTSD patients, and substantial socioeconomic costs, reaching approximately $20,000 dollars per individual with PTSD each year in the US. Despite increased translational research focus in the field of PTSD, the development of novel, effective pharmacotherapies for its treatment remains an important unmet clinical need. Observations In this review, we summarize the evidence implicating dysfunctional activity of the amygdala in the pathophysiology of PTSD. We identify the transient receptor potential canonical (TRPC) ion channels as promising drug targets given their distribution in the amygdala, and evidence from animal studies demonstrating their role in fear response modulation. We discuss the evidence-based pharmacotherapy and psychotherapy treatment approaches for PTSD. Discussion In view of the prevalence and economic burden associated with PTSD, further investigation is warranted into novel treatment approaches based on our knowledge of the involvement of brain circuitry and the role of the amygdala in PTSD, as well as the potential added value of combined pharmacotherapy and psychotherapy to better manage PTSD symptoms.
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Affiliation(s)
- Lori L. Davis
- Mental Health Service, Birmingham VA Health Care System, Birmingham, AL, United States
- Department of Psychiatry, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, United States
- Department of Psychiatry, University of Alabama College of Community Health Science, Tuscaloosa, AL, United States
| | - Mark B. Hamner
- Department of Veterans Affairs, Ralph H. Johnson VA Medical Center, Charleston, SC, United States
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
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3
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Norred MA, Zuschlag ZD, Hamner MB. A Neuroanatomic and Pathophysiologic Framework for Novel Pharmacological Approaches to the Treatment of Post-traumatic Stress Disorder. Drugs 2024; 84:149-164. [PMID: 38413493 DOI: 10.1007/s40265-023-01983-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 02/29/2024]
Abstract
Post-traumatic stress disorder (PTSD) is a debilitating disorder inflicting high degrees of symptomatic and socioeconomic burdens. The development of PTSD results from a cascade of events with contributions from multiple processes and the underlying pathophysiology is complex, involving neurotransmitters, neurocircuitry, and neuroanatomical pathways. Presently, only two medications are US FDA-approved for the treatment of PTSD, both selective serotonin reuptake inhibitors (SSRIs). However, the complex underlying pathophysiology suggests a number of alternative pathways and mechanisms that may be targets for potential drug development. Indeed, investigations and drug development are proceeding in a number of these alternative, non-serotonergic pathways in an effort to improve the management of PTSD. In this manuscript, the authors introduce novel and emerging treatments for PTSD, including drugs in various stages of development and clinical testing (BI 1358894, BNC-210, PRAX-114, JZP-150, LU AG06466, NYV-783, PH-94B, SRX246, TNX-102), established agents and known compounds being investigated for their utility in PTSD (brexpiprazole, cannabidiol, doxasoin, ganaxolone, intranasal neuropeptide Y, intranasal oxytocin, tianeptine oxalate, verucerfont), and emerging psychedelic interventions (ketamine, MDMA-assisted psychotherapy, psilocybin-assisted psychotherapy), with an aim to examine and integrate these agents into the underlying pathophysiological frameworks of trauma-related disorders.
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Affiliation(s)
- Michael A Norred
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans Hospital, Tampa, FL, USA
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Zachary D Zuschlag
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans Hospital, Tampa, FL, USA
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Mark B Hamner
- Behavioral Health Service, Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401, USA.
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
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4
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Almeida TM, Lacerda da Silva UR, Pires JP, Borges IN, Martins CRM, Cordeiro Q, Uchida RR. Effectiveness of Ketamine for the Treatment of Post-Traumatic Stress Disorder - A Systematic Review and Meta-Analysis. CLINICAL NEUROPSYCHIATRY 2024; 21:22-31. [PMID: 38559428 PMCID: PMC10979792 DOI: 10.36131/cnfioritieditore20240102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Objective Post-traumatic stress disorder (PTSD) is an enduring condition characterized by a chronic course and impairments across several areas. Despite its significance, treatment options remain limited, and remission rates are often low. Ketamine has demonstrated antidepressant properties and appears to be a promising agent in the management of PTSD. Method A systematic review was conducted in PubMed/MEDLINE, Cochrane Library, Clinicaltrials.gov, Lilacs, Scopus, and Embase, covering studies published between 2012 and December 2022 to assess the effectiveness of ketamine in the treatment of PTSD. Ten studies, consisting of five RCTs, two crossover trials, and three non-randomized trials, were included in the meta-analysis. Results Ketamine demonstrated significant improvements in PCL-5 scores, both 24 hours after the initial infusion and at the endpoint of the treatment course, which varied between 1 to 4 weeks in each study. Notably, the significance of these differences was assessed using the Two Sample T-test with pooled variance and the Two Sample Welch's T-test, revealing a statistically significant effect for ketamine solely at the endpoint of the treatment course (standardized effect size= 0.25; test power 0.9916; 95% CI = 0.57 to 17.02, p=0.0363). It is important to note that high heterogeneity was observed across all analyses. Conclusions Our findings suggest that ketamine holds promise as an effective treatment option for PTSD. However, further trials are imperative to establish robust data for this intervention.
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Affiliation(s)
- Thales Marcon Almeida
- Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | | | - Jeully Pereira Pires
- School of Medicine, Federal University of Cariri – UFCA, Barbalha, Ceará, Brazil
| | - Isaac Neri Borges
- School of Medicine, Federal University of Cariri – UFCA, Barbalha, Ceará, Brazil
| | | | - Quirino Cordeiro
- Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Ricardo R. Uchida
- Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
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5
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Borgogna NC, Owen T, Vaughn J, Johnson DAL, Aita SL, Hill BD. So how special is special K? A systematic review and meta-analysis of ketamine for PTSD RCTs. Eur J Psychotraumatol 2024; 15:2299124. [PMID: 38224070 PMCID: PMC10791091 DOI: 10.1080/20008066.2023.2299124] [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: 07/21/2023] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
Background: PTSD is a significant mental health problem worldwide. Current evidence-based interventions suffer various limitations. Ketamine is a novel agent that is hoped to be incrementally better than extant interventions.Objective: Several randomized control trials (RCTs) of ketamine interventions for PTSD have now been published. We sought to systematically review and meta-analyse results from these trials to evaluate preliminary evidence for ketamine's incremental benefit above-and-beyond control interventions in PTSD treatment.Results: Omnibus findings from 52 effect sizes extracted across six studies (n = 221) yielded a small advantage for ketamine over control conditions at reducing PTSD symptoms (g = 0.27, 95% CI = 0.03, 0.51). However, bias-correction estimates attenuated this effect (adjusted g = 0.20, 95%, CI = -0.08, 0.48). Bias estimates indicated smaller studies reported larger effect sizes favouring ketamine. The only consistent timepoint assessed across RCTs was 24-hours post-initial infusion. Effects at 24-hours post-initial infusion suggest ketamine has a small relative advantage over controls (g = 0.35, 95% CI = 0.06, 0.64). Post-hoc analyses at 24-hours post-initial infusion indicated that ketamine was significantly better than passive controls (g = 0.44, 95% CI = 0.03, 0.85), but not active controls (g = 0.24, 95% CI = -0.30, 0.78). Comparisons one-week into intervention suggested no meaningful group differences (g = 0.24, 95% CI = 0.00, 0.48). No significant differences were evident for RCTs that examined effects two-weeks post initial infusion (g = 0.17, 95% CI = -0.10, 0.44).Conclusions: Altogether, ketamine-for-PTSD RCTs reveal a nominal initial therapeutic advantage relative to controls. However, bias and heterogeneity appear problematic. While rapid acting effects were observed, all control agents (including saline) also evidenced rapid acting effects. We argue blind penetration to be a serious concern, and that placebo is the likely mechanism behind reported therapeutic effects.
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Affiliation(s)
| | - Tyler Owen
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - Jacob Vaughn
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - David A. L. Johnson
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | | | - Benjamin D. Hill
- Department of Psychology, University of South Alabama, Mobile, AL, USA
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6
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Du S, Wey M, Armstrong DW. d-Amino acids in biological systems. Chirality 2023; 35:508-534. [PMID: 37074214 DOI: 10.1002/chir.23562] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
Investigations on the occurrence and biochemical roles of free D-amino acids and D-amino acid-containing peptides and proteins in living systems have increased in frequency and significance. Their occurrence and roles may vary substantially with progression from microbiotic to evermore advanced macrobiotic systems. We now understand many of the biosynthetic and regulatory pathways, which are outlined herein. Important uses for D-amino acids in plants, invertebrates, and vertebrates are reviewed. Given its importance, a separate section on the occurrence and role of D-amino acids in human disease is presented.
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Affiliation(s)
- Siqi Du
- Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, Texas, USA
| | - Michael Wey
- Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, Texas, USA
| | - Daniel W Armstrong
- Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, Texas, USA
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7
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Tsang VWL, Ragazan DC, Kryskow P, Walsh Z, Dames S. A Pilot Study Comparing a Community of Practice Program with and without Concurrent Ketamine-Assisted Therapy. J Psychoactive Drugs 2023:1-10. [PMID: 37655532 DOI: 10.1080/02791072.2023.2253798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/21/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023]
Abstract
The prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) has increased among healthcare providers, while the effectiveness of conventional treatments remains limited. Ketamine-assisted therapy offers a promising alternative; however, few have integrated ketamine with a group-based therapeutic modality. We report a retrospective, secondary analysis of a 12-week pilot of a Community of Practice (CoP) oriented group therapy program with optional, adjunct ketamine for depression, anxiety, and PTSD in a sample of 57 healthcare providers. All participants moved through the treatment as one group, with 38 electing to also receive three adjunct ketamine sessions in addition to the weekly CoP. Symptoms were assessed at baseline and pilot completion with the PHQ-9 for depression, GAD-7 for anxiety, and PCL-5 for PTSD. We observed significant reductions in the mean change among all participants, suggesting that benefit was derived from the CoP component, with or without ketamine as an adjunct. PHQ-9 scores decreased by 6.79 (95% CI: 5.09-8.49, p < .001), GAD-7 scores decreased by 5.57 (CI: 4.12-7.00, p < .001), and PCL-5 scores decreased by 14.83 (CI: 10.27-19.38, p < .001). Reductions were larger, but statistically nonsignificant, among those receiving ketamine. Further research is required to assess the impact of ketamine as an adjunct in group-based therapies.
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Affiliation(s)
- Vivian W L Tsang
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Dragos C Ragazan
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pamela Kryskow
- Health and Human Services, Vancouver Island University, Nanaimo, BC, Canada
- Department of Family Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zach Walsh
- Department of Psychology, University of British Columbia, Kelowna, BC, Canada
| | - Shannon Dames
- Health and Human Services, Vancouver Island University, Nanaimo, BC, Canada
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8
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Hartland H, Mahdavi K, Jelen LA, Strawbridge R, Young AH, Alexander L. A transdiagnostic systematic review and meta-analysis of ketamine's anxiolytic effects. J Psychopharmacol 2023; 37:764-774. [PMID: 37005739 DOI: 10.1177/02698811231161627] [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] [Indexed: 04/04/2023]
Abstract
BACKGROUND Ketamine may be effective in treating symptoms of anxiety, but the time profile of ketamine's anxiolytic effect is ill-defined. This systematic review and meta-analysis investigated the anxiolytic effect of ketamine at different time points across a range of clinical settings. METHODS Electronic databases were searched to capture randomised control trials measuring the anxiolytic effects of ketamine in contexts including mood disorders, anxiety disorders and chronic pain. Meta-analyses were conducted using a random-effects model. The correlations between (1) improvements in mean anxiety and depression scores, and (2) peak dissociation and improvements in mean anxiety scores were also assessed. RESULTS In all, 14 studies met inclusion criteria. Risk of bias was high in 11 studies. Ketamine significantly reduced anxiety scores compared to placebo at acute (<12 h; standard mean difference (SMD): -1.17, 95% confidence interval (CI) [-1.89, -0.44], p < 0.01), subacute (24 h; SMD: -0.44, 95% CI [-0.65, -0.22], p < 0.01) and sustained (7-14 days; SMD: -0.40, 95% CI [-0.63, -0.17], p < 0.01) time points. Exploratory analyses revealed improvements in anxiety and depression symptoms correlated at both subacute (R2 = 0.621, p = 0.035) and sustained time points (R2 = 0.773, p = 0.021). The relationship between peak dissociation and improvement in anxiety was not significant. CONCLUSIONS Ketamine appears to offer rapid and sustained anxiety symptom relief across a range of clinical settings, with anxiolytic effects occurring within the first 12 h of administration and remaining effective for 1-2 weeks. Future studies could explore the effects of ketamine maintenance therapy on anxiety symptoms.
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Affiliation(s)
- Hannah Hartland
- Department of Psychological Medicine, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Kimia Mahdavi
- Department of Psychological Medicine, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Luke A Jelen
- Department of Psychological Medicine, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Rebecca Strawbridge
- Department of Psychological Medicine, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Allan H Young
- Department of Psychological Medicine, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Laith Alexander
- Department of Psychological Medicine, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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9
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Fremont R, Brown O, Feder A, Murrough J. Ketamine for Treatment of Posttraumatic Stress Disorder: State of the Field. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:257-265. [PMID: 37404968 PMCID: PMC10316217 DOI: 10.1176/appi.focus.20230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a chronic and debilitating condition. Although several psychotherapeutic and pharmacological treatments are recommended for PTSD, many individuals do not respond to treatment or respond only partially, highlighting a critical need for additional treatments. Ketamine has the potential to address this therapeutic need. This review discusses how ketamine emerged as a rapid-acting antidepressant and has become a potential treatment for PTSD. A single dose of intravenous (IV) ketamine has been shown to facilitate rapid reduction of PTSD symptoms. Repeated IV ketamine administration significantly improved PTSD symptoms, compared with midazolam, in a predominantly civilian sample of individuals with PTSD. However, in a veteran and military population, repeated IV ketamine did not significantly reduce PTSD symptoms. Further study of ketamine as a treatment for PTSD is necessary, including which populations benefit most from this therapy and the potential benefits of combining psychotherapy and ketamine.
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Affiliation(s)
- Rachel Fremont
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
| | - Oneysha Brown
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
| | - Adriana Feder
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
| | - James Murrough
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
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10
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Kew BM, Porter RJ, Douglas KM, Glue P, Mentzel CL, Beaglehole B. Ketamine and psychotherapy for the treatment of psychiatric disorders: systematic review. BJPsych Open 2023; 9:e79. [PMID: 37128856 DOI: 10.1192/bjo.2023.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Ketamine is an effective short-term treatment for a range of psychiatric disorders. A key question is whether the addition of psychotherapy to ketamine treatment improves outcomes or delays relapse. AIM To identify all studies combining psychotherapy with ketamine for the treatment of psychiatric disorders to summarise their effects and make recommendations for future research. METHOD The review protocol was prospectively registered with PROSPERO (registration number CRD42022318120). Potential studies were searched for in MEDLINE, Embase, PsycINFO, SCOPUS, the Cochrane library and Google Scholar. Eligible studies combined ketamine and psychotherapy for the treatment of psychiatric disorders and did not use case reports or qualitative designs. Key findings relating to psychotherapy type, diagnosis, ketamine protocol, sequencing of psychotherapy and study design are reported. Risk of bias was assessed using modified Joanna Briggs critical appraisal tools. RESULTS Nineteen studies evaluating 1006 patients were included in the systematic review. A variety of supportive individual and group, manualised and non-manualised psychotherapies were used. The majority of studies evaluated substance use disorders, post-traumatic stress disorder and treatment-resistant depression. Ketamine protocols and sequencing of ketamine/psychotherapy treatment varied substantially between studies. Outcomes were largely positive for the addition of psychotherapy to ketamine treatment. CONCLUSION The combination of psychotherapy and ketamine offers promise for the treatment of psychiatric disorders, but study heterogeneity prevents definitive recommendations for their integration. Larger randomised controlled trials using manualised psychotherapies and standardised ketamine protocols are recommended to clarify the extent to which the addition of psychotherapy to ketamine improves outcomes over ketamine treatment alone.
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Affiliation(s)
- Bess M Kew
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard J Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Katie M Douglas
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Paul Glue
- Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
| | - Charlotte L Mentzel
- Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
| | - Ben Beaglehole
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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11
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Ragnhildstveit A, Roscoe J, Bass LC, Averill CL, Abdallah CG, Averill LA. The potential of ketamine for posttraumatic stress disorder: a review of clinical evidence. Ther Adv Psychopharmacol 2023; 13:20451253231154125. [PMID: 36895431 PMCID: PMC9989422 DOI: 10.1177/20451253231154125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/13/2023] [Indexed: 03/08/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) is a devastating condition, for which there are few pharmacological agents, often with a delayed onset of action and poor efficacy. Trauma-focused psychotherapies are further limited by few trained providers and low patient engagement. This frequently results in disease chronicity as well as psychiatric and medical comorbidity, with considerable negative impact on quality of life. As such, off-label interventions are commonly used for PTSD, particularly in chronic refractory cases. Ketamine, an N-methyl-D-aspartate (NDMA) receptor antagonist, has recently been indicated for major depression, exhibiting rapid and robust antidepressant effects. It also shows transdiagnostic potential for an array of psychiatric disorders. Here, we synthesize clinical evidence on ketamine in PTSD, spanning case reports, chart reviews, open-label studies, and randomized trials. Overall, there is high heterogeneity in clinical presentation and pharmacological approach, yet encouraging signals of therapeutic safety, efficacy, and durability. Avenues for future research are discussed.
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Affiliation(s)
- Anya Ragnhildstveit
- Integrated Research Literacy Group, Draper, UT, USA.,Department of Psychiatry, University of Cambridge, Cambridge, UK.,Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - Jeremy Roscoe
- Integrated Research Literacy Group, Draper, UT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Lisa C Bass
- Integrated Research Literacy Group, Draper, UT, USA.,Neuroscience Interdepartmental Program, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher L Averill
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Yale School of Medicine, New Haven, CT, USA.,National Center for PTSD, West Haven, CT, USA
| | - Chadi G Abdallah
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Yale School of Medicine, New Haven, CT, USA.,National Center for PTSD, West Haven, CT, USA
| | - Lynnette A Averill
- Baylor College of Medicine, 1977 Butler Avenue, 4-E-187, Houston, TX 77030, USA.,Yale School of Medicine, New Haven, CT, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,National Center for PTSD, West Haven, CT, USA
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12
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Albuquerque TRD, Macedo LFR, Delmondes GDA, Rolim Neto ML, Almeida TM, Uchida RR, Cordeiro Q, Lisboa KWDSC, Menezes IRAD. Evidence for the beneficial effect of ketamine in the treatment of patients with post-traumatic stress disorder: A systematic review and meta-analysis. J Cereb Blood Flow Metab 2022; 42:2175-2187. [PMID: 35891578 PMCID: PMC9670007 DOI: 10.1177/0271678x221116477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Post-traumatic stress disorder (PTSD) is an anxiety disorder with manifestations somatic resulting from reliving the trauma. The therapy for the treatment of PTSD has limitations, between reduced efficacy and "PTSD pharmacotherapeutic crisis". Scientific evidence has shown that the use of ketamine has benefits for the treatment of depressive disorders and other symptoms present in PTSD compared to other conventional therapies. Therefore, this study aims to analyze the available evidence on the effect of ketamine in the treatment of post-traumatic stress. The systematic review and the meta-analysis were conducted following PRISMA guidelines and RevManager software, using randomized controlled trials and eligible studies of quality criteria for data extraction and analysis. The sample design evaluated included the last ten years, whose search resulted in 594 articles. After applying the exclusion criteria, 35 articles were selected, of which 14 articles were part of the sample, however, only six articles were selected the meta-analysis. The results showed that the ketamine is a promising drug in the management of PTSD with effect more evident performed after 24 h evaluated by MADRS scale. However, the main limitations of the present review demonstrate that more high-quality studies are needed to investigate the influence of therapy, safety, and efficacy.
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Affiliation(s)
| | | | - Gyllyandeson de Araújo Delmondes
- Laboratory of Pharmacology and Molecular Chemistry, Department of Biological Chemistry, Regional University of Cariri-URCA, Crato, Brazil
| | | | - Thales Marcon Almeida
- Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Ricardo Riyoiti Uchida
- Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Quirino Cordeiro
- Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | | | - Irwin Rose Alencar de Menezes
- Laboratory of Pharmacology and Molecular Chemistry, Department of Biological Chemistry, Regional University of Cariri-URCA, Crato, Brazil
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13
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Shivanekar S, Gopalan P, Pizon A, Spotts C, Cruz N, Lightfoot M, Rohac R, Baumeister A, Griffo A, Panny B, Kucherer S, Israel A, Rengasamy M, Price R. A Pilot Study of Ketamine Infusion after Suicide Attempt: New Frontiers in Treating Acute Suicidality in a Real-World Medical Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13792. [PMID: 36360672 PMCID: PMC9656070 DOI: 10.3390/ijerph192113792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/05/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Ketamine, in research settings, rapidly reduces suicidal thoughts 2-24 h after a single infusion in patients with high suicidal ideation. In this study, the authors investigate ketamine's effects on suicidality in a real-world sample of recent suicide attempters on a tertiary-care Consultation-Liaison (CL) psychiatry service. Using an open-label design, 16 transdiagnostic CL patients were recruited, 18-65 years old, to receive a single dose of intravenous ketamine (0.5 mg/kg) in the acute medical setting. All were psychiatrically hospitalized post-infusion. Baseline suicidality and depression measures were compared to ratings taken at 24 h, 5 days, 12 days, and 1, 3 and 6 months post-infusion using paired t-tests. Across all measures, rapid, statistically significant decreases (p's < 0.001) were observed with large to very large effect sizes (Cohen's d's: 1.7-8.8) at acute timepoints (24 h; 5 days). These gains were uniformly maintained to 6 months post-infusion. Open-label ketamine appeared to rapidly and robustly reduced suicidal symptoms in an ultra-high-risk, heterogeneous, real-world sample. Ketamine infusion may therefore be a safe, feasible, viable method to rapidly reduce suicidality among medically hospitalized patients after a suicide attempt, with potentially enduring benefits. The current pilot findings suggest ketamine could be readily integrated into the settings where high-risk CL patients already receive healthcare, with the potential to become an important and novel tool in the treatment of suicidality.
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Affiliation(s)
- Sharvari Shivanekar
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Priya Gopalan
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Anthony Pizon
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh, 3600 Forbes at Meyran Avenue, Forbes Tower, Suite 10028, Pittsburgh, PA 15213, USA
| | - Crystal Spotts
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Nicolas Cruz
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Michael Lightfoot
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Rebecca Rohac
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Andrew Baumeister
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Angela Griffo
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Benjamin Panny
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Shelly Kucherer
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Alex Israel
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Manivel Rengasamy
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
| | - Rebecca Price
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213, USA
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14
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Muacevic A, Adler JR. The Efficacy of Psychedelic-Assisted Therapy in Managing Post-traumatic Stress Disorder (PTSD): A New Frontier? Cureus 2022; 14:e30919. [PMID: 36465766 PMCID: PMC9710723 DOI: 10.7759/cureus.30919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 01/25/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a significant public health concern for which existing therapies are only marginally effective. Indisputably, the primary line of treatment for PTSD is psychotherapy, according to current treatment guidelines. However, PTSD continues to be a chronic condition even after psychotherapy, with high psychiatric and medical illness rates. There is a dire need to search for new compounds and approaches for managing PTSD. The usage of psychedelic substances is a potential new method. This article reviews the efficacy of psychedelic-assisted therapy in treating PTSD and improving patient outcomes. It will examine current research on the topic and evaluate the benefits and drawbacks of different therapies. The current evidence for the use of four different types of psychedelics (3,4-methylenedioxymethamphetamine, ketamine, classical psychedelics, and cannabis) in the treatment of PTSD will be reviewed. It will also include an overview of the therapeutic justification, context of use, and level of evidence available for each drug. Several questions are formulated that could be studied in future research in order to gain a better understanding of the topic.
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15
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Cavarra M, Falzone A, Ramaekers JG, Kuypers KPC, Mento C. Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Front Psychol 2022; 13:887255. [PMID: 35756295 PMCID: PMC9226617 DOI: 10.3389/fpsyg.2022.887255] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Modern clinical research on psychedelics is generating interesting outcomes in a wide array of clinical conditions when psychedelic-assisted psychotherapy is delivered to appropriately screened participants and in controlled settings. Still, a number of patients relapse or are less responsive to such treatments. Individual and contextual factors (i.e., set and setting) seem to play a role in shaping the psychedelic experience and in determining clinical outcomes. These findings, coupled with data from literature on the effectiveness of psychotherapy, frame the therapeutic context as a potential moderator of clinical efficacy, highlighting the need to investigate how to functionally employ environmental and relational factors. In this review, we performed a structured search through two databases (i.e., PubMed/Medline and Scopus) to identify records of clinical studies on psychedelics which used and described a structured associated psychotherapeutic intervention. The aim is to construct a picture of what models of psychedelic-assisted psychotherapy are currently adopted in clinical research and to report on their clinical outcomes. Ad-hoc and adapted therapeutic methods were identified. Common principles, points of divergence and future directions are highlighted and discussed with special attention toward therapeutic stance, degree of directiveness and the potential suggestive effects of information provided to patients.
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Affiliation(s)
- Mauro Cavarra
- Department of Cognitive, Psychological Science and Cultural Studies, University of Messina, Messina, Italy.,Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Alessandra Falzone
- Department of Cognitive, Psychological Science and Cultural Studies, University of Messina, Messina, Italy
| | - Johannes G Ramaekers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Kim P C Kuypers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Carmela Mento
- Department of Biomedical, Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
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16
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Drozdz SJ, Goel A, McGarr MW, Katz J, Ritvo P, Mattina GF, Bhat V, Diep C, Ladha KS. Ketamine Assisted Psychotherapy: A Systematic Narrative Review of the Literature. J Pain Res 2022; 15:1691-1706. [PMID: 35734507 PMCID: PMC9207256 DOI: 10.2147/jpr.s360733] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Currently, ketamine is used in treating multiple pain, mental health, and substance abuse disorders due to rapid-acting analgesic and antidepressant effects. Its limited short-term durability has motivated research into the potential synergistic actions between ketamine and psychotherapy to sustain benefits. This systematic review on ketamine-assisted psychotherapy (KAP) summarizes existing evidence regarding present-day practices. Through rigorous review, seventeen articles that included 603 participants were identified. From available KAP publications, it is apparent that combined treatments can, in specific circumstances, initiate and prolong clinically significant reductions in pain, anxiety, and depressive symptoms, while encouraging rapport and treatment engagement, and promoting abstinence in patients addicted to other substances. Despite much variance in how KAP is applied (route of ketamine administration, ketamine dosage/frequency, psychotherapy modality, overall treatment length), these findings suggest psychotherapy, provided before, during, and following ketamine sessions, can maximize and prolong benefits. Additional large-scale randomized control trials are warranted to understand better the mutually influential relationships between psychotherapy and ketamine in optimizing responsiveness and sustaining long-term benefits in patients with chronic pain. Such investigations will assist in developing standardized practices and maintenance programs.
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Affiliation(s)
- Sandra J Drozdz
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Akash Goel
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew W McGarr
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joel Katz
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Paul Ritvo
- Department of Psychology, York University, Toronto, ON, Canada.,School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | | | - Venkat Bhat
- Interventional Psychiatry Program, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Karim S Ladha
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
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17
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Moaddel R, Zanos P, Farmer CA, Kadriu B, Morris PJ, Lovett J, Acevedo-Diaz EE, Cavanaugh GW, Yuan P, Yavi M, Thomas CJ, Park LT, Ferrucci L, Gould TD, Zarate CA. Comparative metabolomic analysis in plasma and cerebrospinal fluid of humans and in plasma and brain of mice following antidepressant-dose ketamine administration. Transl Psychiatry 2022; 12:179. [PMID: 35501309 PMCID: PMC9061764 DOI: 10.1038/s41398-022-01941-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022] Open
Abstract
Subanesthetic-dose racemic (R,S)-ketamine (ketamine) produces rapid, robust, and sustained antidepressant effects in major depressive disorder (MDD) and bipolar disorder (BD) and has also been shown to effectively treat neuropathic pain, complex regional pain syndrome, and post-traumatic stress disorder (PTSD). However, to date, its mechanism of action remains unclear. Preclinical studies found that (2 R,6 R;2 S,6 S)-hydroxynorketamine (HNK), a major circulating metabolite of ketamine, elicits antidepressant effects similar to those of ketamine. To help determine how (2 R,6 R)-HNK contributes to ketamine's mechanism of action, an exploratory, targeted, metabolomic analysis was carried out on plasma and CSF of nine healthy volunteers receiving a 40-minute ketamine infusion (0.5 mg/kg). A parallel targeted metabolomic analysis in plasma, hippocampus, and hypothalamus was carried out in mice receiving either 10 mg/kg of ketamine, 10 mg/kg of (2 R,6 R)-HNK, or saline. Ketamine and (2 R,6 R)-HNK both affected multiple pathways associated with inflammatory conditions. In addition, several changes were unique to either the healthy human volunteers and/or the mouse arm of the study, indicating that different pathways may be differentially involved in ketamine's effects in mice and humans. Mechanisms of action found to consistently underlie the effects of ketamine and/or (2 R,6 R)-HNK across both the human metabolome in plasma and CSF and the mouse arm of the study included LAT1, IDO1, NAD+, the nitric oxide (NO) signaling pathway, and sphingolipid rheostat.
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Affiliation(s)
- Ruin Moaddel
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA.
| | - Panos Zanos
- Departments of Psychiatry, Pharmacology, and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, 21201, MD, USA
- Department of Psychology, University of Cyprus, 2109, Nicosia, Cyprus
| | - Cristan A Farmer
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Patrick J Morris
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, 20850, USA
| | - Jacqueline Lovett
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA
| | - Elia E Acevedo-Diaz
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Grace W Cavanaugh
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Peixiong Yuan
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Mani Yavi
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Craig J Thomas
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, 20850, USA
| | - Lawrence T Park
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Luigi Ferrucci
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA
| | - Todd D Gould
- Departments of Psychiatry, Pharmacology, and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, 21201, MD, USA
- Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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18
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Mathai DS, Mora V, Garcia-Romeu A. Toward Synergies of Ketamine and Psychotherapy. Front Psychol 2022; 13:868103. [PMID: 35401323 PMCID: PMC8992793 DOI: 10.3389/fpsyg.2022.868103] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/25/2022] [Indexed: 12/13/2022] Open
Abstract
Ketamine is a dissociative drug that has been used medically since the 1970s primarily as an anesthetic agent but also for various psychiatric applications. Anecdotal reports and clinical research suggest substantial potential for ketamine as a treatment in conjunction with psychological interventions. Here, we review historical and modern approaches to the use of ketamine with psychotherapy, discuss the clinical relevance of ketamine’s acute psychoactive effects, propose a unique model for using esketamine (one isomeric form of ketamine) with Acceptance and Commitment Therapy (ACT), and suggest considerations for moving medication-assisted psychotherapy forward as a field.
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Affiliation(s)
- David S Mathai
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Victoria Mora
- School of Health Professions, Baylor College of Medicine, Houston, TX, United States
| | - Albert Garcia-Romeu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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19
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Glavonic E, Mitic M, Adzic M. Hallucinogenic drugs and their potential for treating fear-related disorders: Through the lens of fear extinction. J Neurosci Res 2022; 100:947-969. [PMID: 35165930 DOI: 10.1002/jnr.25017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 12/29/2022]
Abstract
Fear-related disorders, mainly phobias and post-traumatic stress disorder, are highly prevalent, debilitating disorders that pose a significant public health problem. They are characterized by aberrant processing of aversive experiences and dysregulated fear extinction, leading to excessive expression of fear and diminished quality of life. The gold standard for treating fear-related disorders is extinction-based exposure therapy (ET), shown to be ineffective for up to 35% of subjects. Moreover, ET combined with traditional pharmacological treatments for fear-related disorders, such as selective serotonin reuptake inhibitors, offers no further advantage to patients. This prompted the search for ways to improve ET outcomes, with current research focused on pharmacological agents that can augment ET by strengthening fear extinction learning. Hallucinogenic drugs promote reprocessing of fear-imbued memories and induce positive mood and openness, relieving anxiety and enabling the necessary emotional engagement during psychotherapeutic interventions. Mechanistically, hallucinogens induce dynamic structural and functional neuroplastic changes across the fear extinction circuitry and temper amygdala's hyperreactivity to threat-related stimuli, effectively mitigating one of the hallmarks of fear-related disorders. This paper provides the first comprehensive review of hallucinogens' potential to alleviate symptoms of fear-related disorders by focusing on their effects on fear extinction and the underlying molecular mechanisms. We overview both preclinical and clinical studies and emphasize the advantages of hallucinogenic drugs over current first-line treatments. We highlight 3,4-methylenedioxymethamphetamine and ketamine as the most effective therapeutics for fear-related disorders and discuss the potential molecular mechanisms responsible for their potency with implications for improving hallucinogen-assisted psychotherapy.
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Affiliation(s)
- Emilija Glavonic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Milos Mitic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Miroslav Adzic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
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20
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Jumaili WA, Trivedi C, Chao T, Kubosumi A, Jain S. The safety and efficacy of Ketamine NMDA receptor blocker as a therapeutic intervention for PTSD review of a randomized clinical trial. Behav Brain Res 2022; 424:113804. [PMID: 35181391 DOI: 10.1016/j.bbr.2022.113804] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) has long-lasting debilitating symptoms. PTSD causes a significant burden on healthcare workers and victims' families. The US Food Drug Administration (FDA) has approved only two Serotonin Selective Reuptake Inhibitors (SSRI), sertraline, and paroxetine as pharmacological interventions for PTSD. SSRI has a 50-60% response rate and up to 30% remission rate with a high relapse rate. Ketamine is an NMDA receptor blocker, has a rapid effective onset, a potent antidepressant with anti-suicidal, neuroprotective, and cognitive-enhancement properties. METHOD We retrieved randomized clinical trials (RCT) on PubMed, PubMed Central, and Medline Database of clinical trial studies until Jan/2022. We used the following keywords: "posttraumatic stress disorder. "AND "Ketamine." AND "Esketamine" AND "NMDA receptor antagonist" AND "treatment, pharmacological intervention, management. ". We used Medical Subject Heading [Mesh] Term for "ketamine" and "Esketamine" And "Receptors, N-Methyl-D-Aspartate" and "Stress Disorders, Post-Traumatic" and "Disease management.". RESULT All qualified five randomized clinical studies showed rapid and clear benefits of Ketamine infusion for PTSD symptoms resistant to conventional medications. The clinical improvements were evident in three of the four PTSD symptom categories, intrusions, avoidance, and negative alterations in cognitions and mood. In addition, Ketamine administration was safe well-tolerated, with transient dissociation as the main side effect reported. Ketamine infusion also positively affects comorbidities like chronic pain, alcohol use disorder, and major depression. CONCLUSION Ketamine showed fast, safe, highly effective pharmaceutical intervention for chronic PTSD symptoms. No correlation between ketamine potency and patient age, sex and/or body mass index. Further studies are needed to understand the appropriate therapeutic dose, onset, route of administration, duration of the treatment and comorbidity benefit.
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Affiliation(s)
- Wisam Al Jumaili
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA.
| | - Chintan Trivedi
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
| | - Timothy Chao
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
| | - Aaron Kubosumi
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
| | - Shailesh Jain
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
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21
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Du R, Han R, Niu K, Xu J, Zhao Z, Lu G, Shang Y. The Multivariate Effect of Ketamine on PTSD: Systematic Review and Meta-Analysis. Front Psychiatry 2022; 13:813103. [PMID: 35356723 PMCID: PMC8959757 DOI: 10.3389/fpsyt.2022.813103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a serious stress-related disorder caused by traumatic experiences. However, identifying a key therapy that can be used for PTSD treatment remains difficult. Ketamine, a well-known dissociative anesthetic, is considered safe to be used in anesthesia, pain management, and antidepressant actions since 1970. At present, it is still controversial whether PTSD can be treated with ketamine. The authors performed a meta-analysis to determine whether the use of perioperative ketamine lowers the incidence of PTSD. METHODS Cochrane Central Register of Controlled Trials, Embase, PubMed, and Web of Science were searched to examine the use of ketamine for the treatment of PTSD among soldiers with combating experience. Studies were included if they were randomized placebo-controlled, case-control, and cohort studies. The primary outcome was the incidence of PTSD in the later stage of the wounded or burn soldiers. The secondary outcome was the influence of ketamine on PTSD-scale scores for early and chronic PTSD, respectively. RESULTS Our search yielded a total of three studies (n = 503 patients) comparing the use of ketamine (n = 349) to control (n = 154). The available evidence showed no significant difference in the incidence of PTSD between combatant soldiers on the battlefield with or without ketamine treatment (risk ratio = 0.81, 95% CI, 0.63-1.04; P = 0.10). In 65 patients from three trials, ketamine was not only ineffective in treating early PTSD but also lead to exacerbation of the disease (risk ratio = 2.45, 95% CI, 1.33-3.58; P < 0.001). However, in 91 patients from the other three trials, ketamine is effective in treating chronic PTSD (risk ratio = -3.66, 95% CI, -7.05 to -0.27; P = 0.03). CONCLUSION Ketamine was not effective on lower the PTSD incidence for soldiers on the battlefield, nor on the PTSD-scale scores in early PTSD patients. However, it may improve the PTSD-scale scores for chronic conditions. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255516, PROSPERO, identifier: CRD42021255516.
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Affiliation(s)
- Rui Du
- Institute for Biomedical Sciences of Pain, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Ruili Han
- Department of Anaesthesiology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Kun Niu
- Department of Anaesthesiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jiaqiao Xu
- Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Zihou Zhao
- Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Guofang Lu
- Department of Physiology and Pathophysiology, National Key Discipline of Cell Biology, Fourth Military Medical University, Xi'an, China.,State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yulong Shang
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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22
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Infralimbic BDNF signaling is necessary for the beneficial effects of extinction on set shifting in stressed rats. Neuropsychopharmacology 2022; 47:507-515. [PMID: 34497360 PMCID: PMC8674269 DOI: 10.1038/s41386-021-01171-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 08/24/2021] [Accepted: 08/27/2021] [Indexed: 01/11/2023]
Abstract
Current pharmacotherapies for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are ineffective for many patients, and often do not restore cognitive dysfunction associated with these disorders. Behavioral therapies, such as exposure therapy, can be effective for treatment-resistant patients. The mechanisms underlying exposure therapy are not well-understood. Fear extinction as an intervention after chronic stress can model the beneficial effects of exposure therapy in rats. Extinction requires neuronal activity and protein synthesis in the infralimbic (IL) cortex for its beneficial effects. We hypothesized that extinction requires Brain-Derived Neurotrophic Factor (BDNF) activity in the IL cortex to reverse stress-induced cognitive flexibility impairments. Extinction learning reversed set-shifting deficits induced by Chronic Unpredictable Stress (CUS), tested 24 h after extinction. Blocking BDNF signaling in the IL cortex during extinction by local administration of a neutralizing antibody prevented the beneficial effects of extinction on set shifting after stress. Extinction induced activation of the BDNF TrkB receptor, and signaling pathways associated with BDNF (Akt and Erk). Administration of exogenous BDNF into IL cortex in the absence of extinction was sufficient to reverse the effects of stress on set shifting. The effects of extinction were prevented by blocking either Erk or Akt signaling in the IL cortex, whereas the effects of exogenous BDNF were dependent on Erk, but not Akt, signaling. Our observations suggest that BDNF-Erk signaling induced by extinction underlies plastic changes that can reverse or counteract the effects of chronic stress in the IL cortex.
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23
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Keeler JL, Treasure J, Juruena MF, Kan C, Himmerich H. Ketamine as a Treatment for Anorexia Nervosa: A Narrative Review. Nutrients 2021; 13:4158. [PMID: 34836413 PMCID: PMC8625822 DOI: 10.3390/nu13114158] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 02/05/2023] Open
Abstract
Anorexia nervosa (AN) is a highly complex disorder to treat, especially in severe and enduring cases. Whilst the precise aetiology of the disorder is uncertain, malnutrition and weight loss can contribute to reductions in grey and white matter of the brain, impairments in neuroplasticity and neurogenesis and difficulties with cognitive flexibility, memory and learning. Depression is highly comorbid in AN and may be a barrier to recovery. However, traditional antidepressants are often ineffective in alleviating depressive symptoms in underweight patients with AN. There is an urgent need for new treatment approaches for AN. This review gives a conceptual overview for the treatment of AN with ketamine. Ketamine has rapid antidepressant effects, which are hypothesised to occur via increases in glutamate, with sequelae including increased neuroplasticity, neurogenesis and synaptogenesis. This article provides an overview of the use of ketamine for common psychiatric comorbidities of AN and discusses particular safety concerns and side effects. Potential avenues for future research and specific methodological considerations are explored. Overall, there appears to be ample theoretical background, via several potential mechanisms, that warrant the exploration of ketamine as a treatment for adults with AN.
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Affiliation(s)
- Johanna Louise Keeler
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (J.T.); (H.H.)
| | - Janet Treasure
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (J.T.); (H.H.)
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham BR3 3BX, UK;
| | - Mario F. Juruena
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham BR3 3BX, UK;
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK
| | - Carol Kan
- Eating Disorder Service, Central and North West London NHS Foundation Trust, 1 Nightingale Place, Kensington & Chelsea, London SW10 9NG, UK;
| | - Hubertus Himmerich
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (J.T.); (H.H.)
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham BR3 3BX, UK;
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Philipp-Muller AE, Reshetukha T, Vazquez G, Milev R, Armstrong D, Jagayat J, Alavi N. Combining Ketamine and Internet-Based Cognitive Behavioral Therapy for the Treatment of Posttraumatic Stress Disorder: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e30334. [PMID: 34092549 PMCID: PMC8335614 DOI: 10.2196/30334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 01/23/2023] Open
Abstract
Background Over one third of patients with posttraumatic stress disorder (PTSD) do not respond to current interventions. Ketamine presents a potential treatment option; however, its effects are temporary. Administering ketamine alongside psychotherapy is one potential means of prolonging its effects; however, only a few studies have investigated this treatment method to date, and none have tested ketamine with internet-based or electronically delivered cognitive behavioral therapy (e-CBT). Objective This open-label randomized controlled trial aims to assess the efficacy of a combined treatment method of subanesthetic intravenous ketamine and e-CBT for treating patients with PTSD. Methods In total, 20 patients with refractory PTSD recruited from a community clinic will be randomly assigned to either an experimental group (n=10), receiving a combination of ketamine and therapist-administered e-CBT over 14 weeks, or a waitlist control group (n=10), receiving the experimental treatment after 14 weeks. Both groups will be assessed for the symptoms of PTSD and comorbid disorders before treatment, at two midway points, and at the end of the experiment. Results PTSD symptoms of participants in the experimental group are expected to improve significantly more than those of participants in the waitlist control group (P=.05) with a large effect size (η2=0.14). Conclusions This is the first study to assess the relationship between e-CBT and ketamine and their combined ability to treat refractory PTSD. If successful, this study will open web-based, asynchronous therapeutic options for patients with PTSD and will provide new insights into the functional role of glutamate in trauma-related disorders as well as in learning, memory, and fear extinction. Trial Registration ClinicalTrials.gov NCT04771767; https://clinicaltrials.gov/ct2/show/NCT04771767. International Registered Report Identifier (IRRID) PRR1-10.2196/30334
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Affiliation(s)
| | - Taras Reshetukha
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Gustavo Vazquez
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Roumen Milev
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Dawn Armstrong
- Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Jasleen Jagayat
- Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Nazanin Alavi
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada
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25
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Schwenk ES, Pradhan B, Nalamasu R, Stolle L, Wainer IW, Cirullo M, Olsen A, Pergolizzi JV, Torjman MC, Viscusi ER. Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity. Curr Pain Headache Rep 2021; 25:57. [PMID: 34269883 DOI: 10.1007/s11916-021-00977-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented. RECENT FINDINGS Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.
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Affiliation(s)
- Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA.
| | - Basant Pradhan
- Psychiatry & Pediatrics, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Rohit Nalamasu
- Department of Physical Medicine and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Michael Cirullo
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Olsen
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | | | - Marc C Torjman
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
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26
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Therapeutic potential of ketamine for alcohol use disorder. Neurosci Biobehav Rev 2021; 126:573-589. [PMID: 33989669 DOI: 10.1016/j.neubiorev.2021.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/02/2021] [Accepted: 05/09/2021] [Indexed: 12/12/2022]
Abstract
Excessive alcohol consumption is involved in 1/10 of deaths of U.S. working-age adults and costs the country around $250,000,000 yearly. While Alcohol Use Disorder (AUD) pathology is complex and involves multiple neurotransmitter systems, changes in synaptic plasticity, hippocampal neurogenesis, and neural connectivity have been implicated in the behavioral characteristics of AUD. Depressed mood and stress are major determinants of relapse in AUD, and there is significant comorbidity between AUD, depression, and stress disorders, suggesting potential for overlap in their treatments. Disulfiram, naltrexone, and acamprosate are current pharmacotherapies for AUD, but these treatments have limitations, highlighting the need for novel therapeutics. Ketamine is a N-methyl-D-Aspartate receptor antagonist, historically used in anesthesia, but also affects other neurotransmitters systems, synaptic plasticity, neurogenesis, and neural connectivity. Currently under investigation for treating AUDs and other Substance Use Disorders (SUDs), ketamine has strong support for efficacy in treating clinical depression, recently receiving FDA approval. Ketamine's effect in treating depression and stress disorders, such as PTSD, and preliminary evidence for treating SUDs further suggests a role for treating AUDs. This review explores the behavioral and neural evidence for treating AUDs with ketamine and clinical data on ketamine therapy for AUDs and SUDs.
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Abstract
This review examines the role of trauma in psychiatric morbidity and analogous psychoneurobiological changes. Trauma is a necessary criterion for Post-Traumatic Stress Disorder (PTSD), however, trauma history is highly correlated with a variety of psychiatric conditions. Some evidence suggests that Major Depressive Disorder (MDD) is the most common psychiatric condition that arises following trauma. Approximately 50% of PTSD cases present with co-morbid MDD. Overlapping symptomatology and neurobiology between these conditions underlie the debate over whether these phenomena result from problematic nosology or whether comorbid MDD + PTSD is a distinct phenotype of trauma-related psychopathology. Regardless, similar treatment approaches have been employed historically, with varying success. The drug-assisted psychotherapy treatment model, which combines pharmacological and psychotherapeutic approaches, is currently being trialled as a novel treatment approach in psychiatry. Both psilocybin- and 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy have received Food and Drug Administration 'breakthrough therapy' designation for the treatment of resistant MDD and PTSD, respectively. This paper reviews the therapeutic rationale of both psilocybin and MDMA for treating both trauma-related MDD and PTSD.
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Affiliation(s)
- Catherine I V Bird
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Nadav L Modlin
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James J H Rucker
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
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28
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Varker T, Watson L, Gibson K, Forbes D, O'Donnell ML. Efficacy of Psychoactive Drugs for the Treatment of Posttraumatic Stress Disorder: A Systematic Review of MDMA, Ketamine, LSD and Psilocybin. J Psychoactive Drugs 2020; 53:85-95. [PMID: 32931403 DOI: 10.1080/02791072.2020.1817639] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The aim of this systematic review was to examine the efficacy of MDMA, ketamine, LSD, and psilocybin for the treatment of posttraumatic stress disorder (PTSD). A search of four databases for English language, peer-reviewed literature published from inception to 18th October 2019 yielded 2,959 records, 34 of which were screened on full-text. Observational studies and RCTs which tested the efficacy of MDMA, ketamine, LSD, or psilocybin for reducing PTSD symptoms in adults, and reported changes to PTSD diagnosis or symptomatology, were included. Nine trials (five ketamine and four MDMA) met inclusion criteria. Trials were rated on a quality and bias checklist and GRADE was used to rank the evidence. The evidence for ketamine as a stand-alone treatment for comorbid PTSD and depression was ranked "very low", and the evidence for ketamine in combination with psychotherapy as a PTSD treatment was ranked "low". The evidence for MDMA in combination with psychotherapy as a PTSD treatment was ranked "moderate".
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Affiliation(s)
- Tracey Varker
- Phoenix Australia- Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Loretta Watson
- Phoenix Australia- Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Kari Gibson
- Phoenix Australia- Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - David Forbes
- Phoenix Australia- Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Meaghan L O'Donnell
- Phoenix Australia- Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
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29
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Ahmed H, Haider A, Ametamey SM. N-Methyl-D-Aspartate (NMDA) receptor modulators: a patent review (2015-present). Expert Opin Ther Pat 2020; 30:743-767. [PMID: 32926646 DOI: 10.1080/13543776.2020.1811234] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION - The NMDA receptor is implicated in various diseases including neurodegenerative, neurodevelopmental and mood disorders. However, only a limited number of clinically approved NMDA receptor modulators are available. Today, apparent NMDA receptor drug development strategies entail 1) exploring the unknown chemical space to identify novel scaffolds; 2) using the clinically available NMDA receptor modulators to expand the therapeutic indication space; 3) and to trace physiological functions of the NMDA receptor. AREAS COVERED - The current review reflects on the functional and pharmacological facets of NMDA receptors and the current clinical status quo of NMDA receptor modulators. Patent literature covering 2015 till April 2020 is discussed with emphasis on new indications. EXPERT OPINION - Supporting evidence shows that subtype-selective NMDA receptor antagonists show an improved safety profile compared to broad-spectrum channel blockers. Although GluN2B-selective antagonists are by far the most extensively investigated subtype-selective modulators, they have shown only modest clinical efficacy so far. To overcome the limitations that have hampered the clinical development of previous subtype-selective NMDA receptor antagonists, future studies with improved animal models that better reflect human NMDA receptor pathophysiology are warranted. The increased availability of subtype-selective probes will allow target engagement studies and proper dose finding in future clinical trials.
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Affiliation(s)
- Hazem Ahmed
- Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, ETH Zurich , Zurich, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich , Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich , Schlieren, Switzerland
| | - Simon M Ametamey
- Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, ETH Zurich , Zurich, Switzerland
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30
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Krediet E, Bostoen T, Breeksema J, van Schagen A, Passie T, Vermetten E. Reviewing the Potential of Psychedelics for the Treatment of PTSD. Int J Neuropsychopharmacol 2020; 23:385-400. [PMID: 32170326 PMCID: PMC7311646 DOI: 10.1093/ijnp/pyaa018] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 02/12/2020] [Accepted: 03/12/2020] [Indexed: 12/28/2022] Open
Abstract
There are few medications with demonstrated efficacy for the treatment of posttraumatic stress disorder (PTSD). Treatment guidelines have unequivocally designated psychotherapy as a first line treatment for PTSD. Yet, even after psychotherapy, PTSD often remains a chronic illness, with high rates of psychiatric and medical comorbidity. Meanwhile, the search for and development of drugs with new mechanisms of action has stalled. Therefore, there is an urgent need to explore not just novel compounds but novel approaches for the treatment of PTSD. A promising new approach involves the use of psychedelic drugs. Within the past few years, 2 psychedelics have received breakthrough designations for psychiatric indications from the US Food and Drug Administration, and several psychedelics are currently being investigated for the treatment of PTSD. This review discusses 4 types of compounds: 3,4-methylenedioxymethamphetamine, ketamine, classical psychedelics (e.g., psilocybin and lysergic acid diethylamide), and cannabinoids. We describe the therapeutic rationale, the setting in which they are being administered, and their current state of evidence in the treatment of PTSD. Each compound provides unique qualities for the treatment of PTSD, from their use to rapidly target symptoms to their use as adjuncts to facilitate psychotherapeutic treatments. Several questions are formulated that outline an agenda for future research.
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Affiliation(s)
- Erwin Krediet
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Tijmen Bostoen
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Joost Breeksema
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Torsten Passie
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
- Dr. Senckenberg Institute for the History and Ethics in Medicine, Goethe University Frankfurt/Main, Frankfurt am Main, Germany
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- ARQ National Psychotrauma Center, Diemen, The Netherlands
- Military Mental Health Care, Utrecht, The Netherlands
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Mathew SJ, Price RB. Ketamine Plus Motivational Enhancement Therapy: Leveraging a Rapid Effect to Promote Enduring Change. Am J Psychiatry 2020; 177:107-109. [PMID: 32008392 DOI: 10.1176/appi.ajp.2019.19121242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sanjay J Mathew
- The Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, and the Michael E. DeBakey VA Medical Center, Houston (Mathew); and the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh (Price)
| | - Rebecca B Price
- The Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, and the Michael E. DeBakey VA Medical Center, Houston (Mathew); and the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh (Price)
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Wilkinson ST, Holtzheimer PE, Gao S, Kirwin DS, Price RB. Leveraging Neuroplasticity to Enhance Adaptive Learning: The Potential for Synergistic Somatic-Behavioral Treatment Combinations to Improve Clinical Outcomes in Depression. Biol Psychiatry 2019; 85:454-465. [PMID: 30528745 PMCID: PMC6380941 DOI: 10.1016/j.biopsych.2018.09.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/30/2018] [Accepted: 09/11/2018] [Indexed: 12/17/2022]
Abstract
Until recently, therapeutic development in psychiatry was targeted solely toward symptom reduction. While this is a worthwhile goal, it has yielded little progress in improved therapeutics in the last several decades in the field of mood disorders. Recent advancements in our understanding of pathophysiology suggests that an impairment of neuroplasticity may be a critical part of the development of neuropsychiatric disorders. Interventions that enhance or modulate neuroplasticity often reduce depressive symptoms when applied as stand-alone treatments. Unfortunately, when treatments are discontinued, the disease state often returns as patients relapse. However, treatments that enhance or modulate plasticity not only reduce symptom burden, but also may provide an opportune window wherein cognitive or behavioral interventions could be introduced to harness a state of enhanced neuroplasticity and lead to improved longer-term clinical outcomes. Here, we review the potential of synergistically combining plasticity-enhancing and behavioral therapies to develop novel translational treatment approaches for depression. After reviewing relevant neuroplasticity deficits in depression, we survey biological treatments that appear to reverse such deficits in humans, including N-methyl-D-aspartate receptor modulators (ketamine, D-cycloserine), electroconvulsive therapy, and transcranial brain stimulation. We then review evidence that either directly or indirectly supports the hypothesis that a robust enhancement of neuroplasticity through these methods might promote the uptake of cognitive and behavioral interventions to enhance longer-term treatment outcomes through a synergistic effect. We identify key missing pieces of evidence and discuss future directions to enhance this emerging line of research.
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Affiliation(s)
- Samuel T. Wilkinson
- Department of Psychiatry, Yale School of Medicine and Yale Psychiatric Hospital, New Haven, Connecticut
| | - Paul E. Holtzheimer
- National Center for PTSD, Executive Division, White River Junction VA Medical Center, White River Junction, Vermont;,Department of Psychiatry and Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Shan Gao
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David S. Kirwin
- Department of Psychiatry, Yale School of Medicine and Yale Psychiatric Hospital, New Haven, Connecticut
| | - Rebecca B. Price
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
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