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Klugh JM, Puzio TJ, Wandling MW, Guy-Frank CJ, Green C, Sergot PB, Prater SJ, Balogh J, Stephens CT, Wade CE, Kao LS, Harvin JA. Ketamine for acute pain after trauma: A pragmatic, randomized clinical trial. J Trauma Acute Care Surg 2024; 97:514-519. [PMID: 38689402 PMCID: PMC11424262 DOI: 10.1097/ta.0000000000004325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Non-narcotic intravenous medications may be a beneficial adjunct to oral multimodal pain regimens (MMPRs) which reduce but do not eliminate opioid exposure and prescribing after trauma. We hypothesized that the addition of a subdissociative ketamine infusion (KI) to a standardized oral MMPR reduces inpatient opioid exposure. METHODS Eligible adult trauma patients admitted to the intermediate or intensive care unit were randomized upon admission to our institutional MMPR per usual care (UC) or UC plus subdissociative KI for 24 hours to 72 hours after arrival. The primary outcome was morphine milligram equivalents per day (MME/d) and secondary outcomes included total MME, discharge with an opioid prescription (OP%), and rates of ketamine side effects. Bayesian posterior probabilities (pp) were calculated using neutral priors. RESULTS A total of 300 patients were included in the final analysis with 144 randomized to KI and 156 to UC. Baseline characteristics were similar between groups. The Injury Severity Scores for KI were 19 [14, 29] versus UC 22 [14, 29]. The KI group had a lower rate of long-bone fracture (37% vs. 49%) and laparotomy (16% vs. 24%). Patients receiving KI had an absolute reduction of 7 MME/day, 96 total MME, and 5% in OP%. In addition, KI had a relative risk (RR) reduction of 19% in MME/day (RR, 0.81 [0.69-0.95], pp = 99%), 20% in total MME (RR, 0.80 [0.64-0.99], pp = 98%), and 8% in OP% (RR, 0.92 [0.76-1.11], pp = 81%). The KI group had a higher rate of delirium (11% vs. 6%); however, rates of other side effects such as arrythmias and unplanned intubations were similar between groups. CONCLUSION Addition of a subdissociative ketamine infusion to an oral MMPR resulted in a decrease in opioid exposure in severely injured patients. Subdissociative ketamine infusions can be used as a safe adjunct to decrease opioid exposure in monitored settings. LEVEL OF EVIDENCE Therapeutic/Care Management; Level I.
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Affiliation(s)
- James M Klugh
- From the Department of Surgery (J.M.K., T.J.P., M.W.W., C.J.G.-F., L.S.K., J.A.H.), Center for Translational Injury Research, Department of Surgery (C.G., C.E.W.), McGovern Medical School at UTHealth; Department of Emergency Medicine (P.B.S., S.J.P.), The University of Texas Medical Center at Houston, Houston, Texas; Department of Anesthesia (J.B.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Anesthesiology (C.T.S.), McGovern Medical School at UTHealth, Houston, Texas
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2
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Algin S, Banik D, Rahman SA, Mahmud Tusher S, Tuj Johora F, Akter A, Ahmed T, Biswas MAM, Sinha S, Haque M. Ketamine Infusion in a Resistant Obsessive-Compulsive Disorder Patient in Bangladesh with Severe Suicidal Ideation: A Case Report. Cureus 2024; 16:e57877. [PMID: 38596207 PMCID: PMC11002706 DOI: 10.7759/cureus.57877] [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] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
Treatment of resistant obsessive-compulsive disorder (OCD) typically results in insufficient symptom alleviation, and even long-term medication often fails to have the intended effect. Ketamine is a potent non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Studies have shown that low-dose ketamine infusion results in a considerable reduction in obsessive-compulsive symptoms and a rapid resolution of suicidal ideation. This is a case report on the effect of intravenous ketamine infusion on a patient with resistant OCD and severe suicidal ideation. Intravenous (IV) ketamine was given once a week over consecutive three weeks with necessary precautions. Psychometric tools such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Clinical Global Impressions Scale (CGI-S), the Beck Scale for Suicidal Ideations (BSSI), and Depression Anxiety and Stress Scale 21 (DASS-21) were applied before and after infusions. Obsessive-compulsive symptoms and suicidal severity started to decrease rapidly after the first infusion. However, after a transient improvement, these symptoms again began to increase after a stressful incident on the second day of the first infusion. All the symptoms measured by validated rating scales showed continued improvement after the following two infusions. The improvement was sustained until discharge (one week after the last infusion) and subsequent follow-up in the sixth and 12th weeks. The role of ketamine in reducing suicidal thoughts and behavior is already established. Very few studies emphasized its effectiveness in improving severe/resistant obsessive-compulsive symptoms. This pioneering work may offer scope for similar research in the relevant field.
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Affiliation(s)
- Sultana Algin
- Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Debasish Banik
- Anesthesia, Analgesia, and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Sm Atikur Rahman
- Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Saiful Mahmud Tusher
- Anesthesia, Analgesia, and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Fatema Tuj Johora
- Child and Adolescent Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Asha Akter
- Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | - Tanbir Ahmed
- Child and Adolescent Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
| | | | - Susmita Sinha
- Physiology, Khulna City Medical College and Hospital, Khulna, BGD
| | - Mainul Haque
- Karnavati Scientific Research Center (KSRC), School of Dentistry, Karnavati University, Gandhinagar, IND
- Pharmacology and Therapeutics, National Defence University of Malaysia, Kuala Lumpur, MYS
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3
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Brewerton TD. The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines. Front Psychiatry 2023; 14:1149433. [PMID: 37252137 PMCID: PMC10213703 DOI: 10.3389/fpsyt.2023.1149433] [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: 01/21/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023] Open
Abstract
Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.
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4
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Puzio TJ, Klugh J, Wandling MW, Green C, Balogh J, Prater SJ, Stephens CT, Sergot PB, Wade CE, Kao LS, Harvin JA. Ketamine for acute pain after trauma: the KAPT randomized controlled trial. Trials 2022; 23:599. [PMID: 35897081 PMCID: PMC9326146 DOI: 10.1186/s13063-022-06511-6] [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: 04/11/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background Evidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain. Methods This is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and 6 months. Discussion This trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes. Trial registration The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on October 16, 2019.
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Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA. .,The University of Texas Medical Center at Houston, Houston, TX, USA.
| | - James Klugh
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
| | - Michael W Wandling
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
| | - Charles Green
- Center for Clinical Research and Evidence Based Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Julius Balogh
- Department of Anesthesia, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Samuel J Prater
- Department of Emergency Medicine, The University of Texas Medical Center at Houston, Houston, USA
| | | | - Paulina B Sergot
- Department of Emergency Medicine, The University of Texas Medical Center at Houston, Houston, USA
| | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
| | - John A Harvin
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
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5
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Abdallah CG, Roache JD, Gueorguieva R, Averill LA, Young-McCaughan S, Shiroma PR, Purohit P, Brundige A, Murff W, Ahn KH, Sherif MA, Baltutis EJ, Ranganathan M, D’Souza D, Martini B, Southwick SM, Petrakis IL, Burson RR, Guthmiller KB, López-Roca AL, Lautenschlager KA, McCallin JP, Hoch MB, Timchenko A, Souza SE, Bryant CE, Mintz J, Litz BT, Williamson DE, Keane TM, Peterson AL, Krystal JH. Dose-related effects of ketamine for antidepressant-resistant symptoms of posttraumatic stress disorder in veterans and active duty military: a double-blind, randomized, placebo-controlled multi-center clinical trial. Neuropsychopharmacology 2022; 47:1574-1581. [PMID: 35046508 PMCID: PMC8767037 DOI: 10.1038/s41386-022-01266-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/13/2021] [Accepted: 12/31/2021] [Indexed: 01/27/2023]
Abstract
This study tested the efficacy of repeated intravenous ketamine doses to reduce symptoms of posttraumatic stress disorder (PTSD). Veterans and service members with PTSD (n = 158) who failed previous antidepressant treatment were randomized to 8 infusions administered twice weekly of intravenous placebo (n = 54), low dose (0.2 mg/kg; n = 53) or standard dose (0.5 mg/kg; n = 51) ketamine. Participants were assessed at baseline, during treatment, and for 4 weeks after their last infusion. Primary analyses used mixed effects models. The primary outcome measure was the self-report PTSD Checklist for DSM-5 (PCL-5), and secondary outcome measures were the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Montgomery Åsberg Depression Rating Scale (MADRS). There were no significant group-by-time interactions for PTSD symptoms measured by the PCL-5 or CAPS-5. The standard ketamine dose ameliorated depression measured by the MADRS significantly more than placebo. Ketamine produced dose-related dissociative and psychotomimetic effects, which returned to baseline within 2 h and were less pronounced with repeated administration. There was no evidence of differential treatment discontinuation by ketamine dose, consistent with good tolerability. This clinical trial failed to find a significant dose-related effect of ketamine on PTSD symptoms. Secondary analyses suggested that the standard dose exerted rapid antidepressant effects. Further studies are needed to determine the role of ketamine in PTSD treatment. ClinicalTrials.gov identifier: NCT02655692.
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Affiliation(s)
- Chadi G. Abdallah
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA ,grid.413890.70000 0004 0420 5521Michael E. DeBakey VA Medical Center, Houston, TX USA ,grid.39382.330000 0001 2160 926XMenninger Department of Psychiatry, Baylor College of Medicine, Houston, TX USA ,grid.39382.330000 0001 2160 926XCore for Advanced Magnetic Resonance Imaging (CAMRI), Baylor College of Medicine, Houston, TX USA
| | - John D. Roache
- grid.267309.90000 0001 0629 5880Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX USA ,grid.280682.60000 0004 0420 5695Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX USA
| | - Ralitza Gueorguieva
- grid.47100.320000000419368710Department of Biostatistics, School of Public Health, Yale University School of Medicine, New Haven, CT USA
| | - Lynnette A. Averill
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA ,grid.413890.70000 0004 0420 5521Michael E. DeBakey VA Medical Center, Houston, TX USA ,grid.39382.330000 0001 2160 926XMenninger Department of Psychiatry, Baylor College of Medicine, Houston, TX USA
| | - Stacey Young-McCaughan
- grid.267309.90000 0001 0629 5880Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX USA ,grid.280682.60000 0004 0420 5695Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX USA
| | - Paulo R. Shiroma
- grid.491585.4Minneapolis VA Medical Center and the Department of Psychiatry University of Minnesota, Minneapolis, MN USA
| | - Prerana Purohit
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Antoinette Brundige
- grid.267309.90000 0001 0629 5880Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX USA ,grid.280682.60000 0004 0420 5695Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX USA
| | - William Murff
- grid.267309.90000 0001 0629 5880Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
| | - Kyung-Heup Ahn
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Mohamed A. Sherif
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA ,grid.40263.330000 0004 1936 9094Department of Psychiatry and Human Behavior, and Carney Institute, Brown University; and Lifespan Physician Group, Providence, RI USA
| | - Eric J. Baltutis
- grid.491585.4Minneapolis VA Medical Center and the Department of Psychiatry University of Minnesota, Minneapolis, MN USA
| | - Mohini Ranganathan
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Deepak D’Souza
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Brenda Martini
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Steven M. Southwick
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Ismene L. Petrakis
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
| | - Rebecca R. Burson
- grid.416653.30000 0004 0450 5663Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Kevin B. Guthmiller
- grid.416653.30000 0004 0450 5663Department of Pain Management, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA ,grid.42505.360000 0001 2156 6853Keck School of Medicine at the University of Southern California, Los Angeles, CA USA
| | - Argelio L. López-Roca
- grid.416653.30000 0004 0450 5663Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Karl A. Lautenschlager
- grid.416653.30000 0004 0450 5663Department of Pain Management, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - John P. McCallin
- grid.416653.30000 0004 0450 5663Department of Rehabilitation, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Matthew B. Hoch
- grid.416653.30000 0004 0450 5663Department of Rehabilitation, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Alexandar Timchenko
- grid.416653.30000 0004 0450 5663Department of Rehabilitation, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Sergio E. Souza
- grid.416653.30000 0004 0450 5663Department of Rehabilitation, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Charles E. Bryant
- grid.416653.30000 0004 0450 5663Department of Rehabilitation, Brooke Army Medical Center, Joint Base San Antonio – Fort Sam Houston, Houston, TX USA
| | - Jim Mintz
- grid.267309.90000 0001 0629 5880Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX USA ,grid.280682.60000 0004 0420 5695Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX USA
| | - Brett T. Litz
- grid.410370.10000 0004 4657 1992Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Psychiatry, Boston University School of Medicine, Boston, MA USA
| | - Douglas E. Williamson
- grid.412100.60000 0001 0667 3730Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, NC USA ,grid.512153.1Durham VA Health Care System, Durham, NC USA
| | - Terence M. Keane
- grid.189504.10000 0004 1936 7558Department of Psychiatry, Boston University School of Medicine, Boston, MA USA ,grid.410370.10000 0004 4657 1992National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA USA
| | - Alan L. Peterson
- grid.267309.90000 0001 0629 5880Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX USA ,grid.280682.60000 0004 0420 5695Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX USA ,grid.215352.20000000121845633Department of Psychology, University of Texas at San Antonio, San Antonio, TX USA
| | - John H. Krystal
- grid.418356.d0000 0004 0478 7015National Center for PTSD, Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
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6
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Robison R, Lafrance A, Brendle M, Smith M, Moore C, Ahuja S, Richards S, Hawkins N, Strahan E. A case series of group-based ketamine-assisted psychotherapy for patients in residential treatment for eating disorders with comorbid depression and anxiety disorders. J Eat Disord 2022; 10:65. [PMID: 35524316 PMCID: PMC9077943 DOI: 10.1186/s40337-022-00588-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Depression and anxiety outcome measures, safety/tolerability, patient satisfaction, and ease of implementation of group-based ketamine-assisted psychotherapy (G-KAP) delivered to patients in intensive residential eating disorder (ED) treatment were assessed. CASE PRESENTATION This study reports on five participants with a diagnosis of an ED and comorbid mood and anxiety disorders who received weekly intramuscular ketamine injections in a group setting over 4 weeks. Measures of anxiety (GAD-7) and depression (PHQ-9) were administered pre-dose, 4-h post-dose, and 24-h post dose. Four of the 5 participants experienced clinically significant improvements on the PHQ-9 score (i.e., change greater than 5) while 2 of the 5 participants experienced clinically significant improvements on the GAD-7 score (i.e., change greater than 4) from pre-dose to 24-h post-dose after the last ketamine session. Dosing sessions were well tolerated, and no serious adverse events were reported. Clinical observations and participant reports corroborated improvements in depression and anxiety symptoms, good tolerability of ketamine treatment, and practical implementation of the G-KAP protocol in a residential ED treatment center. CONCLUSIONS This study suggests the potential utility of G-KAP as an adjunct to intensive, specialized ED treatment. Overall, this novel, cross-diagnostic intervention warrants future research to further explore its appropriateness in a treatment setting.
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Affiliation(s)
- Reid Robison
- Center for Change, Orem, UT, USA. .,Novamind Inc., Draper, UT, USA. .,Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | | | - Madeline Brendle
- Novamind Inc., Draper, UT, USA.,Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | | | | | | | | | | | - Erin Strahan
- Wilfrid Laurier University, Brantford, ON, Canada
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7
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Sala N, Paoli C, Bonifacino T, Mingardi J, Schiavon E, La Via L, Milanese M, Tornese P, Datusalia AK, Rosa J, Facchinetti R, Frumento G, Carini G, Salerno Scarzella F, Scuderi C, Forti L, Barbon A, Bonanno G, Popoli M, Musazzi L. Acute Ketamine Facilitates Fear Memory Extinction in a Rat Model of PTSD Along With Restoring Glutamatergic Alterations and Dendritic Atrophy in the Prefrontal Cortex. Front Pharmacol 2022; 13:759626. [PMID: 35370690 PMCID: PMC8968915 DOI: 10.3389/fphar.2022.759626] [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: 08/16/2021] [Accepted: 01/25/2022] [Indexed: 12/17/2022] Open
Abstract
Stress represents a major risk factor for psychiatric disorders, including post-traumatic stress disorder (PTSD). Recently, we dissected the destabilizing effects of acute stress on the excitatory glutamate system in the prefrontal cortex (PFC). Here, we assessed the effects of single subanesthetic administration of ketamine (10 mg/kg) on glutamate transmission and dendritic arborization in the PFC of footshock (FS)-stressed rats, along with changes in depressive, anxious, and fear extinction behaviors. We found that ketamine, while inducing a mild increase of glutamate release in the PFC of naïve rats, blocked the acute stress-induced enhancement of glutamate release when administered 24 or 72 h before or 6 h after FS. Accordingly, the treatment with ketamine 6 h after FS also reduced the stress-dependent increase of spontaneous excitatory postsynaptic current (sEPSC) amplitude in prelimbic (PL)-PFC. At the same time, ketamine injection 6 h after FS was found to rescue apical dendritic retraction of pyramidal neurons induced by acute stress in PL-PFC and facilitated contextual fear extinction. These results show rapid effects of ketamine in animals subjected to acute FS, in line with previous studies suggesting a therapeutic action of the drug in PTSD models. Our data are consistent with a mechanism of ketamine involving re-establishment of synaptic homeostasis, through restoration of glutamate release, and structural remodeling of dendrites.
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Affiliation(s)
- Nathalie Sala
- Laboratory of Neuropsychopharmacology and Functional Neurogenomics, Dipartimento di Scienze Farmaceutiche, Università Degli Studi di Milano, Milano, Italy
| | - Caterina Paoli
- Laboratory of Neuropsychopharmacology and Functional Neurogenomics, Dipartimento di Scienze Farmaceutiche, Università Degli Studi di Milano, Milano, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Tiziana Bonifacino
- Department of Pharmacy, Unit of Pharmacology and Toxicology, University of Genoa, Genoa, Italy
| | - Jessica Mingardi
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Emanuele Schiavon
- Department of Biotechnology and Life Sciences, University of Insubria, Busto Arsizio, Italy
| | - Luca La Via
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marco Milanese
- Department of Pharmacy, Unit of Pharmacology and Toxicology, University of Genoa, Genoa, Italy
| | - Paolo Tornese
- Laboratory of Neuropsychopharmacology and Functional Neurogenomics, Dipartimento di Scienze Farmaceutiche, Università Degli Studi di Milano, Milano, Italy
| | - Ashok K Datusalia
- Laboratory of Neuropsychopharmacology and Functional Neurogenomics, Dipartimento di Scienze Farmaceutiche, Università Degli Studi di Milano, Milano, Italy.,Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli, India
| | - Jessica Rosa
- Laboratory of Neuropsychopharmacology and Functional Neurogenomics, Dipartimento di Scienze Farmaceutiche, Università Degli Studi di Milano, Milano, Italy.,Department of Pharmacology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirao Preto, Brazil
| | - Roberta Facchinetti
- Department of Physiology and Pharmacology "Vittorio Erspamer", SAPIENZA University of Rome, Rome, Italy
| | - Giulia Frumento
- Department of Pharmacy, Unit of Pharmacology and Toxicology, University of Genoa, Genoa, Italy
| | - Giulia Carini
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | | | - Caterina Scuderi
- Department of Physiology and Pharmacology "Vittorio Erspamer", SAPIENZA University of Rome, Rome, Italy
| | - Lia Forti
- Department of Biotechnology and Life Sciences, University of Insubria, Busto Arsizio, Italy
| | - Alessandro Barbon
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Giambattista Bonanno
- Department of Pharmacy, Unit of Pharmacology and Toxicology, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maurizio Popoli
- Laboratory of Neuropsychopharmacology and Functional Neurogenomics, Dipartimento di Scienze Farmaceutiche, Università Degli Studi di Milano, Milano, Italy
| | - Laura Musazzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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8
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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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9
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Glucocorticoid-glucocorticoid receptor-HCN1 channels reduce neuronal excitability in dorsal hippocampal CA1 neurons. Mol Psychiatry 2022; 27:4035-4049. [PMID: 35840797 PMCID: PMC9718682 DOI: 10.1038/s41380-022-01682-9] [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: 02/04/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/07/2023]
Abstract
While chronic stress increases hyperpolarization-activated current (Ih) in dorsal hippocampal CA1 neurons, the underlying molecular mechanisms are entirely unknown. Following chronic social defeat stress (CSDS), susceptible mice displayed social avoidance and impaired spatial working memory, which were linked to decreased neuronal excitability, increased perisomatic hyperpolarization-activated cyclic nucleotide-gated (HCN) 1 protein expression, and elevated Ih in dorsal but not ventral CA1 neurons. In control mice, bath application of corticosterone reduced neuronal excitability, increased tetratricopeptide repeat-containing Rab8b-interacting protein (TRIP8b) and HCN1 protein expression, and elevated Ih in dorsal but not ventral CA1 region/neurons. Corticosterone-induced upregulation of functional Ih was mediated by the glucocorticoid receptor (GR), HCN channels, and the protein kinase A (PKA) but not the calcium/calmodulin-dependent protein kinase II (CaMKII) pathway. Three months after the end of CSDS, susceptible mice displayed persistent social avoidance when exposed to a novel aggressor. The sustained behavioral deficit was associated with lower neuronal excitability and higher functional Ih in dorsal CA1 neurons, both of which were unaffected by corticosterone treatment. Our findings show that corticosterone treatment mimics the pathophysiological effects of dorsal CA1 neurons/region found in susceptible mice. The aberrant expression of HCN1 protein along the somatodendritic axis of the dorsal hippocampal CA1 region might be the molecular mechanism driving susceptibility to social avoidance.
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10
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Kim J, Pokharel K, Sandali M, Kim CS. Establishment of the Mouse Model of Social Avoidance Induced by Female-Directed Female Aggression. CHRONIC STRESS 2022; 6:24705470221129288. [PMID: 36187211 PMCID: PMC9523834 DOI: 10.1177/24705470221129288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022]
Abstract
Background Most preclinical research on the effects of stress has been done on male subjects, even though women are more prone than men to experience stress-related problems. Chronic social defeat stress (CSDS) is a rodent model of psychosocial stress. However, this model has been challenged in female mouse studies since neither male nor female resident mice attack intruder females. A female-to-female CSDS model is needed to investigate the physiological and behavioral aspects. Methods The intruders were either male or female C57BL/6J mice, whereas the residents were male or ovariectomized (OVX) female CD-1 mice. The CD-1 aggressor mice had direct physical contact with the C57BL/6J mice for 10 min before initiating sensory contact with them for 24 h. Jump escape and freezing were evaluated during the social defeat of days 1 and 12. Experimental C57BL/6J mice underwent a social interaction test after suffering social defeat for 12 days. Results We found that the number of attack bites and attack latency had a significant negative correlation during the selection of aggressors. In the single-housed OVX mice, 34% of mice met the criterion of the selection of aggressors. However, single-housed OVX mice did not show sustained aggressive behavior (eg, attack bites) through the 12-day CSDS. As a result, we did not find susceptible mice during the social interaction test. In contrast, during the selection of aggressors, 42% of OVX mice housed with partners satisfied the criterion and displayed consistently aggressive behavior. CSDS produced susceptible (50%) and resilient (50%) phenotypes during the social interaction test. Notably, male and OVX female CD-1 mice housed with partners had similar amounts of attack bites and attack rates over the 12-day CSDS. Finally, we found that chronically socially defeated male and female mice displayed different coping behaviors (eg, active vs passive) with social defeat. Conclusions Our study demonstrates that OVX CD-1 mice housed with mates exhibited territorial aggression toward female intruders, producing susceptibility and resilience to social avoidance. Additionally, socially defeated male and female mice displayed different behavioral susceptibility to social defeat.
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Affiliation(s)
- Jiwon Kim
- Department of Neuroscience & Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Kritika Pokharel
- Department of Neuroscience & Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Michael Sandali
- Department of Neuroscience & Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Chung Sub Kim
- Department of Neuroscience & Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
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11
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Rothärmel M, Benosman C, El-Hage W, Berjamin C, Ribayrol D, Guillin O, Gaillard R, Berkovitch L, Moulier V. Efficacy and Safety of Intranasal Esketamine in Patients With Treatment-Resistant Depression and Comorbid Chronic Post-traumatic Stress Disorder: Open-Label Single-Arm Pilot Study. Front Psychiatry 2022; 13:865466. [PMID: 35873243 PMCID: PMC9305073 DOI: 10.3389/fpsyt.2022.865466] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Major depressive disorder (MDD) is more likely to resist to usual treatment when it is associated with post-traumatic stress disorder (PTSD). Capitalizing on the effect of ketamine in both treatment-resistant depression (TRD) and PTSD, we conducted a study in order to assess the efficacy of intranasal (IN) Esketamine in patients having TRD with comorbid PTSD. MATERIALS AND METHODS In this open-label, single arm, retrospective pilot study, 11 patients were treated with IN Esketamine (56 or 84 mg) with a longitudinal follow-up of 6 months. IN Esketamine was administered twice weekly during the first month, once weekly during the second month, and then once every 1 or 2 weeks. Patients were assessed with Montgomery-Åsberg Depression Rating Scale (MADRS), Patient Health Questionnaire 9 items, Global Assessment of Functioning (GAF), and Clinical Global Impression-Suicide Scale (CGI-SS). RESULTS We included 9 women and 2 men (mean age 47.3 ± 11.1 years). The mean (SD) MADRS scores decreased significantly from 38.6 (6.4) at baseline to 18.2 (10.03) after 6 months of IN Esketamine; 7 patients were responders and 3 patients were in remission. The percentage of patients who were moderately to severely suicidal declined from 63.6% at baseline to 27.3% after 1 month of IN Esketamine sessions. No serious adverse reactions were observed. CONCLUSION This study reports the outcomes of 11 severely ill patients with comorbid TRD and PTSD after IN Esketamine treatment. Esketamine significantly improved depression symptoms, suggesting that it is likely to be a treatment of choice in this specific population.
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Affiliation(s)
- Maud Rothärmel
- Service Hospitalo-Universitaire de Psychiatrie, Centre d'Excellence Thérapeutique-Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
| | - Cherifa Benosman
- Service Hospitalo-Universitaire de Psychiatrie, Centre d'Excellence Thérapeutique-Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
| | - Wissam El-Hage
- Centre Régional de Psychotraumatologie, Centre Hospitalier Régional Universitaire (CHRU) de Tours, Tours, France.,INSERM U1253 Imagerie et Cerveau (iBrain), Tours, France
| | - Caroline Berjamin
- Service Hospitalo-Universitaire de Psychiatrie, Centre d'Excellence Thérapeutique-Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
| | - Diane Ribayrol
- Service Hospitalo-Universitaire de Psychiatrie, Centre d'Excellence Thérapeutique-Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
| | - Olivier Guillin
- Service Hospitalo-Universitaire de Psychiatrie, Centre d'Excellence Thérapeutique-Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France.,Centre Hospitalier Universitaire (CHU) de Rouen, Rouen, France.,Faculté de Médecine, Normandy University, Rouen, France
| | - Raphaël Gaillard
- Service Hospitalo-Universitaire, Pôle Hospitalo-Universitaire Psychiatrie Paris 15, Groupe Hospitalier Universitaire Paris, Paris, France
| | - Lucie Berkovitch
- Service Hospitalo-Universitaire, Pôle Hospitalo-Universitaire Psychiatrie Paris 15, Groupe Hospitalier Universitaire Paris, Paris, France.,Université Paris Cité, Paris, France
| | - Virginie Moulier
- Service Hospitalo-Universitaire de Psychiatrie, Centre d'Excellence Thérapeutique-Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France.,Unité de Recherche Clinique (URC), EPS Ville Evrard, Neuilly-sur-Marne, France
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12
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[Ketamine Augmented Psychotherapy (KAP) in mood disorder: User guide]. Encephale 2021; 48:304-312. [PMID: 34876279 DOI: 10.1016/j.encep.2021.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/30/2021] [Accepted: 08/20/2021] [Indexed: 01/02/2023]
Abstract
Ketamine, a non-competitive NMDA receptor antagonist, is used as a fast-acting antidepressant therapy in depressive disorders. This treatment provokes dissociative effects associating derealization and depersonalization, and a synaptogenic signaling cascade promoting brain plasticity. Despite several preliminary studies suggesting the usefulness of its combination with psychotherapy, administration of ketamine isn't generally combined with per- and post-infusion psychotherapy protocols in its clinical antidepressant use. However, the phenomenology of psychodysleptic experiences and the synaptogenic effect could potentiate cognitive and behavioral therapies (CBT). In this article, we purpose a practical protocol to Ketamine Augmented Psychotherapy (KAP) synthesizing contemporary data from the literature and our clinical experience. We detail proposals for clinical practice, and propose four important steps for the use of a psychodysleptic molecule for antidepressant purposes: preparation, administration, integration, and prolongation. Finally, we discuss the limits and prospects of this combination in the management of mood disorders.
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13
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Verney C, Gressens P, Vitalis T. [Anatomy and physiology of traumatic stress]. Med Sci (Paris) 2021; 37:1002-1010. [PMID: 34851276 DOI: 10.1051/medsci/2021165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Facing a more or less intrusive stress, some individuals can cope as they are more resilient, while others get traumatized and further develop a Post Traumatic Stress Disorder (PTSD). Individuals are not equal facing traumatic stress for genetic/epigenetic or personal reasons. This review analyzes from animal models to human, the neurobiological changes detected when the stress switch from adaptable in everyday life to pathological leading to PTSD. Fear memories lead to the disruption of the anatomy/morphology of emotional-memory networks centered on the amygaloïd complex and hippocampal hub associated with the homeostatic unbalance of the body-brain exchanges of molecules such as hormones, neuromodulators or peptides. Persistent fear memories are hardly handled by the frontal ability for decision making towards action. But these fear memories can be revisited by different therapies recruiting cerebral plasticity and resilience. Current understanding of PTSD allowed to develop a series of efficient treatments associating precise medicine to diverse body-mind therapies.
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Affiliation(s)
- Catherine Verney
- Université de Paris, NeuroDiderot, Paris, France - Inserm UMR 1141, Hôpital Robert-Debré, 48 boulevard Sérurier, 75019 Paris, France - Association, Ensemble pour l'éducation de la petite enfance, 37 allée du Forum, 92100 Boulogne-Billancourt, France
| | - Pierre Gressens
- Université de Paris, NeuroDiderot, Paris, France - Inserm UMR 1141, Hôpital Robert-Debré, 48 boulevard Sérurier, 75019 Paris, France
| | - Tania Vitalis
- Université de Paris, NeuroDiderot, Paris, France - Inserm UMR 1141, Hôpital Robert-Debré, 48 boulevard Sérurier, 75019 Paris, France
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14
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Abstract
Epigenetic mechanisms such as DNA methylation (DNAm) have been associated with stress responses and increased vulnerability to depression. Abnormal DNAm is observed in stressed animals and depressed individuals. Antidepressant treatment modulates DNAm levels and regulates gene expression in diverse tissues, including the brain and the blood. Therefore, DNAm could be a potential therapeutic target in depression. Here, we reviewed the current knowledge about the involvement of DNAm in the behavioural and molecular changes associated with stress exposure and depression. We also evaluated the possible use of DNAm changes as biomarkers of depression. Finally, we discussed current knowledge limitations and future perspectives.
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15
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Radell ML, Hamza EA, Moustafa AA. Depression in post-traumatic stress disorder. Rev Neurosci 2021; 31:703-722. [PMID: 32866132 DOI: 10.1515/revneuro-2020-0006] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/31/2020] [Indexed: 12/12/2022]
Abstract
Major depressive disorder (MDD) symptoms commonly occur after trauma-exposure, both alone and in combination with post-traumatic stress disorder (PTSD). This article reviews recent research on comorbidity between these disorders, including its implications for symptom severity and response to treatment. Despite considerable symptom overlap, the two disorders represent distinct constructs and depend, at least in part, on separate biological mechanisms. Both, however, are also clearly related to stress psychopathology. We recommend that more research focus specifically on the study of individual differences in symptom expression in order to identify distinct subgroups of individuals and develop targeted treatments. However, a barrier to this line of inquiry is the trend of excluding particular patients from clinical trials of new interventions based on symptom severity or comorbidity. Another obstacle is the overreliance on self-report measures in human research. We argue that developing computer-based behavioral measures in order to supplement self-report can help address this challenge. Furthermore, we propose that these measures can help tie findings from human and non-human animal research. A number of paradigms have been used to model MDD-and PTSD-like behavior in animals. These models remain valuable for understanding the biological basis of these disorders in humans and for identifying potential interventions, but they have been underused for the study of comorbidity. Although the interpretation of animal behavior remains a concern, we propose that this can also be overcome through the development of close human analogs to animal paradigms.
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Affiliation(s)
- Milen L Radell
- Department of Psychology, Niagara University, Lewiston, NY, USA
| | - Eid Abo Hamza
- Department of Mental Health, Faculty of Education, Tanta University, Tanta, Egypt
| | - Ahmed A Moustafa
- School of Psychology, Western Sydney University, Sydney, NSW, Australia.,Marcs Institute for Brain, Behaviour and Development, Western Sydney University, Sydney, NSW, Australia.,Department of Human Anatomy and Physiology, The Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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16
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Akhtar A, Pilkhwal Sah S. Advances in the pharmacotherapeutic management of post-traumatic stress disorder. Expert Opin Pharmacother 2021; 22:1919-1930. [PMID: 34124975 DOI: 10.1080/14656566.2021.1935871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Post-traumatic stress disorder (PTSD), a mental disorder, is associated with anxiety, depression, and social awkwardness resulting from past traumatic episodes like natural disasters, accidents, terrorist attacks, war, rape, and sexual violence. It affects primarily the amygdala, cortex, and hippocampus where neurochemical changes result in altered behavior. PTSD patients display impaired fear extinction, and past events keep haunting them. The topic presents relevant sections like PTSD pharmacotherapy, associated challenges, and the novel targets and drugs for future research and therapy.Areas covered: The authors discuss the current pharmacotherapy like SSRIs, NDRIs, SNRIs, anticonvulsants, antidepressants, and benzodiazepines, used to attenuate the associated symptoms. However, the primary focus being the novel and potential targets which can be explored better to understand possible future research and advanced therapy in PTSD. For the same, an account of both preclinical and clinical studies has been covered.Expert opinion: Excessive adverse effects, limited efficacy, and lower patient compliance are some of the major challenges with conventional drugs. Moreover, they correct only fewer symptoms without halting the disease progression. Several agents are investigated in different preclinical and clinical phases, which can potentially overcome the pitfalls and limitations associated with conventional therapies.
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Affiliation(s)
- Ansab Akhtar
- Pharmacology Division, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Sangeeta Pilkhwal Sah
- Pharmacology Division, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
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17
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Marshall LL, Hayslett RL. Post-traumatic Stress Disorder in Middle Age and Beyond. Sr Care Pharm 2021; 36:191-207. [PMID: 33766192 DOI: 10.4140/tcp.n.2021.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the clinical manifestations and treatment of post-traumatic stress disorder (PTSD) in adults and older people. DATA SOURCES Articles indexed in PubMed, Embase, psychology databases, and the Cochrane library over the past 10 years using the key words "post-traumatic stress disorder," "stress disorders," and "post-traumatic stress disorder and treatment." STUDY SELECTION AND DATA EXTRACTION Sixty-seven publications were reviewed and criteria supporting the primary objective were used to identify useful resources. DATA SYNTHESIS The literature included practice guidelines; review articles; original research articles; and product prescribing information for the clinical manifestations, diagnosis, and treatment of PTSD. CONCLUSION Psychotherapy is the first-line therapy for PTSD. Pharmacologic therapy is recommended, as second-line therapy, for adults living with PTSD who do not have access to psychotherapy or refuse psychotherapy. Pharmacologic therapy may also be considered in cases of partial, or no, response to psychotherapy. Current guidelines recommend prescribing one of 3 selective serotonin-reuptake inhibitors, either fluoxetine, paroxetine, or sertraline, or prescribing the serotonin norepinephrine reuptake inhibitor venlafaxine, for adult patients who do not have access to psychotherapy or prefer not to use psychotherapy. Unfortunately, these recommended medications have additional cautions for use in older people so may not be appropriate for many older people living with PTSD. Therapy for older people should be tailored to patient-specific symptoms, with careful consideration of the potential benefits and risks of the therapy and coexisting medical conditions of each patient.
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Affiliation(s)
- Leisa L Marshall
- 1Mercer University College of Pharmacy, Mercer Health Sciences Center, Atlanta, Georgia
| | - Renée L Hayslett
- 1Mercer University College of Pharmacy, Mercer Health Sciences Center, Atlanta, Georgia
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18
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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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19
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20
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Feder A, Rutter SB, Schiller D, Charney DS. The emergence of ketamine as a novel treatment for posttraumatic stress disorder. RAPID ACTING ANTIDEPRESSANTS 2020; 89:261-286. [DOI: 10.1016/bs.apha.2020.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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21
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Olff M, Amstadter A, Armour C, Birkeland MS, Bui E, Cloitre M, Ehlers A, Ford JD, Greene T, Hansen M, Lanius R, Roberts N, Rosner R, Thoresen S. A decennial review of psychotraumatology: what did we learn and where are we going? Eur J Psychotraumatol 2019; 10:1672948. [PMID: 31897268 PMCID: PMC6924542 DOI: 10.1080/20008198.2019.1672948] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
On 6 December 2019 we start the 10th year of the European Journal of Psychotraumatogy (EJPT), a full Open Access journal on psychotrauma. This editorial is part of a special issue/collection celebrating the 10 years anniversary of the journal where we will acknowledge some of our most impactful articles of the past decade (also discussed below and marked with * in the reference list). In this editorial the editors present a decennial review of the field addressing a range of topics that are core to both the journal and to psychotraumatology as a discipline. These include neurobiological developments (genomics, neuroimaging and neuroendocrine research), forms of trauma exposure and impact across the lifespan, mass trauma and early interventions, work-related trauma, trauma in refugee populations, and the potential consequences of trauma such as PTSD or Complex PTSD, but also resilience. We address innovations in psychological, medication (enhanced) and technology-assisted treatments, mediators and moderators like social support and finally how new research methods help us to gain insights in symptom structures or to better predict symptom development or treatment success. We aimed to answer three questions 1. Where did we stand in 2010? 2. What did we learn in the past 10 years? 3. What are our knowledge gaps? We conclude with a number of recommendations concerning top priorities for the future direction of the field of psychotraumatology and correspondingly the journal.
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Affiliation(s)
- Miranda Olff
- Department of Psychiatry, Amsterdam
University Medical Centers (location AMC), University of Amsterdam, Amsterdam
Neuroscience, Amsterdam, The Netherlands
- ARQ National Psychotrauma
Centre, Diemen, The Netherlands
| | - Ananda Amstadter
- Departemnts of Psychiatry, Psychology, &
Human and Molecular Genetics, Virginia Commonwealth University, Richmond,
USA
| | - Cherie Armour
- School of Psychology, Queens University
Belfast, Belfast, Northern Ireland, UK
| | - Marianne S. Birkeland
- Section for implementation and treatment
research, Norwegian Centre for Violence and Traumatic Stress Studies, Oslo
Norway
| | - Eric Bui
- Department of Psychiatry, Massachusetts
General Hospital & Harvard Medical School, Boston, MA,
USA
| | - Marylene Cloitre
- National Center for PTSD Dissemination and
Training Division, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral
Sciences, Stanford University, Palo Alto, CA, USA
| | - Anke Ehlers
- Department of Experimental Psychology,
University of Oxford, Oxford, UK
| | - Julian D. Ford
- Department of Psychiatry, University of
Connecticut Health Center, Farmington, USA
| | - Talya Greene
- Department of Community Mental Health,
University of Haifa, Haifa, Israel
| | - Maj Hansen
- Department of Psychology,
Odense, Denmark
| | - Ruth Lanius
- Posttraumatic Stress Disorder (PTSD) Research
Unit, Western University of Canada, London, ON,
Canada
| | - Neil Roberts
- Psychology and Psychological Therapies
Directorate, Cardiff & Vale University Health Board, Cardiff,
UK
- Division of Psychological Medicine &
Clinical Neurosciences, Cardiff University, Cardiff,
UK
| | - Rita Rosner
- Department of Clinical and Biological
Psychology, KU Eichstaett-Ingolstadt, Eichstaett,
Germany
| | - Siri Thoresen
- Section for trauma, catastrophes and forced
migration – children and youth, Norwegian Centre for Violence and Traumatic Stress
Studies, Oslo, Norway
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22
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DePierro J, Lepow L, Feder A, Yehuda R. Translating Molecular and Neuroendocrine Findings in Posttraumatic Stress Disorder and Resilience to Novel Therapies. Biol Psychiatry 2019; 86:454-463. [PMID: 31466562 PMCID: PMC6907400 DOI: 10.1016/j.biopsych.2019.07.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 12/13/2022]
Abstract
Many biological systems are altered in association with posttraumatic stress disorder (PTSD) and resilience. However, there are only few approved pharmacological treatments for PTSD, and no approved medications to enhance resilience. This article provides a critical review of select neurobiological findings in PTSD and resilience, and also of pharmacologic approaches that have emerged from this work. The medications summarized involve engagement with targets in the adrenergic, hypothalamic-pituitary-adrenal axis, and neuropeptide Y systems. Other highlighted approaches involve the use of ketamine and 3,4-methylenedioxymethamphetamine-assisted psychotherapy, which recently surfaced as promising strategies for PTSD, though the neurobiological mechanisms underlying their actions, including for promoting resilience, are not yet fully understood. The former approaches fall within the broad concept of "rational pharmacotherapy," in that they attempt to directly target dysregulated systems known to be associated with posttraumatic symptoms. To the extent that use of ketamine and 3,4-methylenedioxymethamphetamine promotes symptom improvement and resilience in PTSD, this provides an opportunity for reverse translation and identification of relevant targets and mechanisms of action through careful study of biological changes resulting from these interventions. Promoting resilience in trauma-exposed individuals may involve more than pharmacologically manipulating dysregulated molecules and pathways associated with developing and sustaining PTSD symptom severity, but also producing a substantial change in mental state that increases the ability to engage with traumatic material in psychotherapy. Neurobiological examination in the context of treatment studies may yield novel targets and promote a greater understanding of mechanisms of recovery from trauma.
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Affiliation(s)
- Jonathan DePierro
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren Lepow
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Adriana Feder
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel Yehuda
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, New York.
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