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Baldinger-Melich P, Spies M, Bozic I, Kasper S, Rujescu D, Frey R. Perspectives in treatment-resistant depression: esketamine and electroconvulsive therapy. Wien Klin Wochenschr 2024:10.1007/s00508-024-02358-w. [PMID: 38662240 DOI: 10.1007/s00508-024-02358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/23/2024] [Indexed: 04/26/2024]
Abstract
Modern electroconvulsive therapy (ECT) and the approval of nasal esketamine for clinical use have significantly improved the approach to treatment-resistant depression (TRD), which is defined as non-response to at least two different courses of antidepressants with verified adherence to treatment, adequate dosage, and duration of treatment. The goal of this literature review is to present the newest evidence regarding efficacy and safety. Furthermore, we aim to provide an overview of future perspectives in this field of research, for example, regarding structural and molecular effects. Both treatment methods will be critically evaluated for their individual advantages, disadvantages, and response rates. Firstly, we will discuss the well-established method of ECT and its different treatment modalities. Secondly, we will discuss the properties of ketamine, the discovery of its antidepressive effects and the route to clinical approval of the esketamine nasal spray. We will comment on research settings which have evaluated intravenous ketamine against ECT. The decision-making process between esketamine nasal spray or ECT should include the assessment of contraindications, age, severity of disease, presence of psychotic symptoms, patient preference and treatment accessibility. We conclude that both treatment options are highly effective in TRD. If both are indicated, pragmatically esketamine will be chosen before ECT; however, ECT studies in ketamine non-responders are missing.
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Affiliation(s)
- Pia Baldinger-Melich
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Marie Spies
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Ina Bozic
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Siegfried Kasper
- Department of Molecular Neurosciences, Center for Brain Research, Vienna, Austria
| | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Richard Frey
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria.
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2
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Rhee TG, Shim SR, Popp JH, Trikalinos TA, Rosenheck RA, Kellner CH, Seiner SJ, Espinoza RT, Forester BP, McIntyre RS. Efficacy and safety of ketamine-assisted electroconvulsive therapy in major depressive episode: a systematic review and network meta-analysis. Mol Psychiatry 2024; 29:750-759. [PMID: 38123725 DOI: 10.1038/s41380-023-02366-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive episode (MDE). METHODS PubMed/MEDLINE, Cochrane Library, Embase, GoogleScholar, and US and European trial registries were searched from inception through May 23, 2023, with no language limits. We included RCTs with (1) a diagnosis of MDE; (2) ECT intervention with ketamine and/or other anesthetic agents; and (3) measures included: depressive symptoms, cognitive performance, remission or response rates, and serious adverse events. Network meta-analysis (NMA) was performed to compare ketamine and 7 other anesthetic agents. Hedges' g standardized mean differences (SMDs) were used for continuous measures, and relative risks (RRs) were used for other binary outcomes using random-effects models. RESULTS Twenty-two studies were included in the systematic review. A total of 2322 patients from 17 RCTs were included in the NMA. The overall pooled SMD of ketamine, as compared with propofol as a reference group, was -2.21 (95% confidence interval [CI], -3.79 to -0.64) in depressive symptoms, indicating that ketamine had better antidepressant efficacy than propofol. In a sensitivity analysis, however, ketamine-treated patients had a worse outcome in cognitive performance than propofol-treated patients (SMD, -0.18; 95% CI, -0.28 to -0.09). No other statistically significant differences were found. CONCLUSIONS Ketamine-assisted ECT is tolerable and may be efficacious in improving depressive symptoms, but a relative adverse impact on cognition may be an important clinical consideration. Anesthetic agents should be considered based on patient profiles and/or preferences to improve effectiveness and safety of ECT use.
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Affiliation(s)
- Taeho Greg Rhee
- Department of Psychiatry, School of Medicine, Yale University, New Haven, CT, USA.
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA.
- Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington, CT, USA.
| | - Sung Ryul Shim
- Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon, Chungcheongnam-do, Republic of Korea
| | - Jonah H Popp
- Center for Evidence Synthesis in Health, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Thomas A Trikalinos
- Center for Evidence Synthesis in Health, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Robert A Rosenheck
- Department of Psychiatry, School of Medicine, Yale University, New Haven, CT, USA
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Charles H Kellner
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Stephen J Seiner
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Division of Neurotherapeutics, McLean Hospital, Belmont, MA, USA
| | - Randall T Espinoza
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, CA, USA
| | - Brent P Forester
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Division of Neurotherapeutics, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Tufts University School of Medicine, Boston, MA, USA
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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3
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Ren L, Yu J, Zeng J, Wei K, Li P, Luo J, Shen Y, Lv F, Min S. Comparative efficacy and tolerability of different anesthetics in electroconvulsive therapy for major depressive disorder: A systematic review and network meta-analysis. J Psychiatr Res 2024; 171:116-125. [PMID: 38271762 DOI: 10.1016/j.jpsychires.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Abstract
Electroconvulsive therapy (ECT) is one of the most effective treatments for major depressive disorder. Modern ECT is conducted with anesthesia, however, the optimal anesthetic agent for ECT is yet to be understood. This study is aimed to compare the effects of different anesthetic agents on antidepressant efficacy and tolerability in depressed individuals undergoing ECT. We searched MEDLINE, EMBASE, the CENTRAL and PsycINFO for randomized controlled trials from database inception until Nov 13, 2022 (PROSPERO: CRD42022375407). Global and local inconsistencies, heterogeneity and publication bias were assessed. Rankings were calculated with the surface under the cumulative ranking curve. A total of 33 studies involving 1898 patients were enrolled. Remission rates were higher for ketamine anesthesia as compared to adjunctive ketamine and propofol. In terms of ranking, ketamine was found to be first in terms of response/remission rates and depressive scores after the 1st, 3rd and 6th ECT and at the end of ECT session, while a higher incidence of adverse events was also observed. No significant advantage of any anesthetic was revealed for the cognitive function after ECT. In summary, based on current evidence, no specific anesthetic is recommended for ECT anesthesia. However, despite more side effects, ketamine monoanesthesia seems to reveal a potential benefit in improving antidepressant efficacy of ECT, and further studies are needed to investigate the relationship between anesthetic agents and the therapeutic effect of ECT.
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Affiliation(s)
- Li Ren
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Yu
- Department of Psychiatry, Shanghai Tenth People's Hospital, Anesthesia and Brain Research Institute, Tongji University, Shanghai, China
| | - Jie Zeng
- Department of Anesthesiology, Stomatological Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Wei
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Luo
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yiwei Shen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Lv
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Zhen C, Wang C, Ma Y, Pang Y, Cai F, Meng J, He Y, Xiao P, Liu J, Mei X, Li S, Wu G, Jin G, Zheng B, Liang R, Tan Z. Mechanism of Antidepressant Action of (2R,6R)-6-Hydroxynorketamine (HNK) and Its Compounds: Insights from Proteomic Analysis. Mol Neurobiol 2024; 61:465-475. [PMID: 37632679 DOI: 10.1007/s12035-023-03555-w] [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] [Received: 05/09/2023] [Accepted: 08/02/2023] [Indexed: 08/28/2023]
Abstract
The effects of HNK, I5, and I6 on the expression of protein in hippocampus of depressed mice were studied by isobaric tags for relative and absolute quantitation (iTRAQ) to explore the mechanism of their antidepressant action. HNK, I5, and I6 were administered intragastric administration once a day in the morning for 7 days. The drug was subsequently discontinued for 7 days (without any treatment). On the 15th day, mice in each group were given the drug (1.0, 10.0, 30.0 mg/kg) intragastric stimulation and mouse hippocampal tissues were taken to perform iTRAQ to identify differentially expressed proteins, and bioinformatics was used to analyze the functional enrichment of the differentially expressed proteins. Compared with Ctr group, the number of differentially expressed proteins in HNK, I5, and I6 treatment groups was 158, 88, and 105, respectively. The three groups shared 29 differentially expressed proteins. In addition, compared with HNK group, the number of differentially expressed proteins in I5 and I6 groups was 201 and 203, respectively. A total of 47 and 56 differentially expressed proteins were co-expressed in I5 and I6 groups. Bioinformatics analysis showed that these differentially expressed proteins mainly had the functions of binding, biocatalysis, and transport, and mainly participated in cellular process, biological regulation process, biological metabolism process, and stress reaction process. GO and KEGG pathway analysis found that these differentially expressed proteins were involved long-term potentiation, G13 pathway, platelet activation pathway, and MAPK signaling pathway. HNK, I5, and I6 antidepressants are closely related to sudden stress sensitivity, stress resistance, neurotransmitter, and metabolic pathways. This study provides a scientific basis to further elucidate the mechanism and clinical application of HNK, I5, and I6 antidepressants.
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Affiliation(s)
- Chaohui Zhen
- Department of Surgery, The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan City, 523000, Guangdong Province, China
| | - Chong Wang
- Department of Neurosurgery, Shenzhen Children's Hospital, Shenzhen City, 518026, Guangdong Province, China
| | - Yanjun Ma
- Shenzhen Ruijian Biotechnology Co., Ltd, Shenzhen City, 518057, Guangdong Province, China
| | - Yuli Pang
- Health Management Center, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University, Shenzhen City, 518055, Guangdong Province, China
| | - Feiyue Cai
- Health Management Center, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University, Shenzhen City, 518055, Guangdong Province, China
- General Practice Alliance, Shenzhen City, Guangdong Province, China
| | - Jiali Meng
- General Practice Alliance, Shenzhen City, Guangdong Province, China
- Department of General Practice, Shenzhen University General Hospital, Shenzhen University, Shenzhen City, 518055, Guangdong Province, China
| | - Yuefei He
- General Practice Alliance, Shenzhen City, Guangdong Province, China
- Department of General Practice, Shenzhen University General Hospital, Shenzhen University, Shenzhen City, 518055, Guangdong Province, China
| | - Ping Xiao
- Department of Otorhinolaryngology Head and Neck Surgery, Shenzhen Children's Hospital, Shenzhen City, 518026, Guangdong Province, China
| | - Jianxi Liu
- Shenzhen Ruijian Biotechnology Co., Ltd, Shenzhen City, 518057, Guangdong Province, China
| | - Xi Mei
- Zhuhai Pengkun Biomedicine Technology Co. Ltd, Zhuhai City, 519000, Guangdong Province, China
| | - Shupeng Li
- State Key Laboratory of Oncogenomics, School of Chemical Biology and Biotechnology, Peking University, Shenzhen City, 518055, Guangdong Province, China
| | - Guanzheng Wu
- College of Textiles and Clothing, Yancheng Institute of Technology, Yancheng City, 224051, Jiangsu Province, China
| | - Guangzhen Jin
- Institute of Tissue Regeneration Engineering (ITREN), Dankook University, Cheonan, 31116, Korea
| | - Biao Zheng
- Department of Surgery, The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan City, 523000, Guangdong Province, China.
| | - Rui Liang
- Department of Surgery, The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan City, 523000, Guangdong Province, China.
| | - Zhen Tan
- Department of Surgery, The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan City, 523000, Guangdong Province, China.
- Health Management Center, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University, Shenzhen City, 518055, Guangdong Province, China.
- General Practice Alliance, Shenzhen City, Guangdong Province, China.
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5
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Rhee TG, Shim SR, Popp J, Trikalinos T, Rosenheck R, Kellner C, Seiner S, Espinoza R, Forester B, McIntyre R. Efficacy and Safety of Ketamine-assisted Electroconvulsive Therapy in Major Depressive Episode: A Systematic Review and Network Meta-Analysis. RESEARCH SQUARE 2023:rs.3.rs-3182771. [PMID: 37609159 PMCID: PMC10441463 DOI: 10.21203/rs.3.rs-3182771/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Objective To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive episode (MDE). Methods PubMed/MEDLINE, Cochrane Library, Embase, GoogleScholar, and US and European trial registries were searched from inception through May 23, 2023, with no language limits. We included RCTs with (1) a diagnosis of MDE; (2) ECT intervention with ketamine and/or other anesthetic agents; and (3) measures included: depressive symptoms, cognitive performance, remission or response rates, and serious adverse events. Network meta-analysis (NMA) was performed to compare ketamine and 7 other anesthetic agents. Hedges' g standardized mean differences (SMDs) were used for continuous measures, and relative risks (RRs) were used for other binary outcomes using random-effects models. Results Twenty-two studies were included in the systematic review. A total of 2,322 patients from 17 RCTs were included in the NMA. The overall pooled SMD of ketamine, as compared with a propofol reference group, was -2.21 (95% confidence interval [CI], -3.79 to -0.64) in depressive symptoms, indicating that ketamine had better antidepressant efficacy than propofol. In a sensitivity analysis, however, ketamine-treated patients had a worse outcome in cognitive performance than propofol-treated patients (SMD, -0.18; 95% CI, -0.28 to -0.09). No other statistically significant differences were found. Conclusions Ketamine-assisted ECT is tolerable and may be efficacious in improving depressive symptoms, but a relative adverse impact on cognition may be an important clinical consideration. Anesthetic agents should be considered based on patient profiles and/or preferences to improve effectiveness and safety of ECT use.
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Affiliation(s)
| | | | | | | | | | | | | | - Randall Espinoza
- Departments of Neurology, Psychiatry and Biobehavioral Sciences, University of California
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6
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Nagi T, Jagtiani A, Somvanshi S, Seegobin SA, Singh J, Bachu AK, Pathak M. Ketamine Augmentation of Electroconvulsive Therapy: A Scoping Review of Dose-Dependent Effects in Major Depressive Disorder. Cureus 2023; 15:e40087. [PMID: 37292107 PMCID: PMC10246511 DOI: 10.7759/cureus.40087] [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: 06/07/2023] [Indexed: 06/10/2023] Open
Abstract
Intravenous ketamine infusions in subanesthetic doses have been shown to rapidly alleviate depressive symptoms. However, the efficacy of ketamine as an anesthetic during electroconvulsive therapy (ECT) for major depression has not yet been answered by a large randomized control trial (RCT). This scoping review aims to examine the available literature to determine whether the dose of ketamine used during ECT influences the response to treatment. A literature search was conducted on PubMed to identify all published RCTs within the last 10 years which compared ketamine anesthesia during ECT for major depression with another anesthetic. Studies using low (<0.8 mg/kg) versus high (≥0.8 mg/kg) doses of ketamine during ECT were evaluated for the differences in outcomes using depression rating scales. Studies that examined ketamine as a standalone treatment for depression or focused primarily on the anesthetic benefits of ketamine were excluded from our review. Fifteen studies were utilized for this literature review. Overall, the studies showed inconsistent results in terms of the speed and magnitude of response to ketamine-assisted ECT in patients with major depression. Limitations of the available literature are discussed, including the lack of head-to-head comparisons, differences in methodology, inclusion/exclusion criteria, and primary and secondary endpoints.
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Affiliation(s)
- Tarika Nagi
- Psychiatry, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Amit Jagtiani
- Psychiatry, Burrell Behavioral Health, Springfield, USA
| | - Saurabh Somvanshi
- Psychiatry and Behavioral Sciences, Northwell Health - Zucker Hillside Hospital, New York, USA
| | | | - Jasbir Singh
- Psychiatry, University of California, Los Angeles - Kern Medical Center, Bakersfield, USA
| | - Anil K Bachu
- Psychiatry and Behavioral Sciences, Baptist Health-UAMS (University of Arkansas for Medical Sciences), Little Rock, USA
- Psychiatry and Behavioral Sciences, Allegheny Health Network, Pittsburgh, USA
| | - Meenal Pathak
- Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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7
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Marchi M, Magarini FM, Galli G, Mordenti F, Travascio A, Uberti D, De Micheli E, Pingani L, Ferrari S, Galeazzi GM. The effect of ketamine on cognition, anxiety, and social functioning in adults with psychiatric disorders: A systematic review and meta-analysis. Front Neurosci 2022; 16:1011103. [PMID: 36507365 PMCID: PMC9730521 DOI: 10.3389/fnins.2022.1011103] [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: 08/03/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background It has been shown that ketamine can improve suicidality and depression. Evidence for other dimensions of psychopathology is lacking. We undertook a systematic review to investigate the effect of ketamine on cognition, anxiety, quality of life, and social functioning in adults with psychiatric disorders. Methods PubMed (Medline), Scopus, PsycINFO, and EMBASE were searched up to April 2022. Randomized controlled trials (RCTs) on ketamine [or its S (+) enantiomer] reporting data on cognition, anxiety, quality of life, social functioning in adults with psychiatric disorders were included. Standardized mean difference (SMD) was used for summarizing continuous outcomes. Results Twenty-two reports were included in the final selection, of which 20, corresponding to 1,298 participants, were included in the quantitative synthesis. Affective disorders were the predominant diagnostic category. Median follow-up time was 21 days. The evidence was rated moderate to very low. In most trials, ketamine was administered intravenously or as adjuvant to electro-convulsant therapy (ECT). Only 2 trials of intranasal esketamine were identified. The effect of ketamine on depression was confirmed (SMD: -0.61 [95% CI: -1.06; -0.16]). Furthermore, by pooling results of 6 RCTs, ketamine may be effective in reducing anxiety symptoms (SMD: -0.42 [95% CI: -0.84; 0.003]), particularly when administered not within ECT (5 trials; SMD: -0.58 [95% CI: -1.07; -0.09]). However, there was moderate heterogeneity of results. Patients treated with ketamine also had an improvement in social functioning (SMD: -0.31 [95% CI: -0.52; -0.10]), although the estimate was based only on 2 studies. No difference to comparators was found with respect to cognition and quality of life. Conclusion Alongside the antidepressant effect, ketamine may also improve anxiety and social functioning in adults with affective disorders.
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Affiliation(s)
- Mattia Marchi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy,Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Federica Maria Magarini
- Department of Mental Health and Drug Abuse, Azienda Unità Sanitaria Locale (AUSL) Modena, Modena, Italy
| | | | - Federico Mordenti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Travascio
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Uberti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Edoardo De Micheli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Pingani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy,Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvia Ferrari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy,Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gian Maria Galeazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy,Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy,*Correspondence: Gian Maria Galeazzi
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8
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Bahji A, Zarate CA, Vazquez GH. Efficacy and safety of racemic ketamine and esketamine for depression: a systematic review and meta-analysis. Expert Opin Drug Saf 2022; 21:853-866. [PMID: 35231204 PMCID: PMC9949988 DOI: 10.1080/14740338.2022.2047928] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Racemic ketamine and esketamine have demonstrated rapid antidepressant effects. We aimed to review the efficacy and safety of racemic and esketamine for depression. RESEARCH DESIGN AND METHODS We conducted a PRISMA-guided review for relevant randomized controlled trials of racemic or esketamine for unipolar or bipolar major depression from database inception through 2021. We conducted random-effects meta-analyses using pooled rate ratios (RRs) and Cohen's standardized mean differences (d) with their 95% confidence intervals (CI). RESULTS We found 36 studies (2903 participants, 57% female, 45.1 +/- 7.0 years). Nine trials used esketamine, while the rest used racemic ketamine. The overall study quality was high. Treatment with any form of ketamine was associated with improved response (RR=2.14; 95% CI, 1.72-2.66; I2=65%), remission (RR=1.64; 95% CI, 1.33-2.02; I2=39%), and depression severity (d=-0.63; 95% CI, -0.80 to -0.45; I2=78%) against placebo. Overall, there was no association between treatment with any form of ketamine and retention in treatment (RR=1.00; 95% CI, 0.99-1.01; I2<1%), dropouts due to adverse events (RR=1.56; 95% CI, 1.00-2.45; I2<1%), or the overall number of adverse events reported per participant (OR=2.14; 95% CI, 0.82-5.60; I2=62%) against placebo. CONCLUSIONS Ketamine and esketamine are effective, safe, and acceptable treatments for individuals living with depression.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;,British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Carlos A. Zarate
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gustavo H. Vazquez
- Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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9
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Verdijk JP, van Kessel MA, Oud M, Kellner CH, Hofmeijer J, Verwijk E, van Waarde JA. Pharmacological interventions to diminish cognitive side effects of electroconvulsive therapy: A systematic review and meta-analysis. Acta Psychiatr Scand 2022; 145:343-356. [PMID: 35075641 PMCID: PMC9305858 DOI: 10.1111/acps.13397] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/26/2021] [Accepted: 12/18/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The authors conducted a systematic review and meta-analysis of pharmacological interventions to diminish cognitive side effects of ECT. METHODS Electronic databases of Pubmed, PsycInfo, Embase and Scopus were searched from inception through 1 April, 2021, using terms for ECT (e.g. electroconvulsive therapy), cognitive outcome (e.g. cogni*) and pharmacological intervention (e.g. calcium channel blocker and general terms, like protein). Original studies with humans receiving ECT were included, which applied pharmacological interventions in comparison with placebo or no additive intervention to diminish cognitive side effects. Data quality was assessed using Risk of Bias and GRADE. Random-effects models were used. PROSPERO registration number was CRD42021212773. RESULTS Qualitative synthesis (systematic review) showed 52 studies reporting sixteen pharmacological intervention-types. Quantitative synthesis (meta-analysis) included 26 studies (1387 patients) describing twelve pharmacological intervention-types. Low-quality evidence of efficacy was established for memantine (large effect size) and liothyronine (medium effect size). Very low-quality evidence shows effect of acetylcholine inhibitors, piracetam and melatonin in some cognitive domains. Evidence of no efficacy was revealed for ketamine (very low-quality), herbal preparations with anti-inflammatory properties (very low to low-quality) and opioid receptor agonists (low-quality). CONCLUSION Memantine and liothyronine are promising for further research and future application. Quality of evidence was low because of differences in ECT techniques, study populations and cognitive measurements. These findings provide a guide for rational choices of potential pharmacological intervention research targets to decrease the burden of cognitive side effects of ECT. Future research should be more uniform in design and attempt to clarify pathophysiological mechanisms of cognitive side effects of ECT.
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Affiliation(s)
- Joey P.A.J. Verdijk
- Department of PsychiatryRijnstate HospitalArnhemThe Netherlands,Department of Clinical NeurophysiologyUniversity of TwenteEnschedeThe Netherlands
| | - Mike A. van Kessel
- Department of Psychology, Brain & CognitionUniversity of AmsterdamAmsterdamThe Netherlands,Antes PG (Parnassia Group)Mental Health ServicesRotterdamThe Netherlands
| | | | - Charles H. Kellner
- Department of Psychiatry and Behavioral SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Jeannette Hofmeijer
- Department of Clinical NeurophysiologyUniversity of TwenteEnschedeThe Netherlands,Department of NeurologyRijnstate HospitalThe Netherlands
| | - Esmée Verwijk
- Department of Psychology, Brain & CognitionUniversity of AmsterdamAmsterdamThe Netherlands,Department of Medical Psychology, NeuropsychologyAmsterdam UMCAmsterdamThe Netherlands,ECT Department HaaglandenParnassia Psychiatric InstituteThe HagueThe Netherlands
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10
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Walsh Z, Mollaahmetoglu OM, Rootman J, Golsof S, Keeler J, Marsh B, Nutt DJ, Morgan CJA. Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review. BJPsych Open 2021; 8:e19. [PMID: 35048815 PMCID: PMC8715255 DOI: 10.1192/bjo.2021.1061] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In the past two decades, subanaesthetic doses of ketamine have been demonstrated to have rapid and sustained antidepressant effects, and accumulating research has demonstrated ketamine's therapeutic effects for a range of psychiatric conditions. AIMS In light of these findings surrounding ketamine's psychotherapeutic potential, we systematically review the extant evidence on ketamine's effects in treating mental health disorders. METHOD The systematic review protocol was registered in PROSPERO (identifier CRD42019130636). Human studies investigating the therapeutic effects of ketamine in the treatment of mental health disorders were included. Because of the extensive research in depression, bipolar disorder and suicidal ideation, only systematic reviews and meta-analyses were included. We searched Medline and PsycINFO on 21 October 2020. Risk-of-bias analysis was assessed with the Cochrane Risk of Bias tools and A Measurement Tool to Assess Systematic Reviews (AMSTAR) Checklist. RESULTS We included 83 published reports in the final review: 33 systematic reviews, 29 randomised controlled trials, two randomised trials without placebo, three non-randomised trials with controls, six open-label trials and ten retrospective reviews. The results were presented via narrative synthesis. CONCLUSIONS Systematic reviews and meta-analyses provide support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust, but suggests similarly positive and short-lived effects. The conclusions should be interpreted with caution because of the high risk of bias of included studies. Optimal dosing, modes of administration and the most effective forms of adjunctive psychotherapeutic support should be examined further.
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Affiliation(s)
- Zach Walsh
- Department of Psychology, University of British Columbia, Canada
| | | | - Joseph Rootman
- Department of Psychology, University of British Columbia, Canada
| | - Shannon Golsof
- Department of Psychology, University of British Columbia, Canada
| | - Johanna Keeler
- Eating Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, UK
| | - Beth Marsh
- Psychopharmacology and Addiction Research Centre, Department of Psychology, University of Exeter, UK; and Clinical Psychopharmacology Unit, Department of Clinical, Educational and Health Psychology, University College London, UK
| | - David J Nutt
- Drug Science, UK; and Neuropsychopharmacology Unit, Division of Psychiatry, Department of Brain Sciences, Imperial College London, UK
| | - Celia J A Morgan
- Psychopharmacology and Addiction Research Centre, Department of Psychology, University of Exeter, UK
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Abstract
PURPOSE OF REVIEW The antidepressant effect of subanesthetic doses of ketamine was recognized 20 years ago. This review briefly summarizes the current understanding of the antidepressant mechanisms and the available clinical research on the use of racemic ketamine and enantiomer esketamine for depression. RECENT FINDINGS The antidepressant effect of subanesthetic doses of ketamine is currently considered to be predominantly mediated by improved neuroplasticity in cortico-limbic areas in the brain. Single dose of 0.5 mg/kg of ketamine infused intravenously over 40 min, or single intranasal dose of esketamine cause rapid antidepressant and antisuicidal effects within hours of administration, and the antidepressant effect may last up to a week. Repeated administration of nasal spray esketamine is considered to prevent relapse of depression. Longitudinal studies are currently insufficient. When used in various doses for anesthetic induction for electroconvulsive therapy, ketamine improves seizure quality and may possibly diminish posttherapy cognitive impairment. SUMMARY A rapid onset antidepressive effect of ketamine and esketamine has been proven conclusively. The results of extensive basic science research of the mechanism of action of low-dose ketamine doses has led to an alternative hypothesis of the pathophysiology of depression and the development of a novel neurotrophic concept of depression. Further longitudinal studies are warranted to determine the safety and efficacy of repeated administration of ketamine and its analogs to prevent relapse and recurrence of depression.
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Affiliation(s)
- Irene Rozet
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
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12
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Dean RL, Hurducas C, Hawton K, Spyridi S, Cowen PJ, Hollingsworth S, Marquardt T, Barnes A, Smith R, McShane R, Turner EH, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder. Cochrane Database Syst Rev 2021; 9:CD011612. [PMID: 34510411 PMCID: PMC8434915 DOI: 10.1002/14651858.cd011612.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability and tolerability - of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), 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 were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. MAIN RESULTS Thirty-one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D-cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP-101,606 (1), decoglurant (1), MK-0657 (1), N-acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty-eight studies were placebo-controlled, and 48 were two-arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild-to-moderate depression. Nineteen studies recruited only patients with treatment-resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low-certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) -0.87, 95% CI -1.26 to -0.48; n = 231, studies = 8, very low-certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low-certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low-certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low-certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and placebo (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low-certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate-certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD -0.31, 95% CI -0.45 to -0.17; n = 824, studies = 4, moderate-certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low-certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate-certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. 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. AUTHORS' CONCLUSIONS Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta-analyses for each comparison and the majority of comparisons included only one study. Long term non-inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real-world monitoring are needed to establish comprehensive data on safety and efficacy.
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Affiliation(s)
| | | | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Erick H Turner
- Portland Veterans Affairs Medical Center, P3MHDC, Portland, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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13
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Bansal S, Surve RM, Dayananda R. Challenges during Electroconvulsive Therapy—A Review. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0041-1731627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractElectroconvulsive therapy (ECT) is one of the most successful treatment techniques employed in psychiatric practice. ECT is usually administered as a last resort to a patient who fails to respond to medical management or on an urgent basis as a life-saving procedure when immediate response is desired. It is performed under general anesthesia and is often associated with autonomic changes. All attempts should be made to minimize the resulting hemodynamic disturbances in all the patients using various pharmacological methods. Anesthesiologists providing anesthesia for ECT frequently encounter patients with diverse risk factors. Concurrent cardiovascular, neurological, respiratory, and endocrine disorders may require modification of anesthetic technique. It is ideal to optimize patients before ECT. In this review, the authors discuss the optimization, management, and modification of anesthesia care for patients with various cardiac, neurological, respiratory, and endocrine disorders presenting for ECT to improve the safety of the procedure. It is not infrequent that an anesthesiologist also plays an important role in inducing a seizure. Proconvulsants such as caffeine, adjuvants like opioids, hyperventilation, and appropriate choice of anesthetic agent for induction such as etomidate or ketamine can help. The use of BIS monitoring to guide the timing of electric stimulation is also elaborated in this review.
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Affiliation(s)
- Sonia Bansal
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Rohini M. Surve
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Rajeev Dayananda
- Department of Anaesthesia, BGS Gleneagles Global Hospitals, Kengeri, Bengaluru, Karnataka, India
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15
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Conley AA, Norwood AEQ, Hatvany TC, Griffith JD, Barber KE. Efficacy of ketamine for major depressive episodes at 2, 4, and 6-weeks post-treatment: A meta-analysis. Psychopharmacology (Berl) 2021; 238:1737-1752. [PMID: 33787963 DOI: 10.1007/s00213-021-05825-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/15/2021] [Indexed: 12/11/2022]
Abstract
RATIONALE Major depressive episodes are severe mood episodes which occur both in major depressive disorder and bipolar I and II disorder. Major depressive episodes are characterized by debilitating symptoms that often persist and interfere with typical daily functioning. Various treatments exist for major depressive episodes; however, most primary pharmacologic treatments may take weeks to months to provide relief from depressive symptoms. Ketamine is a demonstrated treatment for major depressive episodes, as relief from depressive symptoms can occur rapidly following treatment. OBJECTIVES Prior meta-analyses have been conducted to analyze the effectiveness of ketamine for the treatment of major depressive episodes, but at the time of this writing, no meta-analysis had been conducted to observe ketamine treatment efficacy beyond 2 weeks. METHODS The present meta-analysis evaluated the efficacy of ketamine for the treatment of major depressive episodes; observations of depressive episode severity were analyzed at 2, 4, and 6-weeks post-treatment. RESULTS The present meta-analysis observed large effects at 2 weeks (g = -1.28), 4 weeks, (g = -1.28), and 6 weeks (g = -1.36) post-treatment. CONCLUSIONS The results from the present meta-analysis indicate that ketamine can be an effective pharmacologic intervention for major depressive episodes, with treatment effects lasting up to 6 weeks post-ketamine administration, which has many positive implications for treatment.
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Affiliation(s)
- Ashley A Conley
- Department of Psychology, Shippensburg University of Pennsylvania, Shippensburg, PA, 17257, USA.
| | - Amber E Q Norwood
- Department of Psychology, Shippensburg University of Pennsylvania, Shippensburg, PA, 17257, USA
| | - Thomas C Hatvany
- Department of Psychology, Shippensburg University of Pennsylvania, Shippensburg, PA, 17257, USA
| | - James D Griffith
- Department of Psychology, Shippensburg University of Pennsylvania, Shippensburg, PA, 17257, USA
| | - Kathryn E Barber
- Department of Psychology, Shippensburg University of Pennsylvania, Shippensburg, PA, 17257, USA
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16
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Woolsey AJ, Nanji JA, Moreau C, Sivapalan S, Bourque SL, Ceccherini-Nelli A, Gragasin FS. Low-dose ketamine does not improve the speed of recovery from depression in electroconvulsive therapy: a randomized controlled trial. ACTA ACUST UNITED AC 2021; 44:6-14. [PMID: 34076068 PMCID: PMC8827368 DOI: 10.1590/1516-4446-2020-1705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is a well-established therapeutic intervention for major depressive disorder. Recent literature has shown that the anesthetic agent ketamine has some antidepressant properties at low doses and may be an alternative therapy for treatment-resistant major depressive disorder. We hypothesized that the use of low-dose ketamine as an anesthetic adjunct in ECT would more rapidly improve depression while maintaining hemodynamic stability than ECT with propofol alone. METHODS Institutional ethics approval was obtained, and the use of ketamine in this study was approved by Health Canada. This is a randomized, double-blinded, placebo-controlled trial that involved ketamine administration at 0.5 mg/kg IV in addition to propofol anesthesia for ECT. The primary outcome was the number of ECT treatments required to achieve a 50% reduction in the Montgomery-Asberg Depression Rating Scale (MADRS). Secondary outcomes included the number of ECT treatments required to achieve a 25% reduction in MADRS score, as well as any differences in the Clinical Global Impression Scale for Severity, hemodynamic variables, and seizure duration. Adverse events were recorded for safety assessment. RESULTS A total of 45 patients completed the study. No difference was found between groups with respect to the primary or secondary outcomes. The ketamine group showed a trend towards a decreased dose of propofol required to achieve adequate anesthesia. No adverse events were reported. CONCLUSION Low-dose ketamine does not improve psychiatric outcomes in the setting of propofol-based anesthesia for ECT. Specifically, ketamine did not reduce the number of ECT sessions necessary to achieve a 50 or 25% reduction in MADRS scores. Reassuringly, the fact that no differences in hemodynamic variables or unexpected adverse events occurred suggests that low-dose ketamine may be safely used in this setting should clinical indications warrant its use. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02579642.
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Affiliation(s)
- Adrianna J Woolsey
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jalal A Nanji
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Chantal Moreau
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Sudhakar Sivapalan
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Stephane L Bourque
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Ferrante S Gragasin
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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17
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Luo L, Feng B, Yang S, Zhang N, Qiu S. Clinical characteristics of moderate-severe obsessive-compulsive disorder in children and adolescents in China. J Int Med Res 2021; 48:300060520922679. [PMID: 32458715 PMCID: PMC7273799 DOI: 10.1177/0300060520922679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective This study reports clinical characteristic of moderate–severe
obsessive–compulsive disorder (OCD) among school students in China. Methods We examined 153 patients for the distribution of OCD symptoms using the
Yale-Brown Obsessive Compulsive Scale Symptoms Checklist, the severity of
anxiety and depression symptoms using the Hamilton Anxiety Scale and the
Hamilton Depression Scale-24, respectively, and impairment in learning,
family and social functions using the Pediatric Quality of Life Enjoyment
and Satisfaction Questionnaire. Results The number of total OCD, obsession and compulsion symptoms was 6.71 (standard
deviation [SD] = 2.25), 3.77 (SD = 1.32) and 2.94 (SD = 1.59), respectively.
The incidence of moderate and severe depressive symptoms for junior high
school students was significantly higher than for primary and high school
students. The number of children and adolescents with OCD increased with
age, reaching a peak in the senior high school stage. Conclusion The most common symptoms in children and adolescent OCD patients are
miscellaneous obsessions, aggressiveness, religiousness, checking,
miscellaneous compulsions, cleaning-washing and repeating. These patients
show a relatively high co-occurrence rate of anxiety symptoms and depressive
symptoms, which impairs their learning, as well as their family and social
functions.
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Affiliation(s)
- Liyuan Luo
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, P.R. China
| | - Bin Feng
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, P.R. China
| | - Senjun Yang
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, P.R. China
| | - Ning Zhang
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, P.R. China
| | - Shengliang Qiu
- Department of Internal Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, P.R. China
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18
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Gonçalves CL, Abelaira HM, Rosa T, de Moura AB, Veron DC, Borba LA, Botelho MEM, Goldim MP, Garbossa L, Fileti ME, Petronilho F, Ignácio ZM, Quevedo J, Réus GZ. Ketamine treatment protects against oxidative damage and the immunological response induced by electroconvulsive therapy. Pharmacol Rep 2021; 73:525-535. [PMID: 33393059 DOI: 10.1007/s43440-020-00200-4] [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: 08/19/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is often recommended for major depressive disorder (MDD) for those who do not respond to the first and second antidepressant trials. A combination of two therapies could improve antidepressant efficacy. Thus, this study aimed to investigate the synergistic effects of ECT combined to antidepressants with a different mechanism of action. METHODS Rats were treated once a day, for five days with ketamine (5 mg/kg), fluoxetine (1 mg/kg), and bupropion (4 mg/kg) alone or in combination with ECT (1 mA; 100 V). After, oxidative damage and antioxidant capacity were assessed in the prefrontal cortex (PFC) and hippocampus, and pro-inflammatory cytokines levels were evaluated in the serum. RESULTS ECT alone increased lipid peroxidation in the PFC and hippocampus. In the PFC of rats treated with ECT in combination with fluoxetine and bupropion, and in the hippocampus of rats treated with ECT combined with ketamine and bupropion there was a reduction in the lipid peroxidation. The nitrite/nitrate was increased by ECT alone but reverted by combination with ketamine in the hippocampus. Superoxide dismutase (SOD) was increased by ECT and maintained by fluoxetine and bupropion in the PFC. ECT alone increased interleukin-1β (IL-1β) and the administration of ketamine was able to revert this increase showing a neuroprotective effect of this drug when in combination with ECT. CONCLUSION The treatment with ECT leads to an increase in oxidative damage and alters the immunological system. The combination with ketamine was able to protect against oxidative damage and the immunological response induced by ECT.
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Affiliation(s)
- Cinara Ludvig Gonçalves
- Experimental Neurology Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, Brazil
| | - Helena Mendes Abelaira
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil
| | - Thayse Rosa
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil
| | - Airam Barbosa de Moura
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil
| | - Deise Cristina Veron
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil
| | - Laura Araújo Borba
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil
| | - Maria Eduarda Mendes Botelho
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil
| | - Mariana Pereira Goldim
- Neurobiology of Metabolic and Inflammatory Processes Laboratory, Graduate Program in Health Sciences, University of South Santa Catarina, Tubarão, SC, Brazil
| | - Leandro Garbossa
- Neurobiology of Metabolic and Inflammatory Processes Laboratory, Graduate Program in Health Sciences, University of South Santa Catarina, Tubarão, SC, Brazil
| | - Maria Eduarda Fileti
- Neurobiology of Metabolic and Inflammatory Processes Laboratory, Graduate Program in Health Sciences, University of South Santa Catarina, Tubarão, SC, Brazil
| | - Fabricia Petronilho
- Neurobiology of Metabolic and Inflammatory Processes Laboratory, Graduate Program in Health Sciences, University of South Santa Catarina, Tubarão, SC, Brazil
| | - Zuleide Maria Ignácio
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil.,Laboratory of Physiology, Pharmacology and Psychopathology, Campus Chapecó, Federal University of South Frontier (UFFS), Chapecó, Santa Catarina, Brazil.,State Secretary for Justice and Citizenship of Santa Catarina, Chapecó, Brazil
| | - João Quevedo
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil.,Department of Psychiatry and Behavioral Sciences, Center of Excellence On Mood Disorders, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.,Neuroscience Graduate Program, Graduate School of Biomedical Sciences, The University of Texas Health Science Center At Houston (UTHealth), Houston, TX, USA
| | - Gislaine Zilli Réus
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, SC, 88806-000, Brazil.
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Brunelin J, Iceta S, Plaze M, Gaillard R, Simon L, Suaud-Chagny MF, Galvao F, Poulet E. The Combination of Propofol and Ketamine Does Not Enhance Clinical Responses to Electroconvulsive Therapy in Major Depression-The Results From the KEOpS Study. Front Pharmacol 2020; 11:562137. [PMID: 33041803 PMCID: PMC7522396 DOI: 10.3389/fphar.2020.562137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
Objective We investigated the clinical effects of the combination of ketamine and propofol as anesthetic agents during electroconvulsive therapy (ECT) in patients with uni- or bipolar major depressive episodes. We hypothesized that ketamine may confer short- and long- term advantages in improving depressive symptoms at the early stages of ECT. Methods In a randomized placebo-controlled trial, remission rates after 4 and 8 weeks of ECT were compared between patients who were randomly allocated to receive either the combination of ketamine (0.5 mg/kg) + propofol (n= 11) or placebo + propofol (n = 16). Depressive symptoms were assessed weekly using the Montgomery-Åsberg Depression Rating Scale (MADRS); ECT sessions were administered twice per week for a maximum of 8 weeks (16 sessions). Results After 4 weeks, we observed significantly fewer remitters (MADRS score < 10) in the ketamine + propofol group (0/11; 0%) than in the placebo + propofol group (5/16; 31%; χ2 = 4.22; p = 0.040). No significant difference was observed between the two groups regarding the number of patients who achieved remission weekly throughout the study period (Chi² = 3.588; p = 0.058). The mean duration of seizures was significantly shorter in the ketamine + propofol group than in the placebo + propofol group. Conclusions The results from the current study corroborated results from previously published studies and did not support the use of the combination of ketamine + propofol as an anesthetic agent for ECT in patients with major depressive episodes in clinical settings.
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Affiliation(s)
- Jerome Brunelin
- CH Le Vinatier, Bron, France.,INSERM, U1028, CNRS, UMR5292, Lyon Neuroscience Research Center, PSYR2 Team, Université de Lyon, Lyon, France
| | - Sylvain Iceta
- CH Le Vinatier, Bron, France.,INSERM, U1028, CNRS, UMR5292, Lyon Neuroscience Research Center, PSYR2 Team, Université de Lyon, Lyon, France.,Obesity Research Center, Quebec Heart and Lung Institute (IUCPQ), Québec, QC, Canada.,School of Nutrition, Laval University, Québec, QC, Canada
| | - Marion Plaze
- GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
| | - Raphaël Gaillard
- GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
| | - Louis Simon
- CH Le Vinatier, Bron, France.,INSERM, U1028, CNRS, UMR5292, Lyon Neuroscience Research Center, PSYR2 Team, Université de Lyon, Lyon, France
| | - Marie-Françoise Suaud-Chagny
- CH Le Vinatier, Bron, France.,INSERM, U1028, CNRS, UMR5292, Lyon Neuroscience Research Center, PSYR2 Team, Université de Lyon, Lyon, France
| | | | - Emmanuel Poulet
- CH Le Vinatier, Bron, France.,INSERM, U1028, CNRS, UMR5292, Lyon Neuroscience Research Center, PSYR2 Team, Université de Lyon, Lyon, France.,Service de psychiatrie des urgences, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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Xu M, Guo Y, Wei Y, Wang L, Feng X, Chen Y, Yan J. Non-pharmacological interventions for depressive disorder in patients after traumatic brain injury: A protocol for a systematic review and network meta-analysis. Medicine (Baltimore) 2020; 99:e22375. [PMID: 32991457 PMCID: PMC7523874 DOI: 10.1097/md.0000000000022375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Depressive disorder has gradually become one of the most commonly reported disabling psychiatric complication that occurs after traumatic brain injury (TBI). Currently classical antidepressant medications may not have the same effectiveness in patients with TBI as in patients without TBI. Non-pharmacological interventions have been considered to be effective for managing depressive symptoms or treating depressive disorder. But to date the comparative effectiveness of various types of non-pharmacological interventions has been synthesized in few studies, the evidence remains inconclusive. Thus, the purpose of this systematic review and network meta-analyses is to summarize high-quality evidence and identify the most effective non-pharmacological intervention when applied to treat the depressive disorder in patients after TBI. METHODS The comprehensive literature search in electronic database including PubMed, Ovid Medline, Cochrane Library, Web of Science database, Embase Database, China National Knowledge Infrastructure (CNKI), and Wanfang Data Chinese database from inception to the search date. Only high-quality randomized controlled trials (RCTs) that have used non-pharmacological interventions to treat depressive disorder after TBI will be considered. Two independent reviewers will identify eligible studies, extract and manage data information, and then determine methodical quality of included studies. Overall efficacy will be assessed as primary outcome. Secondary outcomes involved treatment response, remission rate, overall acceptability, tolerability of treatment, social functioning, occurrence of adverse events, and suicide-related outcome. Cochrane risk of bias assessment tool will be adopted to assess the risk of bias. Study heterogeneity will be measured by the I statistic. Traditional pairwise meta-analyses will be performed using STATA, while WinBUGS with GeMTC package of R software will be used to carry out network meta-analysis. RESULTS This systematic review will examine the relative efficacy, effectiveness, safety, tolerability and acceptability of non-pharmacological interventions, and then to identify the most effective non-pharmacological intervention for depressive disorder after TBI. EXPECTED CONCLUSION Our work could be used to give clinical recommendations for practice guideline developers, psychiatrist, neurologist, policymakers, researchers as well as individual with depressive disorder after TBI, and will also identify gaps in knowledge that could be the subject of future research. ETHICS AND DISSEMINATION Neither ethics approval nor patient informed consent is necessary since this protocol was designed based on the existing literature. The results will be disseminated electronically or in print through publications in peer-reviewed scientific journal. INPLASY REGISTRATION INPLASY202080022.
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Affiliation(s)
- Mingmin Xu
- School of Acupuncture-Moxibustion and Tuina/The Third Affiliated Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Yu Guo
- Teaching and Research Section of Acupuncture
- Formula-Pattern Research Center, School of Traditional Chinese Medicine, Jinan University, Guangzhou
| | - Yulong Wei
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Lu Wang
- School of Acupuncture-Moxibustion and Tuina/The Third Affiliated Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Xiumei Feng
- School of Acupuncture-Moxibustion and Tuina/The Third Affiliated Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Yue Chen
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jian Yan
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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21
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Jagtiani A, Khurana H, Malhotra N. Comparison of efficacy of ketamine versus thiopentone-assisted modified electroconvulsive therapy in major depression. Indian J Psychiatry 2020; 62:442-443. [PMID: 33165361 PMCID: PMC7597702 DOI: 10.4103/psychiatry.indianjpsychiatry_518_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 03/26/2020] [Accepted: 05/03/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Hitesh Khurana
- Department of Psychiatry, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Naveen Malhotra
- Department of Anesthesiology, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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22
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Kalmoe MC, Janski AM, Zorumski CF, Nagele P, Palanca BJ, Conway CR. Ketamine and nitrous oxide: The evolution of NMDA receptor antagonists as antidepressant agents. J Neurol Sci 2020; 412:116778. [PMID: 32240970 DOI: 10.1016/j.jns.2020.116778] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 02/20/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
N-methyl-d-aspartate receptor (NMDAR) antagonists, including ketamine and nitrous oxide, are currently intensely studied as rapid-acting antidepressant agents. Interestingly, both of these compounds are also drugs of abuse. Intravenous ketamine, a dissociative anesthetic that induces complex downstream effects via NMDARs, rapidly reduces depressive and suicidal symptoms in treatment-resistant depression (TRD), as demonstrated by several trials. Recently, the United States Food and Drug Administration (FDA) approved an intranasal version of ketamine (esketamine) for TRD. The United States Drug Enforcement Agency (DEA) lists ketamine as a Class III scheduled drug (moderate-low potential for physical and psychological abuse). The FDA has established a Risk Evaluation and Management Strategy (REMS) program to ensure proper drug storage, handling, dispensing, and monitoring intranasal esketamine to minimize misuse/abuse opportunities. Nitrous Oxide is a colorless, odorless, gas that has been in medical use for over 150 years. The mechanisms of action of nitrous oxide are not fully understood; however, it is known to act as a non-competitive inhibitor of NMDA-type glutamate receptors. Currently, nitrous oxide is used for inhalational general anesthesia and analgesia for short procedures. Inhaled nitrous oxide is also used recreationally, primarily by teens and young adults, but is not believed to have strong addiction potential. In contrast to ketamine, nitrous oxide is not a controlled substance and can be legally purchased without a prescription. A recent double-blind, prospective, cross-over study demonstrated that nitrous oxide reduced depressive symptoms in a group of severely ill TRD patients. Though this is a promising initial study, further investigation is needed.
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Affiliation(s)
- Molly C Kalmoe
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Alvin M Janski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Peter Nagele
- Department of Anesthesia and Critical Care, The University of Chicago Medical Center, Chicago, IL, United States of America
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America.
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23
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Huang XB, Huang X, He HB, Mei F, Sun B, Zhou SM, Yan S, Zheng W, Ning Y. BDNF and the Antidepressant Effects of Ketamine and Propofol in Electroconvulsive Therapy: A Preliminary Study. Neuropsychiatr Dis Treat 2020; 16:901-908. [PMID: 32308393 PMCID: PMC7147607 DOI: 10.2147/ndt.s248190] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/23/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Ketamine and propofol have become increasingly popular in electroconvulsive therapy (ECT) anaesthesia. This study was conducted to examine whether changes in serum levels of brain-derived neurotrophic factor (BDNF) are associated with the antidepressant effects of ketofol, a combination of ketamine and propofol, in ECT for patients with treatment-resistant depression (TRD). METHODS Thirty patients with TRD (18-65 years) were enrolled and underwent eight ECT sessions with ketamine (0.5 mg/kg) plus propofol (0.5 mg/kg) (ketofol). Symptom severity was monitored using the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Brief Psychiatric Rating Scale (BPRS), and serum levels of BDNF were examined by enzyme-linked immunosorbent assay (ELISA) at baseline and after 2, 4, and 8 ECT treatments. Serum levels of BDNF were also collected from thirty healthy controls. RESULTS At baseline, there were no significant differences in serum levels of BDNF between patients with TRD and healthy controls. The response and remission rates in patients with TRD were 100% (30/30) and 53.3% (16/30) after ECT treatment, respectively. Despite a significant reduction in HAMD-17 and BPRS scores after ECT, no changes in serum levels of BDNF were observed after ECT treatment when compared to baseline. No association was found between serum levels of BDNF and changes in illness severity. CONCLUSION Serum levels of BDNF did not represent a suitable candidate biomarker for determining the antidepressant effects of ketofol during ECT for patients with TRD.
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Affiliation(s)
- Xing-Bing Huang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Xiong Huang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Hong-Bo He
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Fang Mei
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Bin Sun
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Su-Miao Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Su Yan
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
| | - Yuping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, People's Republic of China
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24
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Dong J, Min S, Qiu H, Chen Q, Ren L. Intermittent administration of low dose ketamine can shorten the course of electroconvulsive therapy for depression and reduce complications: A randomized controlled trial. Psychiatry Res 2019; 281:112573. [PMID: 31586838 DOI: 10.1016/j.psychres.2019.112573] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 01/03/2023]
Abstract
This study aimed to investigate the efficacy and safety of intermittent low-dose ketamine on improving the efficacy of ECT. Patients diagnosed with Major Depressive Disorder (MDD) (n = 134) were randomized into 3 groups: routine ECT group (group E, n = 45); repeated ketamine-assisted ECT group (group RK, n = 43), and intermittent ketamine-assisted ECT group (group IK, n = 46). Patients in group RK were given ketamine at the dose of 0.3 mg/kg for each ECT treatment, patients in group IK were given ketamine once a week during ECT course. The depressive symptoms were assessed using the Hamilton Depression Rating Scale (HAM-D) at baseline, the end of ECT course, after 1 and 3 months, followed by an analysis of the psychiatric complications. Results indicated that ketamine-assisted ECT achieved a higher remission rate (P < 0.05), and no difference was observed between repeated and intermittent ketamine administrations. The total incidence rate of psychiatric complications in group RK (20.93%) was higher than that in group E (0%) and group IK (4.35%). In conclusion, intermittent administration of low dose ketamine in ECT significantly improved the effects of ECT and decreased psychiatric complications compared with repeated ketamine addition.
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Affiliation(s)
- Jun Dong
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Haitang Qiu
- The Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qibing Chen
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Ren
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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25
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Corriger A, Pickering G. Ketamine and depression: a narrative review. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:3051-3067. [PMID: 31695324 PMCID: PMC6717708 DOI: 10.2147/dddt.s221437] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/01/2019] [Indexed: 12/20/2022]
Abstract
Depression is the third leading cause of disability in the world. Depressive symptoms may be reduced within several weeks after the start of conventional antidepressants, but treatment resistance concerns one-third of patients who fail to achieve recovery. Over the last 20 years, ketamine, an antagonist of the N-methyl-D-aspartate receptor, has been described to have antidepressant properties. A literature review was conducted through an exhaustive electronic search. It was restricted to Cochrane reviews, meta-analyses, and randomized controlled trials (RCTs) of ketamine for major depressive disorder and/or bipolar disorder. This review included two Cochrane reviews, 14 meta-analyses and 15 trials. Ketamine was studied versus placebo, versus other comparators and as an anesthetic adjuvant before electroconvulsive therapy. In 14 publications, ketamine provided a rapid antidepressant effect with a maximum efficacy reached at 24 hrs. Its effect lasted for 1–2 weeks after infusion, but a longer-term effect is little reported. Ketamine does not seem to improve depressive symptoms at the end of electroconvulsive sessions. Safety and tolerability profiles with ketamine at low single dose are generally good in depressed patients. However, there is a lack of data concerning ketamine with repeated administration at higher doses. The clinical use of ketamine is increasing. Intranasal (S)-ketamine has recently been approved for depression by the Food and Drug Administration. It could be a promising treatment in depressed patients with suicidal ideation. Collectively, the level of proof of efficacy remains low and more RCTs are needed to explore efficacy and safety issues of ketamine in depression.
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Affiliation(s)
- Alexandrine Corriger
- Neuro-Dol Laboratory Inserm 1107, Clermont Auvergne University, Clermont-Ferrand, France.,Clinical Pharmacology Department CPC/CIC Inserm 1405, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Gisèle Pickering
- Neuro-Dol Laboratory Inserm 1107, Clermont Auvergne University, Clermont-Ferrand, France.,Clinical Pharmacology Department CPC/CIC Inserm 1405, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
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26
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Zheng W, Li XH, Zhu XM, Cai DB, Yang XH, Ungvari GS, Ng CH, Ning YP, Hu YD, He SH, Wang G, Xiang YT. Adjunctive ketamine and electroconvulsive therapy for major depressive disorder: A meta-analysis of randomized controlled trials. J Affect Disord 2019; 250:123-131. [PMID: 30852364 DOI: 10.1016/j.jad.2019.02.044] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/14/2019] [Accepted: 02/16/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Adjunctive ketamine with electroconvulsive therapy (ECT) has been investigated for treating major depressive disorder (MDD), but the findings have been inconsistent. AIM This is an updated meta-analysis of the efficacy and safety of ketamine augmentation of ECT in the treatment of MDD. METHODS Randomized controlled trials (RCTs) reporting on the efficacy and safety of ketamine and ECT were identified and analyzed. RESULTS Seventeen RCTs (n = 1,035) compared ketamine alone or ketamine plus other anesthetic drugs (n = 557) with other anesthetic agents (n = 478) in MDD patients who received ECT. Ketamine+other anesthetic drugs was superior in improving depressive symptoms over other anesthetic medications at early study time point, but not at post-ECT or end of study time points. Ketamine alone was not more efficacious in treating depressive symptoms than other anesthetic drugs at early study, post-ECT and end of study time points. Sensitivity analysis and 19 of the 20 subgroup analyses also confirmed the lack of significance of these findings. Eleven RCTs testing the effects of ketamine on neurocognitive functions with various test batteries found mixed results. Ketamine alone significantly increased blood pressure more than other anesthetic drugs in MDD treated with ECT. CONCLUSION Compared to other anesthetic agents, ketamine alone does not appear to improve the efficacy of ECT. However, ketamine+other anesthetic combinations may confer a short-term advantage in improving depressive symptom at the early stages of ECT.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiao-Hong Li
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & The Advanced Innovation Center for Human Brain Protection, Capital Medical University, School of Mental Health, Beijing, China
| | - Xiao-Min Zhu
- Suzhou Guangji Hospital, The Affiliated Guangji Hospital of Soochow University, Suzhou, China
| | - Dong-Bin Cai
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Xin-Hu Yang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Gabor S Ungvari
- The University of Notre Dame Australia, Fremantle, Australia; Division of Psychiatry, School of Medicine, Perth, Australia
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yong-Dong Hu
- Department of Psychological Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | | | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & The Advanced Innovation Center for Human Brain Protection, Capital Medical University, School of Mental Health, Beijing, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, 3/F, Building E12 Taipa, Macao SAR, China..
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27
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Zhou QG, Zhu XH, Nemes AD, Zhu DY. Neuronal nitric oxide synthase and affective disorders. IBRO Rep 2018; 5:116-132. [PMID: 30591953 PMCID: PMC6303682 DOI: 10.1016/j.ibror.2018.11.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 01/08/2023] Open
Abstract
Affective disorders including major depressive disorder (MDD), bipolar disorder (BPD), and general anxiety affect more than 10% of population in the world. Notably, neuronal nitric oxide synthase (nNOS), a downstream signal molecule of N-methyl-D-aspartate receptors (NMDARs) activation, is abundant in many regions of the brain such as the prefrontal cortex (PFC), hippocampus, amygdala, dorsal raphe nucleus (DRN), locus coeruleus (LC), and hypothalamus, which are closely associated with the pathophysiology of affective disorders. Decreased levels of the neurotransmitters including 5-hydroxytryptamine or serotonin (5-HT), noradrenalin (NA), and dopamine (DA) as well as hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis are common pathological changes of MDD, BPD, and anxiety. Increasing data suggests that nNOS in the hippocampus play a crucial role in the etiology of MDD whereas nNOS-related dysregulation of the nitrergic system in the LC is closely associated with the pathogenesis of BPD. Moreover, hippocampal nNOS is implicated in the role of serotonin receptor 1 A (5-HTR1 A) in modulating anxiety behaviors. Augment of nNOS and its carboxy-terminal PDZ ligand (CAPON) complex mediate stress-induced anxiety and disrupting the nNOS-CAPON interaction by small molecular drug generates anxiolytic effect. To date, however, the function of nNOS in affective disorders is not well reviewed. Here, we summarize works about nNOS and its signal mechanisms implicated in the pathophysiology of affective disorders. On the basis of this review, it is suggested that future research should more fully focus on the role of nNOS in the pathomechanism and treatment of affective disorders.
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Affiliation(s)
- Qi-Gang Zhou
- Department of Clinical Pharmacology, Pharmacy College, Nanjing Medical University, Nanjing 211166, PR China
| | - Xian-Hui Zhu
- Department of Clinical Pharmacology, Pharmacy College, Nanjing Medical University, Nanjing 211166, PR China
| | - Ashley D Nemes
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA
| | - Dong-Ya Zhu
- Department of Clinical Pharmacology, Pharmacy College, Nanjing Medical University, Nanjing 211166, PR China
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28
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Ketamine and depression. Br J Anaesth 2018; 121:1198-1202. [PMID: 30442244 DOI: 10.1016/j.bja.2018.08.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/26/2018] [Accepted: 08/28/2018] [Indexed: 11/21/2022] Open
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29
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30
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Ren L, Deng J, Min S, Peng L, Chen Q. Ketamine in electroconvulsive therapy for depressive disorder: A systematic review and meta-analysis. J Psychiatr Res 2018; 104:144-156. [PMID: 30077114 DOI: 10.1016/j.jpsychires.2018.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/07/2018] [Accepted: 07/06/2018] [Indexed: 01/12/2023]
Abstract
Electroconvulsive therapy (ECT) is one of the most effective treatments for depressive disorder. Sub-anesthetic dose of ketamine exerts a rapid and robust antidepressive effect. However, it is still unclear whether ketamine usage in ECT is efficacious as an antidepressant. We aimed to conduct a systematic review and meta-analysis on the effects of ketamine in ECT among patients with depressive disorder. MEDLINE, EMBASE, the CENTRAL and PsycINFO for randomized controlled trials were searched to assess the effects of ketamine used in ECT until 31 Mar 2018 (PROSPERO: CRD42018081024). Sixteen studies including 928 patients were enrolled. At the end of ECT, no significant standardized mean difference (SMD) was observed in favor of the ketamine group. Depressive scores were lower in the ketamine group after 1st ECT and 3rd to 6th ECTs. The depressive scores were lower after 2nd, 3rd, 4th and 6th ECTs when the ketamine was used as an add-on anesthetic, while the depressive scores were lower after 1st ECT when ketamine alone was used. Ketamine in ECT showed no better response and remission rate, while increased adverse events, especially related to cardiovascular and psychiatric systems, during the whole ECT course. In conclusion, although ketamine used in ECT cannot reduce the depressive symptoms at the end of treatment, it could accelerate the antidepressive effect in depressive patients receiving ECT, especially in those who used ketamine as an add-on anesthetic. However, ketamine cautiously needs to be administered in ECT due to the possibility of increased risk of side effects.
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Affiliation(s)
- Li Ren
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, China
| | - Jie Deng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, China.
| | - Lihua Peng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, China
| | - Qibin Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, China
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Abstract
PURPOSE OF REVIEW Anesthetics, such as thiopental, methohexital, propofol and ketamine have been used to induce unconsciousness for electroconvulsive therapy (ECT), each with its advantages and disadvantages. Only until recently was it discovered that ketamine may have inherent antidepressant effects. We reviewed the side effect profile of ketamine and examined the literature for whether or not ketamine augments the antidepressant effects of ECT. RECENT FINDINGS Systematic reviews and meta-analyses of randomized controlled trials of the potential benefits of adding ketamine to ECT treatment have generated varied conclusions. Currently there is a lack of clear evidence that ketamine with ECT is more efficacious than ECT alone. SUMMARY Large, multicenter randomized controlled trials are needed to further investigate the potential advantages of adding ketamine to ECT for patients with severe or refractory depression. The addition of ketamine to ECT treatment may have some early beneficial effect in patients with acute depressive disorders. Most likely, ECT itself is responsible for lasting remission from severe depression. Ketamine's side effect profile may be undesirable in certain patient populations, and so the risks and benefits of the addition of this drug to ECT treatment must be weighed.
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