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Elersič K, Banjac A, Živin M, Zorović M. Behavioral sensitization and tolerance induced by repeated treatment with ketamine enantiomers in male Wistar rats. PLoS One 2024; 19:e0299379. [PMID: 38427622 PMCID: PMC10906899 DOI: 10.1371/journal.pone.0299379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/03/2024] Open
Abstract
Ketamine has gained significant attention as a fast-acting antidepressant. However, ketamine is also associated with undesirable side effects. In our preclinical study, we explored the behavioral effects of ketamine enantiomers at subanesthetic doses. During repeated intermittent treatment, we examined locomotor stimulation and sensitization, ataxia, and expression of natural behaviors (grooming and rearing). Male Wistar rats were subcutaneously treated repeatedly with either 5 mg/kg of R-ketamine or S-ketamine, 15 mg/kg of R-ketamine, S-ketamine or racemic ketamine, 30 mg/kg of racemic ketamine or saline every third day for three weeks (seven treatments overall). After the first treatment, only 15 mg/kg of S-ketamine induced locomotor stimulation, and both 15 mg/kg of S-ketamine and 30 mg/kg of racemic ketamine induced ataxia. Upon repeated administration, doses of 15 mg/kg of R-ketamine, S-ketamine, and racemic ketamine, as well as 30 mg/kg of racemic ketamine, stimulated locomotion. 15 mg/kg of R-ketamine, S-ketamine, and racemic ketamine additionally resulted in locomotor sensitization. The last administration of 15 mg/kg of S-ketamine, 15 mg/kg of racemic ketamine, and 30 mg/kg of racemic ketamine resulted in ataxia. In the case of 15 mg/kg of S-ketamine, ataxic effects were significantly weaker in comparison to the effects from the first administration, indicating tolerance. Natural behaviors were attenuated after 5 and 15 mg/kg of S-ketamine and 15 and 30 mg/kg of racemic ketamine. Neither of the R-ketamine doses produced such an effect. We conclude that S-ketamine has a stronger behavioral effect than R-ketamine.
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Affiliation(s)
- Kristian Elersič
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anamarija Banjac
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marko Živin
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Zorović
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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2
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Impact of Repeated Doses of Subcutaneous Esketamine on Acute Dissociative Symptoms in Treatment-Resistant Depression. Pharmaceuticals (Basel) 2022; 16:ph16010031. [PMID: 36678528 PMCID: PMC9861342 DOI: 10.3390/ph16010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Esketamine has been approved by the US Food and Drug Administration (FDA) as an adjunctive treatment for use in conjunction with an oral antidepressant for patients with treatment-resistant depression (TRD), but dissociative symptoms are common adverse effects. METHODS A retrospective analysis of 394 subcutaneous esketamine injections given to 70 patients with TRD that were administered once a week during a six-week trial in conjunction with oral antidepressant therapy. Doses between 0.5 to 1.0 mg/kg were administered according to the patient's response. Dissociative symptoms were assessed using the Clinician-Administered Dissociative States Scale (CADSS) 30 and 60 min after every weekly treatment (day 1, 8, 15, 22, 29 and 36). RESULTS Seventy patients received a total of 394 subcutaneous esketamine injections over six weeks. Over time, the evolution of CADSS scores demonstrated a significant mean difference of CADSS at 60 min post-injection (p = 0.010) throughout the six infusions. The mean CADSS scores at 60 min on day 22, 29 and 36 were similar. There were no differences between mean CADSS scores 30 min after the injections, no clinical correlation between response and dissociative symptoms, no correlation between time and demographic and clinical characteristics and no interactions between time and combined medication. CONCLUSIONS Our results suggest that repeated subcutaneous esketamine doses are safe and well-tolerated regarding their acute dissociative and psychotomimetic symptoms. Symptoms usually peak at 30 min and decrease at 60 min post-injection, returning to their pretreatment levels at 120 min. Dissociative symptoms do not correlate with antidepressant response.
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Walsh CA, Livne O, Shmulewitz D, Stohl M, Hasin DS. Use of plant-based hallucinogens and dissociative agents: U.S. Time Trends, 2002-2019. Addict Behav Rep 2022; 16:100454. [PMID: 36119808 PMCID: PMC9471967 DOI: 10.1016/j.abrep.2022.100454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/28/2022] [Accepted: 09/03/2022] [Indexed: 11/29/2022] Open
Abstract
Aims Information on time trends in use of different plant-based hallucinogens is lacking. The current study used nationally representative U.S. data to assess overall and age-specific time trends in the prevalence of lifetime and 12-month use of plant-based hallucinogens and dissociative agents. Methods Participants were respondents aged ≥ 12 years (N = 1,006,051) from the National Survey on Drug Use and Health, 2002-2019. Predictors were continuous years. Outcomes included illicit use of peyote, mescaline, psilocybin, ketamine, salvia, and tryptamine. Sociodemographic variables (gender; age; race/ethnicity; educational level; family income) were modeled as covariates. Trends were estimated overall and by age (12-17, 18-25, 26+). Prevalence differences [PDs] were obtained for each category, along with 95 % confidence intervals [CI]. Results Increases in lifetime use were observed for psilocybin (2002-2019 PD=+1.61), tryptamine (2006-2014 PD=+0.55; 2015-2019 PD=+0.44), and ketamine (2006-2014 PD=+0.27; 2015-2019 PD=+0.21). Mescaline use decreased (PD = -0.89). While overall lifetime salvia use increased between 2006 and 2014 (PD=+1.81), prevalence did not change between 2015 and 2019. Twelve-month use of tryptamine and ketamine increased between 2006 and 2014 (PD=+0.14; +0.03, respectively). Twelve-month ketamine use also increased from 2015 to 2019 (PD=+0.03). By age, participants aged 12-17 and 18-25 showed decreases in use of most types of hallucinogens, but those age 26+ generally showed increases. Conclusions While use of plant-based hallucinogens and dissociative agents remains rare, lifetime use of ketamine, tryptamine, and psilocybin is increasing in adults. Considering these increases alongside concerns about unsupervised use of illicit products whose dose and composition is uncertain, clinicians and policymakers should remain mindful of the rising rates of illicit use in the general population.
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Affiliation(s)
- Claire A. Walsh
- New York State Psychiatric Institute, New York, NY, United States
| | - Ofir Livne
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Dvora Shmulewitz
- New York State Psychiatric Institute, New York, NY, United States,Department of Psychiatry, Columbia University Medical Center, New York, NY, United States
| | - Malki Stohl
- New York State Psychiatric Institute, New York, NY, United States
| | - Deborah S. Hasin
- New York State Psychiatric Institute, New York, NY, United States,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States,Department of Psychiatry, Columbia University Medical Center, New York, NY, United States,Corresponding author at: Columbia University/New York State Psychiatric Institute, 1051 Riverside Drive, Box 123, New York, NY 10032, United States.
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Bayes A, Dong V, Martin D, Alonzo A, Kabourakis M, Loo C. Ketamine treatment for depression: A model of care. Aust N Z J Psychiatry 2021; 55:1134-1143. [PMID: 34384256 DOI: 10.1177/00048674211039166] [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: 11/17/2022]
Abstract
OBJECTIVE Ketamine and related compounds are emerging as rapidly acting therapies for treatment-resistant depression. Ketamine differs from standard antidepressants in its speed of action, specific acute and cumulative side effects, risk of dependence and regulatory requirements. However, there is currently little guidance offering translation from research studies into clinical practice. We therefore detail a comprehensive model of care for ketamine treatment of depression. METHOD We formulated a set of policies and procedures for a 'compassionate use' ketamine programme that developed out of our clinical research in ketamine. These policies and procedures were formulated into a detailed model of care. RESULTS The current Australian and New Zealand regulatory frameworks and professional bodies' recommendations regarding ketamine are detailed along with clinical governance and infrastructure considerations. We next describe a four-step model comprising initial assessment, pre-treatment, treatment and post-treatment phases. The model comprises thorough psychiatric and medical assessments examining patient suitability, a rigorous consenting process and structured safety monitoring across an acute treatment course or maintenance therapy. Our ketamine dose-titration method is detailed allowing flexible dosing of patients across a treatment course enabling individualised treatment. CONCLUSION The model of care aims to bridge the gap between efficacy studies and clinical care outside of research settings as ketamine and related compounds become increasingly important therapies for treatment-resistant depression.
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Affiliation(s)
- Adam Bayes
- Black Dog Institute, Sydney Neurostimulation Centre (SyNC), Sydney, NSW, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vanessa Dong
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Michael Kabourakis
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Colleen Loo
- Black Dog Institute, Sydney Neurostimulation Centre (SyNC), Sydney, NSW, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
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5
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Di Vincenzo JD, Siegel A, Lipsitz O, Ho R, Teopiz KM, Ng J, Lui LMW, Lin K, Cao B, Rodrigues NB, Gill H, McIntyre RS, Rosenblat JD. The effectiveness, safety and tolerability of ketamine for depression in adolescents and older adults: A systematic review. J Psychiatr Res 2021; 137:232-241. [PMID: 33706168 DOI: 10.1016/j.jpsychires.2021.02.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/22/2021] [Accepted: 02/20/2021] [Indexed: 12/23/2022]
Abstract
The majority of antidepressant medication trials have focused on adult populations (ages 18-65), with much less research in older and younger populations. Moreover, key differences in the efficacy and safety of antidepressants have been identified between these age groups. Ketamine has emerged as a promising new treatment for treatment resistant depression (TRD). The objective of this review is to summarize and synthesize the extant literature on the effectiveness, safety and tolerability of ketamine for depression in special age populations (age ≤18 and ≥ 60). Following PRISMA guidelines, a systematic review was performed, searching EMBASE, PsycInfo, and PubMed from inception through July 2020. Studies reporting the use of any ketamine formulation with variable routes of administration to treat clinically diagnosed depression in adolescents or older adults were included. Thirteen studies were included in the analysis and ten observed rapid (≤2 week latency) antidepressant effects following ketamine treatments, with better outcomes following larger, repeated doses, and in open-label rather than blinded settings. Two case reports in adolescents assessed measures of suicidal ideation and both found ketamine to effectuate rapid anti-suicidal effects. Ketamine appears to be safe and well-tolerated in adolescents and older adults. The small quantity, high heterogeneity, and generally low quality of available studies precludes statistical syntheses and significantly limits the strength of our conclusions. Preliminary proof-of-concept studies are promising, however, rigorously designed randomized controlled trials (RCTs) are still required to ascertain effectiveness, safety and tolerability in these groups.
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Affiliation(s)
- Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Medical Sciences Building, 1 King's College Circle, ON, M5S 1A8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Ashley Siegel
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Orly Lipsitz
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, 119228, Singapore; Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, MD6, 14 Medical Drive #14-01, 117599, Singapore
| | - Kayla M Teopiz
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - Jason Ng
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - Kangguang Lin
- Department of Affective Disorders, The Affiliated Hospital of Guangzhou Medical University, Guangzhou (Guangzhou Huiai Hospital), China
| | - Bing Cao
- Key Laboratory of Cognition and Personality (SWU), Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, 400715, PR China
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Medical Sciences Building, 1 King's College Cir, M5S 1A8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Medical Sciences Building, 1 King's College Circle, ON, M5S 1A8, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, M5T 1R8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, M5T 1R8, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada.
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6
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Cavenaghi VB, da Costa LP, Lacerda ALT, Hirata ES, Miguel EC, Fraguas R. Subcutaneous Ketamine in Depression: A Systematic Review. Front Psychiatry 2021; 12:513068. [PMID: 34122156 PMCID: PMC8193034 DOI: 10.3389/fpsyt.2021.513068] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Ketamine has been shown to produce a rapid and robust antidepressant effect. Though numerous routes of administration have been studied, subcutaneous (SC) has proven to be a convenient and cost-effective route making its use particularly relevant in developing countries. Here we provide a systematic review covering the use of SC racemic ketamine and esketamine in depression, including its efficacy, safety and tolerability. Methods: A systematic literature search was carried out, from inception through March, 2021, using PubMed/MEDLINE, EMBASE and Web of Science, with no limits of language. After identifying 159 potentially relevant articles, 12 articles were selected after applying our inclusion/exclusion criteria. These comprised two randomized clinical trials, five case-reports and five retrospective studies. Given the small number of studies found and their heterogeneous nature, a meta-analysis was not considered appropriate. Here we provide a synthesis of these data including participant characteristics, dose range, efficacy, safety/ tolerability. Risk of bias was accessed using the Cochrane risk of bias tool. Results: SC Ketamine was administered to unipolar and bipolar patients a single or multiple doses, weekly or twice-weekly, a dose-titration approach was made in major studies, dose ranged from 0.1 to 0.5 mg/Kg of racemic ketamine and 0.5-1 mg/Kg of esketamine. Across all studies, SC ketamine showed a rapid and robust antidepressant effect, with response/ remission rates from 50 to 100% following both single or multiple doses, with transitory side effects. Conclusion: SC racemic ketamine and esketamine in depression is a promising strategy showing beneficial efficacy and tolerability. Future studies exploring the SC route, its cost-effectiveness, and a direct comparison with IV and intranasal (IN) protocols are warranted. Systematic Review Registration: CRD42019137434.
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Affiliation(s)
| | - Leandro Paulino da Costa
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Programa de Transtornos Afetivos, Laboratório Interdisciplinar de Neurociências Clínicas, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Edson Shiguemi Hirata
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Renério Fraguas
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.,University Hospital, University of São Paulo, São Paulo, Brazil
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7
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Viana GSB, Vale EMD, Araujo ARAD, Coelho NC, Andrade SM, Costa ROD, Aquino PEAD, Sousa CNSD, Medeiros ISD, Vasconcelos SMMD, Neves KRT. Rapid and long-lasting antidepressant-like effects of ketamine and their relationship with the expression of brain enzymes, BDNF, and astrocytes. ACTA ACUST UNITED AC 2020; 54:e10107. [PMID: 33331415 PMCID: PMC7747878 DOI: 10.1590/1414-431x202010107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/28/2020] [Indexed: 12/28/2022]
Abstract
Ketamine (KET) is an N-methyl-D-aspartate (NMDA) antagonist with rapid and long-lasting antidepressant effects, but how the drug shows its sustained effects is still a matter of controversy. The objectives were to evaluate the mechanisms for KET rapid (30 min) and long-lasting (15 and 30 days after) antidepressant effects in mice. A single dose of KET (2, 5, or 10 mg/kg, po) was administered to male Swiss mice and the forced swim test (FST) was performed 30 min, 15, or 30 days later. Imipramine (IMI, 30 mg/kg, ip), a tricyclic antidepressant drug, was used as reference. The mice were euthanized, separated into two time-point groups (D1, first day after KET injection; D30, 30 days later), and brain sections were processed for glycogen synthase kinase-3 (GSK-3), histone deacetylase (HDAC), brain-derived neurotrophic factor (BDNF), and glial fibrillary acidic protein (GFAP) immunohistochemical assays. KET (5 and 10 mg/kg) presented rapid and long-lasting antidepressant-like effects. As expected, the immunoreactivities for brain GSK-3 and HDAC decreased compared to control groups in all areas (striatum, DG, CA1, CA3, and mainly pre-frontal cortex, PFC) after KET injection. Increases in BDNF immunostaining were demonstrated in the PFC, DG, CA1, and CA3 areas at D1 and D30 time-points. GFAP immunoreactivity was also increased in the PFC and striatum at both time-points. In conclusion, KET changed brain BDNF and GFAP expressions 30 days after a single administration. Although neuroplasticity could be involved in the observed effects of KET, more studies are needed to explain the mechanisms for the drug’s sustained antidepressant-like effects.
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Affiliation(s)
- G S B Viana
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - E M do Vale
- Departamento de Biofisiologia, Faculdade de Medicina Estácio de Juazeiro do Norte, Juazeiro do Norte, CE, Brasil
| | - A R A de Araujo
- Departamento de Biofisiologia, Faculdade de Medicina Estácio de Juazeiro do Norte, Juazeiro do Norte, CE, Brasil
| | - N C Coelho
- Departamento de Biofisiologia, Faculdade de Medicina Estácio de Juazeiro do Norte, Juazeiro do Norte, CE, Brasil
| | - S M Andrade
- Departamento de Biofisiologia, Faculdade de Medicina Estácio de Juazeiro do Norte, Juazeiro do Norte, CE, Brasil
| | - R O da Costa
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - P E A de Aquino
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - C N S de Sousa
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - I S de Medeiros
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - S M M de Vasconcelos
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - K R T Neves
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
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Del Sant LC, Sarin LM, Magalhães EJM, Lucchese AC, Tuena MA, Nakahira C, Fava VAR, Delfino R, Surjan J, Steiglich MS, Barbosa M, Abdo G, Cohrs FM, Liberatori A, Del Porto JA, Lacerda ALT, de Jesus Mari J. Effects of subcutaneous esketamine on blood pressure and heart rate in treatment-resistant depression. J Psychopharmacol 2020; 34:1155-1162. [PMID: 32638662 DOI: 10.1177/0269881120922955] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES The impact of multiple subcutaneous (s.c.) esketamine injections on the blood pressure (BP) and heart rate (HR) of patients with unipolar and bipolar treatment-resistant depression (TRD) is poorly understood. This study aimed to assess the cardiovascular safety of multiple s.c. doses of esketamine in patients with TRD. METHODS Seventy TRD patients received 394 weekly s.c. esketamine injections in conjunction with oral antidepressant therapy for up to six weeks. Weekly esketamine doses were 0.5, 0.75 or 1.0 mg/kg according to each patient's response to treatment. Participants were monitored before each treatment and every 15 minutes thereafter for 120 minutes. We assessed systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR measurements for the entire treatment course. RESULTS BP increased after the first s.c. esketamine injection, reaching maximum mean SBP/DBP levels of 4.87/5.54 mmHg within 30-45 minutes. At the end of monitoring, 120 minutes post dose, vital signs returned to pretreatment levels. We did not detect significant differences in BP between doses of 0.5, 0.75, and 1 mg/kg esketamine. Mean HR did not differ significantly between doses or before and after s.c. esketamine injection. CONCLUSIONS The BP changes observed with repeated s.c. esketamine injections were mild and well tolerated for doses up to 1 mg/kg. The s.c. route is a simple and safe method of esketamine administration, even for patients with clinical comorbidities, including obesity, hypertension, diabetes, and dyslipidemia. However, 14/70 patients experienced treatment-emergent transient hypertension (SBP >180 mmHg and/or a DBP >110 mmHg). Therefore, we strongly recommend monitoring BP for 90 minutes after esketamine dosing. Since s.c. esketamine is cheap, requires less frequent dosing (once a week), and is a simpler procedure compared to intravenous infusions, it might have an impact on public health.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Rodrigo Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Souza Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Barbosa
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Aroldo Liberatori
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - José Alberto Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,LiNC-Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,Center for Interventional Psychiatry, Hospital Sao Marcos, Jaboticabal, Brazil
| | - Jair de Jesus Mari
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,LiNC-Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
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9
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Bayes A, Dong V, Loo C. Considerations for use of ketamine to treat depression in Australia and New Zealand. Aust N Z J Psychiatry 2019; 53:1117-1120. [PMID: 31364369 DOI: 10.1177/0004867419866510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam Bayes
- School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia.,Sydney Neurostimulation Centre, Black Dog Institute, Randwick, NSW, Australia
| | - Vanessa Dong
- School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia.,Sydney Neurostimulation Centre, Black Dog Institute, Randwick, NSW, Australia
| | - Colleen Loo
- School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia.,Sydney Neurostimulation Centre, Black Dog Institute, Randwick, NSW, Australia
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10
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Domany Y, Bleich-Cohen M, Tarrasch R, Meidan R, Litvak-Lazar O, Stoppleman N, Schreiber S, Bloch M, Hendler T, Sharon H. Repeated oral ketamine for out-patient treatment of resistant depression: randomised, double-blind, placebo-controlled, proof-of-concept study. Br J Psychiatry 2019; 214:20-26. [PMID: 30246667 DOI: 10.1192/bjp.2018.196] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Ketamine has been demonstrated to improve depressive symptoms.AimsEvaluation of efficacy, safety and feasibility of repeated oral ketamine for out-patients with treatment-resistant depression (TRD). METHOD In a randomised, double-blind, placebo-controlled, proof-of-concept trial, 41 participants received either 1 mg/kg oral ketamine or placebo thrice weekly for 21 days (ClinicalTrials.gov Identifier: NCT02037503). Evaluation was performed at baseline, 40 and 240 min post administration and on days 3, 7, 14 and 21. The main outcome measure was change in Montgomery-Åsberg Depression Rating Scale (MADRS). RESULTS Twenty-two participants were randomised to the ketamine group, and 19 to the control, with 82.5% (n = 33) completing the study. In the ketamine group, a decrease in depressive symptoms was evident at all time points, whereas in the control group a decrease was evident only 40 min post administration. The reduction in MADRS score on day 21 was 12.75 in the ketamine group versus 2.49 points with placebo (P < 0.001). Six participants in the ketamine group (27.3%) achieved remission compared with none of the controls (P < 0.05). The number needed to treat for remission was 3.7. Side-effects were mild and transient. CONCLUSIONS Repeated oral ketamine produced rapid and persistent amelioration of depressive symptoms in out-patients with TRD, and was well tolerated. These results suggest that add-on oral ketamine may hold significant promise in the care of patients suffering from TRD in the community.Declaration of interestNone.
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Affiliation(s)
- Yoav Domany
- Senior Psychiatrist,Department of Psychiatry,Tel Aviv Sourasky Medical Center and Sackler School of Medicine,Tel Aviv University,Israeland Postdoctoral Research Fellow,Department of Psychiatry and Behavioral Neuroscience,University of Cincinnati,USA
| | - Maya Bleich-Cohen
- Senior Researcher,Sagol Brain Institute Tel-Aviv Sourasky Medical Center and Clinical Manager,Brainsway Ltd,Israel
| | - Ricardo Tarrasch
- Psychologist, Researcher,Statistician and Educator,Assistant Professor,School of Education and School of Neuroscience,Tel Aviv University,Israel
| | - Roi Meidan
- Physician for Emergency Medicine,Department of Emergency Medicine,Tel Aviv Sourasky Medical Centre,Israel
| | - Olga Litvak-Lazar
- Research Coordinator,Department of Psychiatry,Tel Aviv Sourasky Medical Centre,Israel
| | - Nadav Stoppleman
- Researcher, Center for Brain Functions Wohl Institute for Advanced Imaging,Tel-Aviv Sourasky Medical,Israel
| | - Shaul Schreiber
- Director, Department of Psychiatry,Tel Aviv Sourasky Medical CenterandProfessor of Psychiatry,Tel Aviv University,Sackler Faculty of Medicine and Member,Sagol School of Neuroscience,Tel Aviv University,Israel
| | - Miki Bloch
- Head of Inpatient Psychiatric Ward,Tel Aviv Sourasky Medical Centre and Sackler School of Medicine,Tel Aviv University,Israel
| | - Talma Hendler
- Head of Sagol Brain Institute,Wohl Institute for Advanced Imaging,Tel Aviv Sourasky Medical Center,Sackler School of Medicine and Sagol School of Neuroscience,Tel Aviv University,Israel
| | - Haggai Sharon
- Senior Physician,Institute of Pain Medicine,Department of Anesthesiology,Pain and Critical Care Medicine,Tel Aviv Sourasky Medical CentreandResearcher, Center for Brain Functions,Wohl Institute for Advanced Imaging,Tel-Aviv Sourasky Medical Centre and Sackler School of Medicine,Tel Aviv University,Israel and Pain Management & Neuromodulation Centre,Guy's & St Thomas' NHS Foundation Trust,UK
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Berk M, Loo C, Davey CG, Harvey BH. Ketamine and rapidly acting antidepressants: Breaking the speed of sound or light? Aust N Z J Psychiatry 2018; 52:1026-1029. [PMID: 29952212 DOI: 10.1177/0004867418783567] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
There is an urgent need for rapidly acting antidepressants. Current therapies share a delayed onset of action, contrasting with drugs of abuse that have rapid psychotropic effects but cause tolerance and dependence. A key uncertainty is whether there is a finite speed limit imposed by the critical role of homeostatic adaptive mechanisms that underpin the efficacy and onset of available psychotropic agents and whether this is mutable with emerging agents with potential rapid onset, in particular ketamine.
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Affiliation(s)
- Michael Berk
- 1 Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, VIC, Australia.,2 Centre for Youth Mental Health, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,3 Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia.,4 The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Collen Loo
- 5 School of Psychiatry and Black Dog Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Christopher G Davey
- 2 Centre for Youth Mental Health, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,3 Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Brian H Harvey
- 6 Division of Pharmacology, School of Pharmacy and Centre of Excellence for Pharmaceutical Sciences, North-West University, Potchefstroom, South Africa
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12
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Le Nedelec M, Glue P, Winter H, Goulton C, Medlicott NJ. The effect of route of administration on the enantioselective pharmacokinetics of ketamine and norketamine in rats. J Psychopharmacol 2018; 32:1127-1132. [PMID: 29895202 DOI: 10.1177/0269881118780013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ketamine has been shown to produce a rapid and potent antidepressant response in patients with treatment-resistant depression. Currently ketamine is most commonly administered as a 40-minute intravenous infusion, though it is unknown whether this is the optimal route of administration. AIMS To determine the plasma concentration time course of the R- and S-enantiomers of ketamine and norketamine following administration of ketamine by four different routes of administration. METHODS Plasma from conscious non-anaesthetised rats was collected following administration of ketamine by either subcutaneous (SC), intramuscular (IM), intravenous infusion (IVI) or intravenous bolus (IVB) routes of administration. Concentrations of the enantiomers of ketamine and norketamine were determined by LC/MS. RESULTS Administration by the SC, IM and IVI routes produced an overall similar drug exposure. In contrast, administration by the IVB route produced approximately 15-fold higher peak plasma concentrations for the enantiomers of ketamine and an approximately four-fold lower AUC for the enantiomers of norketamine. CONCLUSIONS Route of administration can significantly influence ketamine and norketamine exposures. These differences may influence safety and tolerability, and potentially drug efficacy in humans. This knowledge adds to current research into the optimisation of the use of ketamine for the treatment of depression.
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Affiliation(s)
- Martin Le Nedelec
- 1 School of Pharmacy, University of Otago, Dunedin, New Zealand.,2 Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, New Zealand.,3 Department of Physiology, University of New South Wales, Sydney, Australia
| | - Paul Glue
- 2 Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, New Zealand
| | | | - Chelsea Goulton
- 3 Department of Physiology, University of New South Wales, Sydney, Australia
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Chou D, Peng HY, Lin TB, Lai CY, Hsieh MC, Wen YC, Lee AS, Wang HH, Yang PS, Chen GD, Ho YC. (2R,6R)-hydroxynorketamine rescues chronic stress-induced depression-like behavior through its actions in the midbrain periaqueductal gray. Neuropharmacology 2018; 139:1-12. [DOI: 10.1016/j.neuropharm.2018.06.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/04/2018] [Accepted: 06/24/2018] [Indexed: 12/28/2022]
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Is Ketamine the Future Clozapine for Depression? A Case Series and Literature Review on Maintenance Ketamine in Treatment-resistant Depression With Suicidal Behavior. J Psychiatr Pract 2018; 24:279-291. [PMID: 30427812 DOI: 10.1097/pra.0000000000000316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive serial maintenance ketamine infusions in restoring functionality in treatment-resistant unipolar and bipolar (mixed) depression with significant suicide risk and multiple comorbidities, including alcohol dependence. Two cases of TRD achieved functional remission with long-term maintenance ketamine treatment. The first case illustrates the potential synergistic interaction between ketamine and lamotrigine to achieve a sustained antidepressant response in the patient for 7 months. The second case may possibly be the longest reported case of maintenance ketamine therapy, with treatment continuing for 5 years to date. Ketamine treatment showed acute effectiveness in another 7 cases, especially in terms of reduction of suicidal ideation, albeit without significant long-term antidepressant effect. Factors that may contribute to lack of effectiveness of serial ketamine include inadequate mood stabilization in TRD in bipolar spectrum diagnoses, concomitant benzodiazepine use, complex comorbidities, and adverse effects such as significant hypertension and severe dissociation. Future systematic controlled studies are warranted to establish the efficacy and safety profile of long-term ketamine as maintenance therapy for TRD with suicidal behavior.
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Loo C. Can we confidently use ketamine as a clinical treatment for depression? Lancet Psychiatry 2018; 5:11-12. [PMID: 29277196 DOI: 10.1016/s2215-0366(17)30480-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia; St George Hospital, Sydney, NSW, Australia; Black Dog Institute, Randwick, Sydney, NSW 2031, Australia.
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Side-effects associated with ketamine use in depression: a systematic review. Lancet Psychiatry 2018; 5:65-78. [PMID: 28757132 DOI: 10.1016/s2215-0366(17)30272-9] [Citation(s) in RCA: 307] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 12/31/2022]
Abstract
This is the first systematic review of the safety of ketamine in the treatment of depression after single and repeated doses. We searched MEDLINE, PubMed, PsycINFO, and Cochrane Databases and identified 288 articles, 60 of which met the inclusion criteria. After acute dosing, psychiatric, psychotomimetic, cardiovascular, neurological, and other side-effects were more frequently reported after ketamine treatment than after placebo in patients with depresssion. Our findings suggest a selective reporting bias with limited assessment of long-term use and safety and after repeated dosing, despite these being reported in other patient groups exposed to ketamine (eg, those with chronic pain) and in recreational users. We recommend large-scale clinical trials that include multiple doses of ketamine and long-term follow up to assess the safety of long-term regular use.
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Pilot Randomized Controlled Trial of Titrated Subcutaneous Ketamine in Older Patients with Treatment-Resistant Depression. Am J Geriatr Psychiatry 2017; 25:1199-1209. [PMID: 28739263 DOI: 10.1016/j.jagp.2017.06.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 05/08/2017] [Accepted: 06/06/2017] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the efficacy and safety of subcutaneous ketamine for geriatric treatment-resistant depression. Secondary aims were to examine if repeated treatments were safe and more effective in inducing or prolonging remission than a single treatment. METHODS In this double-blind, controlled, multiple-crossover study with a 6-month follow-up (randomized controlled trial [RCT] phase), 16 participants (≥60 years) with treatment-resistant depression who relapsed after remission or did not remit in the RCT were administered an open-label phase. Up to five subcutaneous doses of ketamine (0.1, 0.2, 0.3, 0.4, and 0.5 mg/kg) were administered in separate sessions (≥1 week apart), with one active control (midazolam) randomly inserted (RCT phase). Twelve ketamine treatments were given in the open-label phase. Mood, hemodynamic, and psychotomimetic outcomes were assessed by blinded raters. Remitters in each phase were followed for 6 months. RESULTS Seven of 14 RCT-phase completers remitted with ketamine treatment. Five remitted at doses below 0.5 mg/kg. Doses ≥ 0.2 mg/kg were significantly more effective than midazolam. Ketamine was well tolerated. Repeated treatments resulted in higher likelihood of remission or longer time to relapse. CONCLUSION Results provide preliminary evidence for the efficacy and safety of ketamine in treating elderly depressed. Dose titration is recommended for optimizing antidepressant and safety outcomes on an individual basis. Subcutaneous injection is a practical method for giving ketamine. Repeated treatments may improve remission rates (clinicaltrials.gov; NCT01441505).
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Hanna AF, Abraham B, Hanna A, Smith AJ. Effects of intravenous ketamine in a patient with post-treatment Lyme disease syndrome. Int Med Case Rep J 2017; 10:305-308. [PMID: 28860873 PMCID: PMC5571854 DOI: 10.2147/imcrj.s137975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Post-treatment Lyme disease syndrome (PTLDS) is a pain disorder for which there remains no gold standard treatment option. Here, we report a case of PTLDS in a female patient whose pain was refractory to treatment options such as radiofrequency ablation, vitamin infusion therapy, opioid analgesics, and other pharmacotherapies. The patient commenced an experimental intravenous ketamine infusion therapy at the Florida Spine Institute (Clearwater, FL, USA) and achieved relief from her chronic pain, an improved quality of life, reduced depression and suicidal ideation, and reduced opioid consumption.
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Affiliation(s)
- Ashraf F Hanna
- Department of Pain Management, Florida Spine Institute, Clearwater, FL, USA
| | - Bishoy Abraham
- Department of Pain Management, Florida Spine Institute, Clearwater, FL, USA
| | - Andrew Hanna
- Department of Pain Management, Florida Spine Institute, Clearwater, FL, USA
| | - Adam J Smith
- Department of Pain Management, Florida Spine Institute, Clearwater, FL, USA
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19
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Ryan CJ, Loo C. The practicalities and ethics of ketamine for depression. Lancet Psychiatry 2017; 4:354-355. [PMID: 28395987 DOI: 10.1016/s2215-0366(17)30155-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 12/11/2016] [Accepted: 12/12/2016] [Indexed: 01/26/2023]
Affiliation(s)
- Christopher James Ryan
- Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia.
| | - Colleen Loo
- School of Psychiatry, University of New South Wales and Clinical & Research Psychiatrist, Black Dog Institute, Sydney, NSW, Australia
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Gálvez V, Nikolin S, Ho KA, Alonzo A, Somogyi AA, Loo CK. Increase in PAS-induced neuroplasticity after a treatment course of intranasal ketamine for depression. Report of three cases from a placebo-controlled trial. Compr Psychiatry 2017; 73:31-34. [PMID: 27886522 DOI: 10.1016/j.comppsych.2016.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/27/2016] [Accepted: 10/29/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Animal studies suggest that neural plasticity may play a role in the antidepressant effects of a single ketamine dose. However, the potential effects of repeated ketamine treatments on human neuroplasticity are unknown. METHODS This pilot RCT study measured plasticity-induced changes before and after a ketamine course, in three treatment-resistant depressed subjects, who were randomized to receive 8 intranasal treatments of 100mg ketamine or 4.5mg midazolam. Mood ratings were performed by a trained blinded rater at baseline and 24h-48h after the ketamine course, using the Montgomery Asberg Depression Rating Scale (MADRS). Neuroplasticity was assessed in the motor cortex using a paired associative stimulation (PAS) paradigm at baseline and 24h-48h after the treatment course. No changes in current psychotropic medication or dosage were permitted for 4weeks prior to trial entry and throughout the trial. RESULTS The subject receiving ketamine, but not those receiving midazolam, presented a marked increase in neural plasticity after the treatment course. However, mood changes were not associated with changes in neural plasticity. LIMITATIONS Pilot study with small sample size. Concomitant antidepressant medications taken. Plasticity was tested in the motor cortex only, thus the generalizability of these findings to other brain areas cannot be assumed. CONCLUSIONS These results suggest that a course of intranasal ketamine may enhance synaptic plasticity in subjects with depression, but this was not associated with antidepressant effects. Further research on this topic is warranted.
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Affiliation(s)
- Verònica Gálvez
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia.
| | - Stevan Nikolin
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia
| | - Kerrie-Anne Ho
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, School of Medicine, University of Adelaide, Adelaide, 5005, SA, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; St. George Hospital, Department of Psychiatry, Gray St, Kogarah, 2217, NSW, Australia
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21
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Cusin C, Ionescu DF, Pavone KJ, Akeju O, Cassano P, Taylor N, Eikermann M, Durham K, Swee MB, Chang T, Dording C, Soskin D, Kelley J, Mischoulon D, Brown EN, Fava M. Ketamine augmentation for outpatients with treatment-resistant depression: Preliminary evidence for two-step intravenous dose escalation. Aust N Z J Psychiatry 2017; 51:55-64. [PMID: 26893373 DOI: 10.1177/0004867416631828] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Preliminary evidence supports the safety and efficacy of subanesthetic ketamine as an experimental antidepressant, although its effects are often not sustained beyond one week. Studies are lacking that have examined the sustained effects of escalating ketamine doses as augmentation in outpatients with treatment-resistant depression. Therefore, the aims of this study were twofold: (1) to assess the safety and antidepressant efficacy of two-step, repeated-dose ketamine augmentation and (2) to assess the duration of ketamine's antidepressant efficacy as augmentation to ongoing antidepressant pharmacotherapy for 3 months after the final infusion. METHODS Fourteen patients with treatment-resistant depression were eligible to receive augmentation with six open-label intravenous ketamine infusions over 3 weeks. For the first three infusions, ketamine was administered at a dose of 0.5 mg/kg over 45 minutes; the dose was increased to 0.75 mg/kg over 45 minutes for the subsequent three infusions. The primary outcome measure was response (as measured on Hamilton Depression Rating Scale-28 items). RESULTS After the completion of three ketamine infusions, 7.1% (1/14) responded; after all six ketamine infusions, 41.7% (5/12) completers responded and 16.7% (2/12) remitted. Intent-to-treat response and remission rates at the end of the final infusion were 35.7% (5/14) and 14.3% (2/14), respectively. However, all but one responder relapsed within 2 weeks after the final infusion. CONCLUSION Repeated, escalating doses of intravenous ketamine augmentation were preliminarily found to be feasible, efficacious and well tolerated. Interaction with concomitant medications and elevated level of treatment resistance are possible factors for non-response.
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Affiliation(s)
- Cristina Cusin
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Dawn Flosnik Ionescu
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Kara Jean Pavone
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Oluwaseun Akeju
- 2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paolo Cassano
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Norman Taylor
- 2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matthias Eikermann
- 2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kelley Durham
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Michaela Ballentyne Swee
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Trina Chang
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Christina Dording
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - John Kelley
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,4 Department of Psychology, Endicott College, Beverly, MA, USA
| | - David Mischoulon
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Emery Neal Brown
- 2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Maurizio Fava
- 1 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Loo CK, Gálvez V, O'Keefe E, Mitchell PB, Hadzi-Pavlovic D, Leyden J, Harper S, Somogyi AA, Lai R, Weickert CS, Glue P. Placebo-controlled pilot trial testing dose titration and intravenous, intramuscular and subcutaneous routes for ketamine in depression. Acta Psychiatr Scand 2016; 134:48-56. [PMID: 27028832 DOI: 10.1111/acps.12572] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE This pilot study assessed the feasibility, efficacy and safety of an individual dose-titration approach, and of the intravenous (IV), intramuscular (IM) and subcutaneous (SC) routes for treating depression with ketamine. METHOD Fifteen treatment-refractory depressed participants received ketamine or midazolam (control treatment) in a multiple crossover, double-blind study. Ketamine was administered by IV (n = 4), IM (n = 5) or SC (n = 6) injection. Dose titration commenced at 0.1 mg/kg, increasing by 0.1 mg/kg up to 0.5 mg/kg, given in separate treatment sessions separated by ≥1 week, with one placebo control treatment randomly inserted. Mood, psychotomimetic and hemodynamic effects were assessed and plasma ketamine concentrations assayed. RESULTS Twelve participants achieved response and remission criteria, achieved at doses as low as 0.1 mg/kg. All three routes of administration resulted in comparable antidepressant effects. Fewest adverse effects were noted with the SC route. Antidepressant response, adverse effects and ketamine concentrations were dose-related. CONCLUSION Antidepressant response occurred at a range of doses and at <0.5 mg/kg. The dose-titration approach is a practical method for optimizing the efficacy - side-effects trade-off on an individual patient basis. This pilot study provides preliminary evidence for SC injection as a practical, feasible and efficacious treatment approach.
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Affiliation(s)
- C K Loo
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Black Dog Institute, Randwick, NSW, Australia.,Wesley Hospital, Kogarah, NSW, Australia.,St George Hospital, Kogarah, NSW, Australia
| | - V Gálvez
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Black Dog Institute, Randwick, NSW, Australia
| | - E O'Keefe
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - P B Mitchell
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Black Dog Institute, Randwick, NSW, Australia
| | - D Hadzi-Pavlovic
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Black Dog Institute, Randwick, NSW, Australia
| | - J Leyden
- Wesley Hospital, Kogarah, NSW, Australia.,Royal North Shore Hospital, St Leonards, NSW, Australia
| | - S Harper
- Wesley Hospital, Kogarah, NSW, Australia.,University of New South Wales, Randwick, NSW, Australia
| | - A A Somogyi
- University of Adelaide, Adelaide, SA, Australia.,Royal Adelaide Hospital, Adelaide, SA, Australia
| | - R Lai
- Macquarie Hospital, Sydney, NSW, Australia
| | - C S Weickert
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Schizophrenia Research Institute, Randwick, NSW, Australia.,Neuroscience Research Australia, Randwick, NSW, Australia
| | - P Glue
- Psychological Medicine, University of Otago, Dunedin, New Zealand
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Caddy C, Amit BH, McCloud TL, Rendell JM, Furukawa TA, McShane R, Hawton K, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults. Cochrane Database Syst Rev 2015:CD011612. [PMID: 26395901 DOI: 10.1002/14651858.cd011612.pub2] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Considering the ample evidence of involvement of the glutamate system in the pathophysiology of depression, pre-clinical and clinical studies have been conducted to assess the antidepressant efficacy of glutamate inhibition, and glutamate receptor modulators in particular. This review focuses on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability - of ketamine and other glutamate receptor modulators in comparison to placebo (or saline placebo), other pharmacologically active agents, or electroconvulsive therapy (ECT) in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR, to 9 January 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blind RCTs comparing ketamine, memantine, or other glutamate receptor modulators with placebo (or saline placebo), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. DATA COLLECTION AND ANALYSIS Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes for this review were response rate and adverse events. MAIN RESULTS We included 25 studies (1242 participants) on ketamine (9 trials), memantine (3), AZD6765 (3), D-cycloserine (2), Org26576 (2), atomoxetine (1), CP-101,606 (1), MK-0657 (1), N-acetylcysteine (1), riluzole (1) and sarcosine (1). Twenty-one studies were placebo-controlled and the majority were two-arm studies (23 out of 25). Twenty-two studies defined an inclusion criteria specifying the severity of depression; 11 specified at least moderate depression; eight, severe depression; and the remaining three, mild-moderate depression. Nine studies recruited only treatment-resistant patients.We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. We rated three studies as having high risk for selective outcome reporting. Many trials did not provide information on all the prespecified outcomes and we found no data, or very limited data, on very important issues like suicidality, cognition, quality of life, costs to healthcare services and dropouts due to lack of efficacy.Among all glutamate receptor modulators, only ketamine (administered intravenously) proved to be more efficacious than placebo, though the quality of evidence was limited by risk of bias and small sample sizes. There was low quality evidence that treatment with ketamine increased the likelihood of response after 24 hours (odds ratio (OR) 10.77, 95% confidence interval (CI) 2.00 to 58.00; 3 RCTs, 56 participants), 72 hours (OR 12.59, 95% CI 2.38 to 66.73; 3 RCTs, 56 participants), and one week (OR 2.58, 95% CI 1.08 to 6.16; 4 RCTs, 131 participants). The effect of ketamine was even less certain at two weeks, as data were available from only one trial (OR 0.93, 95% CI 0.31 to 2.83; 51 participants, low quality evidence). This was consistent across all efficacy outcomes. Ketamine caused more confusion and emotional blunting compared to placebo. There was insufficient evidence to determine if this increased the likelihood of leaving the study early (OR 1.90, 95% CI 0.43 to 8.47; 5 RCTs, 139 participants, low quality evidence).One RCT with 72 participants reported higher numbers of responders on ketamine than midazolam at 24 hours (OR 0.36, 95% CI 0.14 to 0.58), 72 hours (OR 0.37, 95% CI 0.16 to 0.59), and one week (OR 0.29, 95% CI 0.08 to 0.49). However, midazolam was better tolerated than ketamine in terms of blurred vision, dizziness, general malaise and nausea/vomiting at 24 hours post-infusion. The evidence contributing to these outcomes was of low quality.We found better efficacy of sarcosine over citalopram at four weeks (OR 6.93, 95% CI 1.53 to 31.38; 1 study, 40 participants), but not at two weeks (OR: 8.14, 95% CI 0.88 to 75.48); fewer participants in the sarcosine group experienced adverse events (OR 0.04, 95% CI 0.00 to 0.68; P = 0.03, 1 study, 40 participants). This was based on low quality evidence. No significant results were found for the remaining glutamate receptor modulators.In one study with 18 participants, ketamine was more effective than ECT at 24 hours (OR 28.00, 95% CI 2.07 to 379.25) and 72 hours (OR 12.25, 95% CI 1.33 to 113.06), but not at one week (OR 3.35, 95% CI 0.12 to 93.83), or two weeks (OR 3.35, 95% CI 0.12 to 93.83). No differences in terms of adverse events were found between ketamine and ECT, however the only adverse events reported were blood pressure and heart rate. This study was rated as very low quality. AUTHORS' CONCLUSIONS We found limited evidence for ketamine's efficacy over placebo at time points up to one week in terms of the primary outcome, response rate. The effects were less certain at two weeks post-treatment. No significant results were found for the remaining ten glutamate receptor modulators, except for sarcosine being more effective than citalopram at four weeks. In terms of adverse events, the only significant differences in favour of placebo over ketamine were in regards to confusion and emotional blunting. Despite the promising nature of these preliminary results, our confidence in the evidence was limited by risk of bias and the small number of participants. Many trials did not provide information on all the prespecified outcomes and we found no data, or very limited data, on very important issues like suicidality, cognition, quality of life, costs to healthcare services and dropouts due to lack of efficacy.All included studies administered ketamine intravenously, which can pose practical problems in clinical practice. Very few trials were included in the meta-analyses for each comparison; the majority of comparisons contained only one study. Further RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine with longer follow-up, which test the comparative efficacy of ketamine and the efficacy of repeated administrations.
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Affiliation(s)
- Caroline Caddy
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK, OX3 7JX
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Khalili-Mahani N, Niesters M, van Osch MJ, Oitzl M, Veer I, de Rooij M, van Gerven J, van Buchem MA, Beckmann CF, Rombouts SARB, Dahan A. Ketamine interactions with biomarkers of stress: a randomized placebo-controlled repeated measures resting-state fMRI and PCASL pilot study in healthy men. Neuroimage 2014; 108:396-409. [PMID: 25554429 DOI: 10.1016/j.neuroimage.2014.12.050] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 11/24/2014] [Accepted: 12/17/2014] [Indexed: 12/17/2022] Open
Abstract
Ketamine, an NMDA receptor antagonist, is increasingly used to study the link between glutamatergic signaling dysregulation and mood and chronic pain disorders. Glutamatergic neurotransmission and stress corticosteroids (cortisol in human) are critical for Ca(2+) mediated neuroplasticity and behavioral adaptation. The mechanisms of action of glutamatergic neurotransmission and stress corticosteroids on the NMDA-receptors of the hippocampus have been long investigated in animals, but given little attention in human studies. In this randomized single-blinded placebo-controlled crossover study (12 healthy young men), five sets of resting-state fMRI (RSFMRI), pseudocontinuous arterial spin labeling (PCASL), and corresponding salivary cortisol samples were acquired over 4h, at given intervals under pharmacokinetically-controlled infusion of subanesthetic ketamine (20 & 40mg/70kg/h). An identical procedure was repeated under a sham placebo condition. Differences in the profile of ketamine versus placebo effect over time were examined. Compared to placebo, ketamine mimicked a stress-like response (increased cortisol, reduced calmness and alertness, and impaired working memory). Ketamine effects on the brain included a transient prefrontal hyperperfusion and a dose-related reduction of relative hippocampal perfusion, plus emerging hyperconnectivity between the hippocampus and the occipital, cingulate, precuneal, cerebellar and basal ganglia regions. The spatiotemporal profiles of ketamine effects on different hippocampal subnetworks suggest a topographically dissociable change in corticohippocampal functional connectivity. We discuss our findings in the context of the negative feedback inhibition theory of the hippocampal stress-control. This pilot study provides a methodological framework for multimodal functional neuroimaging under resting-state conditions, which may be generalized for translational studies of glutamatergic- or stress-related etiology of neuropsychiatric disorders.
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Affiliation(s)
- Najmeh Khalili-Mahani
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands; Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, The Netherlands; Department of Radiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; Montreal Neurological Institute, McGill University, Montreal, Canada.
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias J van Osch
- Department of Radiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Melly Oitzl
- SILS-CNS, University of Amsterdam, Amsterdam, The Netherlands
| | - Ilya Veer
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, The Netherlands; Department of Radiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; Charité Universitätsmedizin Berlin, Division of Mind and Brain Research, Department of Psychiatry and Psychotherapy, Berlin, Germany
| | - Mark de Rooij
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, The Netherlands
| | - Joop van Gerven
- Department of Neurology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Christian F Beckmann
- Donders Institute for Brain, Cognition and Behaviour; Centre for Cognitive Neuroimaging, Radboud University, Nijmegen, The Netherlands
| | - Serge A R B Rombouts
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, The Netherlands; Department of Radiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Nekovarova T, Yamamotova A, Vales K, Stuchlik A, Fricova J, Rokyta R. Common mechanisms of pain and depression: are antidepressants also analgesics? Front Behav Neurosci 2014; 8:99. [PMID: 24723864 PMCID: PMC3971163 DOI: 10.3389/fnbeh.2014.00099] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 03/09/2014] [Indexed: 12/16/2022] Open
Abstract
Neither pain, nor depression exist as independent phenomena per se, they are highly subjective inner states, formed by our brain and built on the bases of our experiences, cognition and emotions. Chronic pain is associated with changes in brain physiology and anatomy. It has been suggested that the neuronal activity underlying subjective perception of chronic pain may be divergent from the activity associated with acute pain. We will discuss the possible common pathophysiological mechanism of chronic pain and depression with respect to the default mode network of the brain, neuroplasticity and the effect of antidepressants on these two pathological conditions. The default mode network of the brain has an important role in the representation of introspective mental activities and therefore can be considered as a nodal point, common for both chronic pain and depression. Neuroplasticity which involves molecular, cellular and synaptic processes modifying connectivity between neurons and neuronal circuits can also be affected by pathological states such as chronic pain or depression. We suppose that pathogenesis of depression and chronic pain shares common negative neuroplastic changes in the central nervous system (CNS). The positive impact of antidepressants would result in a reduction of these pathological cellular/molecular processes and in the amelioration of symptoms, but it may also increase survival times and quality of life of patients with chronic cancer pain.
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Affiliation(s)
- Tereza Nekovarova
- Institute of Physiology, Academy of Sciences of the Czech RepublicPrague, Czech Republic
- Department of Zoology, Ecology and Ethology Research Group, Faculty of Natural Science, Charles University in PraguePrague, Czech Republic
| | - Anna Yamamotova
- Department of Normal, Pathological and Clinical Physiology, Third Faculty of Medicine, Charles University in PraguePrague, Czech Republic
| | - Karel Vales
- Institute of Physiology, Academy of Sciences of the Czech RepublicPrague, Czech Republic
| | - Ales Stuchlik
- Institute of Physiology, Academy of Sciences of the Czech RepublicPrague, Czech Republic
| | - Jitka Fricova
- Department of Anesthesiology and Intensive Care Medicine, Pain Management Center, First Faculty of Medicine and General University Hospital, Charles University in PraguePrague, Czech Republic
| | - Richard Rokyta
- Department of Normal, Pathological and Clinical Physiology, Third Faculty of Medicine, Charles University in PraguePrague, Czech Republic
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