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Buxbaum Grice AS, Sloofman L, Levy T, Walker H, Ganesh G, Rodriguez de Los Santos M, Amini P, Buxbaum JD, Kolevzon A, Kostic A, Breen MS. Transient peripheral blood transcriptomic response to ketamine treatment in children with ADNP syndrome. Transl Psychiatry 2024; 14:307. [PMID: 39054328 PMCID: PMC11272924 DOI: 10.1038/s41398-024-03005-8] [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: 08/02/2023] [Revised: 06/26/2024] [Accepted: 07/02/2024] [Indexed: 07/27/2024] Open
Abstract
Activity-dependent neuroprotective protein (ADNP) syndrome is a rare neurodevelopmental disorder resulting in intellectual disability, developmental delay and autism spectrum disorder (ASD) and is due to mutations in the ADNP gene. Ketamine treatment has emerged as a promising therapeutic option for ADNP syndrome, showing safety and apparent behavioral improvements in a first open label study. However, the molecular perturbations induced by ketamine remain poorly understood. Here, we investigated the longitudinal effect of ketamine on the blood transcriptome of 10 individuals with ADNP syndrome. Transcriptomic profiling was performed before and at multiple time points after a single low-dose intravenous ketamine infusion (0.5 mg/kg). We show that ketamine triggers immediate and profound gene expression alterations, with specific enrichment of monocyte-related expression patterns. These acute alterations encompass diverse signaling pathways and co-expression networks, implicating upregulation of immune and inflammatory-related processes and down-regulation of RNA processing mechanisms and metabolism. Notably, these changes exhibit a transient nature, returning to baseline levels 24 hours to 1 week after treatment. These findings enhance our understanding of ketamine's molecular effects and lay the groundwork for further research elucidating its specific cellular and molecular targets. Moreover, they contribute to the development of therapeutic strategies for ADNP syndrome and potentially, ASD more broadly.
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Affiliation(s)
- Ariela S Buxbaum Grice
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura Sloofman
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tess Levy
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hannah Walker
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gauri Ganesh
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miguel Rodriguez de Los Santos
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pardis Amini
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph D Buxbaum
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ana Kostic
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael S Breen
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Scheil KKA, Sánchez-Lafuente CL, Reive BS, Halvorson CS, Floyd J, Reid HMO, Johnston JN, Kalynchuk LE, Caruncho HJ. Time-dependent antidepressant-like effects of reelin and ketamine in the repeated-corticosterone model of chronic stress. Prog Neuropsychopharmacol Biol Psychiatry 2024; 132:110998. [PMID: 38552775 DOI: 10.1016/j.pnpbp.2024.110998] [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: 01/05/2024] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/01/2024]
Abstract
There is an urgent need for novel antidepressants, given that approximately 30% of those diagnosed with depression do not respond adequately to first-line treatment. Additionally, monoaminergic-based antidepressants have a substantial therapeutic time-lag, often taking months to reach full therapeutic effect. Ketamine, an N-methyl-d-aspartate receptor (NMDAR) antagonist is the only current effective rapid-acting antidepressant, demonstrating efficacy within hours and lasting up to two weeks with an acute dose. Reelin, an extracellular matrix glycoprotein, has demonstrated rapid-acting antidepressant-like effects at 24 h, however the exact timescale of these effects has not been investigated. To determine the short and long-term effects of reelin, female Long Evans rats (n = 120) underwent a chronic corticosterone (CORT; or vehicle) paradigm (40 mg/kg, 21 days). On day 21, rats were treated with reelin (3μg; i.v.), ketamine (10 mg/kg; i.p.), both reelin and ketamine (same doses), or vehicle (saline). Behavioural and biological effects were then evaluated at 1 h, 6 h, 12 h, and 1 week after treatment. The 1-week cohort continued CORT injections to ensure the effect of chronic stress was not lost. Individually, both reelin and ketamine significantly rescued CORT-induced behaviour and hippocampal reelin expression at all timepoints. Ketamine rescued a decrease in dendritic maturity as induced by CORT. Synergistic effects of reelin and ketamine appeared at 1-week, suggesting a potential additive effect of the antidepressant-like actions. Taken together, this study provides further support for reelin-based therapeutics to develop rapid-acting antidepressant.
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Affiliation(s)
- Kaylene K A Scheil
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | | | - Brady S Reive
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | - Ciara S Halvorson
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | - Jennifer Floyd
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | - Hannah M O Reid
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | - Jenessa N Johnston
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | - Lisa E Kalynchuk
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada
| | - Hector J Caruncho
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada.
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Deng Q, Parker E, Wu C, Zhu L, Liu TCY, Duan R, Yang L. Repurposing Ketamine in the Therapy of Depression and Depression-Related Disorders: Recent Advances and Future Potential. Aging Dis 2024:AD.2024.0239. [PMID: 38916735 DOI: 10.14336/ad.2024.0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/29/2024] [Indexed: 06/26/2024] Open
Abstract
Depression represents a prevalent and enduring mental disorder of significant concern within the clinical domain. Extensive research indicates that depression is very complex, with many interconnected pathways involved. Most research related to depression focuses on monoamines, neurotrophic factors, the hypothalamic-pituitary-adrenal axis, tryptophan metabolism, energy metabolism, mitochondrial function, the gut-brain axis, glial cell-mediated inflammation, myelination, homeostasis, and brain neural networks. However, recently, Ketamine, an ionotropic N-methyl-D-aspartate (NMDA) receptor antagonist, has been discovered to have rapid antidepressant effects in patients, leading to novel and successful treatment approaches for mood disorders. This review aims to summarize the latest findings and insights into various signaling pathways and systems observed in depression patients and animal models, providing a more comprehensive view of the neurobiology of anxious-depressive-like behavior. Specifically, it highlights the key mechanisms of ketamine as a rapid-acting antidepressant, aiming to enhance the treatment of neuropsychiatric disorders. Moreover, we discuss the potential of ketamine as a prophylactic or therapeutic intervention for stress-related psychiatric disorders.
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Affiliation(s)
- Qianting Deng
- College of Physical Education and Sport Science, South China Normal University, Guangzhou, China
| | - Emily Parker
- Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
| | - Chongyun Wu
- College of Physical Education and Sport Science, South China Normal University, Guangzhou, China
| | - Ling Zhu
- College of Physical Education and Sport Science, South China Normal University, Guangzhou, China
| | - Timon Cheng-Yi Liu
- College of Physical Education and Sport Science, South China Normal University, Guangzhou, China
| | - Rui Duan
- College of Physical Education and Sport Science, South China Normal University, Guangzhou, China
| | - Luodan Yang
- College of Physical Education and Sport Science, South China Normal University, Guangzhou, China
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Gutierrez G, Kang MJY, Vazquez G. IV low dose ketamine infusions for treatment resistant depression: Results from a five-year study at a free public clinic in an academic hospital. Psychiatry Res 2024; 335:115865. [PMID: 38518518 DOI: 10.1016/j.psychres.2024.115865] [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: 11/21/2023] [Revised: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 03/24/2024]
Abstract
Individuals with major depressive disorder and treatment resistant depression (MDD-TRD) have limited and sometimes poorly tolerated therapeutic options. Low dose ketamine has presented promising and potent antidepressant effects in this population. To support the existent literature, we conducted a longitudinal study examining five years of real-world clinical data on the use of IV low-dose ketamine alongside standard care for MDD-TRD outpatients. For this study we collected demographic information, clinical scale scores, side effects and dropout data. The data was analyzed using descriptive statistics, effect size using Cohen's D analysis, and multivariate ANOVA (MANOVA) to determine the impact of sociodemographic variables. 71 outpatients (50.28 years old, SD: 14.26; female 74.65%) were included in the analysis. The results showed a significant reduction in depressive symptoms and suicide ideation (SI) by treatment endpoint. 54.93% of patients responded to the treatment, 78.26% experienced transient and mild side effects, and 11.27% of dropped out of the treatment. Multivariate analysis showed that the demographic variables did not impact treatment effect or tolerability. The results of this study suggest that IV low dose ketamine treatment is effective, fast-acting, and well tolerated for the management of depressive symptoms and SI in patients with MDD-TRD in naturalistic clinical practice.
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Affiliation(s)
- Gilmar Gutierrez
- Queen's University, Department of Psychiatry, 752 King Street West, Kingston, Ontario K7L7X3, Canada; Providence Care Hospital, Kingston, Ontario, Canada
| | - Melody J Y Kang
- Center for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada; Imaging Genetics Center, Mark and Mary Stevens Neuroimaging & Informatics Institute, Keck School of Medicine, University of Southern California, United States
| | - Gustavo Vazquez
- Queen's University, Department of Psychiatry, 752 King Street West, Kingston, Ontario K7L7X3, Canada; Providence Care Hospital, Kingston, Ontario, Canada; Center for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada.
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5
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Zhou L, Duan J. The role of NMDARs in the anesthetic and antidepressant effects of ketamine. CNS Neurosci Ther 2024; 30:e14464. [PMID: 37680076 PMCID: PMC11017467 DOI: 10.1111/cns.14464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/19/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND As a phencyclidine (PCP) analog, ketamine can generate rapid-onset and substantial anesthetic effects. Contrary to traditional anesthetics, ketamine is a dissociative anesthetic and can induce loss of consciousness in patients. Recently, the subanaesthetic dose of ketamine was found to produce rapid-onset and lasting antidepressant effects. AIM However, how different concentrations of ketamine can induce diverse actions remains unclear. Furthermore, the molecular mechanisms underlying the NMDAR-mediated anesthetic and antidepressant effects of ketamine are not fully understood. METHOD In this review, we have introduced ketamine and its metabolism, summarized recent advances in the molecular mechanisms underlying NMDAR inhibition in the anesthetic and antidepressant effects of ketamine, explored the possible functions of NMDAR subunits in the effects of ketamine, and discussed the future directions of ketamine-based anesthetic and antidepressant drugs. RESULT Both the anesthetic and antidepressant effects of ketamine were thought to be mediated by N-methyl-D-aspartate receptor (NMDAR) inhibition. CONCLUSION The roles of NMDARs have been extensively studied in the anaesthetic effects of ketamine. However, the roles of NMDARs in antidepressant effects of ketamine are complicated and controversial.
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Affiliation(s)
- Liang Zhou
- Department of Pharmacology, College of Pharmaceutical SciencesSoochow UniversitySuzhouChina
| | - Jingjing Duan
- Department of Anatomy and Neurobiology, Zhongshan School of MedicineSunYat‐sen UniversityGuangzhouChina
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Danyeli LV, Sen ZD, Colic L, Opel N, Refisch A, Blekic N, Macharadze T, Kretzschmar M, Munk MJ, Gaser C, Speck O, Walter M, Li M. Cortical thickness of the posterior cingulate cortex is associated with the ketamine-induced altered sense of self: An ultra-high field MRI study. J Psychiatr Res 2024; 172:136-143. [PMID: 38382237 DOI: 10.1016/j.jpsychires.2024.02.019] [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: 08/14/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Subanesthetic doses of ketamine induce an antidepressant effect within hours in individuals with treatment-resistant depression while it furthermore induces immediate but transient psychotomimetic effects. Among these psychotomimetic effects, an altered sense of self has specifically been associated with the antidepressant response to ketamine as well as psychedelics. However, there is plenty of variation in the extent of the drug-induced altered sense of self experience that might be explained by differences in basal morphological characteristics, such as cortical thickness. Regions that have been previously associated with a psychedelics-induced sense of self and with ketamine's mechanism of action, are the posterior cingulate cortex (PCC) and the pregenual anterior cingulate cortex (pgACC). In this randomized, placebo-controlled, double-blind cross-over magnetic resonance imaging study, thirty-five healthy male participants (mean age ± standard deviation (SD) = 25.1 ± 4.2 years) were scanned at 7 T. We investigated whether the cortical thickness of two DMN regions, the PCC and the pgACC, are associated with disembodiment and experience of unity scores, which were used to index the ketamine-induced altered sense of self. We observed a negative correlation between the PCC cortical thickness and the disembodiment scores (R = -0.54, p < 0.001). In contrast, no significant association was found between the pgACC cortical thickness and the ketamine-induced altered sense of self. In the context of the existing literature, our findings highlight the importance of the PCC as a structure involved in the mechanism of ketamine-induced altered sense of self that seems to be shared with different antidepressant agents with psychotomimetic effects operating on different classes of transmitter systems.
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Affiliation(s)
- Lena Vera Danyeli
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany
| | - Zümrüt Duygu Sen
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany
| | - Lejla Colic
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany
| | - Nils Opel
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany
| | - Alexander Refisch
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany
| | - Nikolai Blekic
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany
| | - Tamar Macharadze
- Department of Anesthesiology and Intensive Care Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany; Department Systems Physiology of Learning, Leibniz Institute for Neurobiology, Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany; Department of Behavioral Neurology, Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - Moritz Kretzschmar
- Department of Anesthesiology and Intensive Care Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - MatthiasH J Munk
- Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany; Systems Neurophysiology, Department of Biology, Darmstadt University of Technology, Darmstadt, Germany
| | - Christian Gaser
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany; Department of Neurology, Jena University Hospital, Jena, Germany
| | - Oliver Speck
- Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany; Department of Behavioral Neurology, Leibniz Institute for Neurobiology, Magdeburg, Germany; Department of Biomedical Magnetic Resonance, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany; German Center for Mental Health (DZPG), partner site Halle-Jena-Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany; Department of Behavioral Neurology, Leibniz Institute for Neurobiology, Magdeburg, Germany.
| | - Meng Li
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany; Center for Intervention and Research on adaptive and maladaptive brain Circuits underlying mental health (C-I-R-C), Halle-Jena-Magdeburg, Germany.
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7
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Hanna AF, Bolling D, Tadros M. From Wheelchair Bound to Working: A Case Study of Intravenous Ketamine Infusions in Treating Stiff Person Syndrome. Cureus 2024; 16:e59397. [PMID: 38817534 PMCID: PMC11139490 DOI: 10.7759/cureus.59397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Stiff Person Syndrome (SPS) is a rare autoimmune condition marked by extremely painful muscle spasms, stiffness, and rigidity throughout the body. Its rarity often translates to limited treatment options for patients and, occasionally, challenges in obtaining a definitive diagnosis. SPS also impacts patients' mental health, social and economic involvement, and overall quality of life. A 43-year-old man was initially being seen for lumbar radicular pain. A clinical diagnosis of SPS was made by a neurologist and confirmed by in-clinic follow-ups and anti-glutamic acid decarboxylase (anti-GAD) antibody testing. The Pain Management doctor agreed with this diagnosis and offered intravenous (IV) ketamine treatment, which he has found to positively impact the treatment of similar disorders. After an initial 10-day infusion, the patient reported improvement in pain and function. For almost two years, the patient received intravenous immunoglobulin (IVIg) and IV ketamine treatments to manage their condition and maintain pain control as well as quality of life. When the patient's symptoms began worsening after IVIg infusions, the decision to withdraw IVIg infusions and continue ketamine infusions was made. After discontinuing IVIg infusions, the patient reported improvement in function and pain level and continues to receive monthly two-day ketamine boosters. Outside of the infusions, the patient was able to discontinue the use of fentanyl patches and continued taking ketamine lozenges, oxycodone-acetaminophen, and dextromethorphan for at-home pain management. The patient's symptoms continue to be managed effectively with their current regimen, enabling their return to work and experiencing an enhanced quality of life. This case illustrates the potential benefits of IV ketamine treatment for patients with treatment-resistant SPS and similar neurologic and autoimmune disorders. Understanding and examining treatment alternatives for rare syndromes is crucial for achieving optimal patient outcomes. Additionally, documenting such cases offers valuable insights into the mechanism of ketamine, extending beyond these syndromes.
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Affiliation(s)
- Ashraf F Hanna
- Pain Management/Anesthesiology, Florida Spine Institute, Clearwater, USA
| | - Danielle Bolling
- Pain Management, University of South Florida (USF) Health Morsani College of Medicine, Tampa, USA
| | - Mariam Tadros
- Pain Management, Lake Erie College of Osteopathic Medicine, Bradenton, USA
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8
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Terao I, Tsuge T, Endo K, Kodama W. Comparative efficacy, tolerability and acceptability of intravenous racemic ketamine with intranasal esketamine, aripiprazole and lithium as augmentative treatments for treatment-resistant unipolar depression: A systematic review and network meta-analysis. J Affect Disord 2024; 346:49-56. [PMID: 37949235 DOI: 10.1016/j.jad.2023.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Intravenous racemic ketamine is a promising treatment for treatment-resistant depression. However, its clinical utility compared with intranasal esketamine and the other well-studied conventional pharmacological interventions (i.e., aripiprazole and lithium) as augmentative treatments for treatment-resistant unipolar depression in adults remains unclear. Therefore, we aimed to compare the efficacy, tolerability and acceptability of intravenous racemic ketamine with intranasal esketamine, aripiprazole and lithium under such conditions. METHODS The Cochrane Library, PubMed, CINHAL and ClinicalTrials.gov databases were systematically searched from their inception to 10 May 2023. Randomised controlled trials evaluating these drugs were included. A random-effects network meta-analysis was also performed. RESULTS In the primary analysis, all four drugs were significantly more effective than placebo. In addition, intravenous racemic ketamine was significantly more effective and acceptable than intranasal esketamine and aripiprazole. Intravenous racemic ketamine was not significantly different from placebo in tolerability, whereas intranasal esketamine and aripiprazole were significantly less tolerable than placebo. Lithium did not differ significantly from intravenous racemic ketamine in efficacy, tolerability and acceptability. LIMITATIONS The sample size of patients treated with intravenous racemic ketamine was small. CONCLUSIONS Intravenous racemic ketamine may be a better augmentative treatment for treatment-resistant unipolar depression than intranasal esketamine and aripiprazole. Whether intravenous racemic ketamine or lithium is superior is unclear currently. A larger head-to-head trial of intravenous racemic ketamine versus conventional augmentative treatments for treatment-resistant unipolar depression is needed.
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Affiliation(s)
- Itsuki Terao
- Department of Psychiatry, Ikokoro Clinic Nihonbashi, Chuo-ku, Tokyo 103-0012, Japan.
| | - Takahiro Tsuge
- Department of Rehabilitation, Kurashiki Medical Center, Kurashiki, Okayama 710-8522, Japan; Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Shikata-cho, Okayama 700-8558, Japan
| | - Kaori Endo
- National Coalition of independent scholars, 125 Putney Rd, Battleboro, VT, 05301, USA
| | - Wakako Kodama
- Department of Psychiatry, Negishi Hospital, Fuchu-shi, Tokyo 183-0042, Japan
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9
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Grice ASB, Sloofman L, Levy T, Walker H, Ganesh G, de Los Santos MR, Armini P, Buxbaum JD, Kolevzon A, Kostic A, Breen MS. Transient peripheral blood transcriptomic response to ketamine treatment in children with ADNP syndrome. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.29.24301949. [PMID: 38352457 PMCID: PMC10863029 DOI: 10.1101/2024.01.29.24301949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Activity-dependent neuroprotective protein (ADNP) syndrome is a rare neurodevelopmental disorder resulting in intellectual disability, developmental delay and autism spectrum disorder (ASD) and is due to mutations in the ADNP gene. Ketamine treatment has emerged as a promising therapeutic option for ADNP syndrome, showing safety and apparent behavioral improvements in a first open label study. However, the molecular perturbations induced by ketamine remain poorly understood. Here, we investigated the longitudinal effect of ketamine on the blood transcriptome of 10 individuals with ADNP syndrome. Transcriptomic profiling was performed before and at multiple time points after a single low-dose intravenous ketamine infusion (0.5mg/kg). We show that ketamine triggers immediate and profound gene expression alterations, with specific enrichment of monocyte-related expression patterns. These acute alterations encompass diverse signaling pathways and co-expression networks, implicating up-regulation of immune and inflammatory-related processes and down-regulation of RNA processing mechanisms and metabolism. Notably, these changes exhibit a transient nature, returning to baseline levels 24 hours to 1 week after treatment. These findings enhance our understanding of ketamine's molecular effects and lay the groundwork for further research elucidating its specific cellular and molecular targets. Moreover, they contribute to the development of therapeutic strategies for ADNP syndrome and potentially, ASD more broadly.
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Affiliation(s)
- Ariela S Buxbaum Grice
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura Sloofman
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tess Levy
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hannah Walker
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gauri Ganesh
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miguel Rodriguez de Los Santos
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pardis Armini
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph D Buxbaum
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ana Kostic
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael S Breen
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Hauser J, Sarlon J, Liwinski T, Brühl AB, Lang UE. Listening to music during intranasal (es)ketamine therapy in patients with treatment-resistant depression correlates with better tolerability and reduced anxiety. Front Psychiatry 2024; 15:1327598. [PMID: 38322143 PMCID: PMC10844460 DOI: 10.3389/fpsyt.2024.1327598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
Background Although the effectiveness of (es)ketamine for therapy-resistant depression (TRD) has been established, potential treatment-limiting factors include side effects like dissociation, anxiety, or elevated blood pressure. Music can reduce stress and negative emotions as anxiety. This study aimed to investigate the impact of listening to music during intranasal (es)ketamine administration on both tolerability and efficacy. Methods Records of 494 sessions (of 37 patients) with intranasal (es)ketamine administration, each containing data of blood pressure measurements, DSS-IV (dissociation symptoms scale-IV), anxiety and euphoria analogue scale, MADRS (Montgomery-Åsberg Depression Rating Scale) and BDI (Beck's Depression Inventory) were evaluated. Results The between-group analysis, comparing participants who listened to music with those who did not, revealed significant differences in the administered dose (p-value: 0.003, mean: 131.5 mg with music vs. 116.7 mg without music), scores on the DSS Item 1 (p-value: 0.005, mean: 3 points vs. 2.4 points), levels of anxiety (p-value: <0.001, mean: 0.4 points vs. 1.4 points), and measurements of maximal systolic blood pressure after administration (p-value: 0.017, mean: 137.9 mmHg vs. 140.3 mmHg). Listening to music had no impact on the MARDS-change score between the sessions. Limitations Key limitations include a non-randomized naturalistic design and the non-standardized selection of music, which was based on individual patient preferences. Conclusion Listening to music during intranasal (es)ketamine therapy appears to be linked to reduced anxiety and lower blood pressure, stable or increased dissociation levels, and improved tolerance for higher doses. These findings could potentially contribute to the optimization of (es)ketamine therapy, both in terms of treatment efficacy and managing side effects.
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Affiliation(s)
- Johannes Hauser
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Jan Sarlon
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Timur Liwinski
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Annette B. Brühl
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Undine E. Lang
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
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11
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Ribeiro-Davis A, Al Saeedy DY, Jahr FM, Hawkins E, McClay JL, Deshpande LS. Ketamine Produces Antidepressant Effects by Inhibiting Histone Deacetylases and Upregulating Hippocampal Brain-Derived Neurotrophic Factor Levels in a Diisopropyl Fluorophosphate-Based Rat Model of Gulf War Illness. J Pharmacol Exp Ther 2024; 388:647-654. [PMID: 37863487 PMCID: PMC10801753 DOI: 10.1124/jpet.123.001824] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 10/22/2023] Open
Abstract
Approximately one-third of Gulf War veterans suffer from Gulf War Illness (GWI), which encompasses mood disorders and depressive symptoms. Deployment-related exposure to organophosphate compounds has been associated with GWI development. Epigenetic modifications have been reported in GWI veterans. We previously showed that epigenetic histone dysregulations were associated with decreased brain-derived neurotrophic factor (BDNF) expression in a GWI rat model. GWI has no effective therapies. Ketamine (KET) has recently been approved by the Food and Drug Administration for therapy-resistant depression. Interestingly, BDNF upregulation underlies KET's antidepressant effect in GWI-related depression. Here, we investigated whether KET's effect on histone mechanisms signals BDNF upregulations in GWI. Male Sprague-Dawley rats were injected once daily with diisopropyl fluorophosphate (DFP; 0.5 mg/kg, s.c., 5 days). At 6 months following DFP exposure, KET (10 mg/kg, i.p.) was injected, and brains were dissected 24 hours later. Western blotting was used for protein expression, and epigenetic studies used chromatin immunoprecipitation methods. Dil staining was conducted for assessing dendritic spines. Our results indicated that an antidepressant dose of KET inhibited the upregulation of histone deacetylase (HDAC) enzymes in DFP rats. Furthermore, KET restored acetylated histone occupancy at the Bdnf promoter IV and induced BDNF protein expression in DFP rats. Finally, KET treatment also increased the spine density and altered the spine diversity with increased T-type and decreased S-type spines in DFP rats. Given these findings, we propose that KET's actions involve the inhibition of HDAC expression, upregulation of BDNF, and dendritic modifications that together ameliorates the pathologic synaptic plasticity and exerts an antidepressant effect in DFP rats. SIGNIFICANCE STATEMENT: This study offers evidence supporting the involvement of epigenetic histone pathways in the antidepressant effects of ketamine (KET) in a rat model of Gulf War Illness (GWI)-like depression. This effect is achieved through the modulation of histone acetylation at the Bdnf promoter, resulting in elevated brain-derived neurotrophic factor expression and subsequent dendritic remodeling in the hippocampus. These findings underscore the rationale for considering KET as a potential candidate for clinical trials aimed at managing GWI-related depression.
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Affiliation(s)
- Ana Ribeiro-Davis
- Departments of Neurology (A.R.-D., E.H., L.S.D.), Pharmacology and Toxicology (L.S.D.), School of Medicine, Virginia Commonwealth University, Richmond, Virginia and Department of Pharmacotherapy and Outcome Sciences (D.Y.A.S., F.M.J., J.L.M.), School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Dalia Y Al Saeedy
- Departments of Neurology (A.R.-D., E.H., L.S.D.), Pharmacology and Toxicology (L.S.D.), School of Medicine, Virginia Commonwealth University, Richmond, Virginia and Department of Pharmacotherapy and Outcome Sciences (D.Y.A.S., F.M.J., J.L.M.), School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Fay M Jahr
- Departments of Neurology (A.R.-D., E.H., L.S.D.), Pharmacology and Toxicology (L.S.D.), School of Medicine, Virginia Commonwealth University, Richmond, Virginia and Department of Pharmacotherapy and Outcome Sciences (D.Y.A.S., F.M.J., J.L.M.), School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Elisa Hawkins
- Departments of Neurology (A.R.-D., E.H., L.S.D.), Pharmacology and Toxicology (L.S.D.), School of Medicine, Virginia Commonwealth University, Richmond, Virginia and Department of Pharmacotherapy and Outcome Sciences (D.Y.A.S., F.M.J., J.L.M.), School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Joseph L McClay
- Departments of Neurology (A.R.-D., E.H., L.S.D.), Pharmacology and Toxicology (L.S.D.), School of Medicine, Virginia Commonwealth University, Richmond, Virginia and Department of Pharmacotherapy and Outcome Sciences (D.Y.A.S., F.M.J., J.L.M.), School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Laxmikant S Deshpande
- Departments of Neurology (A.R.-D., E.H., L.S.D.), Pharmacology and Toxicology (L.S.D.), School of Medicine, Virginia Commonwealth University, Richmond, Virginia and Department of Pharmacotherapy and Outcome Sciences (D.Y.A.S., F.M.J., J.L.M.), School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
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12
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Kadiyala S, Bhamidipati P, Malla RR. Neuroplasticity: Pathophysiology and Role in Major Depressive Disorder. Crit Rev Oncog 2024; 29:19-32. [PMID: 38989735 DOI: 10.1615/critrevoncog.2024051197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Neuroplasticity is characterized by the brain's ability to change its activity in response to extrinsic and intrinsic factors and is thought to be the mechanism behind all brain functions. Neuroplasticity causes structural and functional changes on a molecular level, specifically the growth of different regions in the brain and changes in synaptic and post-synaptic activities. The four types of neuroplasticity are homologous area adaption, compensatory masquerade, cross-modal reassignment, and map expansion. All of these help the brain work around injuries or new information inputs. In addition to baseline physical functions, neuroplasticity is thought to be the basis of emotional and mental regulations and the impairment of it can cause various mental illnesses. Concurrently, these mental illnesses further the damage of synaptic plasticity in the brain. Major depressive disorder (MDD) is one of the most common mental illnesses. It is affected by and accelerates the impairment of neuroplasticity. It is characterized by a chronically depressed state of mind that can impact the patient's daily life, including work life and interests. This review will focus on highlighting the physiological aspects of the disease and the role of neuroplasticity in the pathogenesis and pathology of the disorder. Moreover, the role of monoamine regulation and ketamine uptake will be discussed in terms of their antidepressant effects on the outcomes of MDD.
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Affiliation(s)
| | - Priyamvada Bhamidipati
- Cancer Biology Laboratory, Department of Biochemistry and Bioinformatics, GITAM School of Science, GITAM (Deemed to be University), Visakhapatnam 530045, Andhra Pradesh, India
| | - Rama Rao Malla
- Cancer Biology Laboratory, Department of Biochemistry and Bioinformatics, School of Science, Gandhi Institute of Technology and Management (GITAM) (Deemed to be University), Visakhapatnam-530045, Andhra Pradesh, India; Department of Biochemistry and Bioinformatics, School of Science, GITAM (Deemed to be University), Visakhapatnam-530045, Andhra Pradesh, India
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13
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Johnston JN, Kadriu B, Kraus C, Henter ID, Zarate CA. Ketamine in neuropsychiatric disorders: an update. Neuropsychopharmacology 2024; 49:23-40. [PMID: 37340091 PMCID: PMC10700638 DOI: 10.1038/s41386-023-01632-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant led to a new era in the development of neuropsychiatric therapeutics, one characterized by an antidepressant response that occurred within hours or days rather than weeks or months. Considerable clinical research supports the use of-or further research with-subanesthetic-dose ketamine and its (S)-enantiomer esketamine in multiple neuropsychiatric disorders including depression, bipolar disorder, anxiety spectrum disorders, substance use disorders, and eating disorders, as well as for the management of chronic pain. In addition, ketamine often effectively targets symptom domains associated with multiple disorders, such as anxiety, anhedonia, and suicidal ideation. This manuscript: 1) reviews the literature on the pharmacology and hypothesized mechanisms of subanesthetic-dose ketamine in clinical research; 2) describes similarities and differences in the mechanism of action and antidepressant efficacy between racemic ketamine, its (S) and (R) enantiomers, and its hydroxynorketamine (HNK) metabolite; 3) discusses the day-to-day use of ketamine in the clinical setting; 4) provides an overview of ketamine use in other psychiatric disorders and depression-related comorbidities (e.g., suicidal ideation); and 5) provides insights into the mechanisms of ketamine and therapeutic response gleaned from the study of other novel therapeutics and neuroimaging modalities.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Translational and Experimental Medicine, Neuroscience at Jazz Pharmaceuticals, San Diego, CA, USA
| | - Christoph Kraus
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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14
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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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15
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Johnston JN, Henter ID, Zarate CA. The antidepressant actions of ketamine and its enantiomers. Pharmacol Ther 2023; 246:108431. [PMID: 37146727 PMCID: PMC10213151 DOI: 10.1016/j.pharmthera.2023.108431] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/07/2023]
Abstract
Ketamine, an N-methyl-d-aspartate receptor (NMDAR) antagonist first developed as an anesthetic, has shown significant promise as a medication with rapid antidepressant properties in treatment-resistant depression. However, concerns such as adverse side effects and potential misuse liability have limited its widespread use. Racemic ketamine has two enantiomers-(S)- and (R)-ketamine-that appear to have disparate underlying mechanisms. This brief review summarizes some of the most recent preclinical and clinical research regarding the convergent and divergent prophylactic, immediate, and sustained antidepressant effects of (S)- and (R)-ketamine while addressing potential differences in their side effect and misuse liability profiles. Preclinical research suggests divergent mechanisms underlying (S)- and (R)-ketamine, with (S)-ketamine more directly affecting mechanistic target of rapamycin complex 1 (mTORC1) signaling and (R)-ketamine more directly affecting extracellular signal-related kinase (ERK) signaling. Clinical research suggests that (R)-ketamine has a milder side effect profile than (S)-ketamine and decreases depression rating scale scores, but recent randomized, controlled trials found that it had no significant antidepressant efficacy compared to placebo, suggesting that caution is warranted in interpreting its therapeutic potential. Future preclinical and clinical research is needed to maximize the efficacy of each enantiomer, either by optimizing dose, route of administration, or administration paradigm.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MA, United States.
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MA, United States
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MA, United States
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16
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Sadko K, Jakuszkowiak-Wojten K. Cardiovascular and Metabolic Comorbidities as the Factors for Adverse Events With Ketamine. J Clin Psychopharmacol 2023:00004714-990000000-00134. [PMID: 37186662 DOI: 10.1097/jcp.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Krzysztof Sadko
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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17
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Ding J, Yu Y, Luo M, Fang X, Tan D, Qin H, Ren X, Zhang Y, Luo T, Chen L, Yu W, Zhu Z. Thrifty effect of subanesthetic-dose S-ketamine on postoperative opioids and its safety and analgesic effectiveness: A prospective, triple-blind, randomized controlled, polycentric clinical trial. IBRAIN 2023; 9:171-182. [PMID: 37786549 PMCID: PMC10529155 DOI: 10.1002/ibra.12104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/19/2023] [Accepted: 04/30/2023] [Indexed: 10/04/2023]
Abstract
Aim To investigate the thrifty effects of subanesthetic-dose S-ketamine on postoperative opioids and its safety and analgesic efficacy. Methods Four-hundred and twenty patients were divided into the control group (CON group), the S-ketamine 0.2 mg/kg group (ES0.2 group), and the S-ketamine 0.3 mg/kg group (ES0.3 group) randomly. Major indicators include the Visual Analogue Scale (VAS), the times of compression with analgesic pumps after surgery, and analgesic drug consumption from anesthesia induction to 48 h after surgery. Minor records include vital signs, the use of vasoactive drugs, the Ramsay scores, the occurrence of adverse events including nervous system reaction, and the patient's satisfaction with anesthesia. Results Compared with the CON group, VAS scores decreased in the ES0.2 and ES0.3 groups (p < 0.05). At 10 min after extubation, the VAS scores of the ES0.3 group were lower than that of the ES0.2 group (p < 0.05). The total number of compression with analgesic pumps of the ES0.3 group was lower than that of the CON group (p < 0.05). The opioid consumption after surgery of the ES0.3 group was lower than those of the CON group and the ES0.2 group (p < 0.05). The ES0.3 group's heart rate (HR) was faster but the use of vasoactive, drug consumption was less than the other two groups (p < 0.05). There were no significant differences in the incidence of postoperative adverse events and anesthetic satisfaction among the three groups. Conclusion Subanesthetic-dose S-ketamine at 0.2-0.3 mg/kg especially the 0.3 mg/kg in general anesthesia induction can safely and effectively reduce postoperative pain and save postoperative opioid consumption.
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Affiliation(s)
- Jun Ding
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Yun‐Mei Yu
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Man Luo
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Xu Fang
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Dan‐Dan Tan
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Han‐Rui Qin
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Xue‐Feng Ren
- Department of AnesthesiologyPeople's Hospital of Anshuan CityAnshunGuizhouChina
| | - Yong‐Guo Zhang
- Department of AnesthesiologyPeople's Hospital of QiannanQiannanGuizhouChina
| | - Tao Luo
- Department of AnesthesiologyThe People's Hospital of TongrenTongrenGuizhouChina
| | - Lei Chen
- Department of AnesthesiologyQian Xi Nan People's HospitalQianxinanGuizhouChina
| | - Wan‐Qiu Yu
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Zhao‐Qiong Zhu
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
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18
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Liu B, Du Y, Xu C, Liu Q, Zhang L. Antidepressant effects of repeated s-ketamine administration as NMDAR Antagonist: Involvement of CaMKIIα and mTOR signaling in the hippocampus of CUMS mice. Brain Res 2023; 1811:148375. [PMID: 37146745 DOI: 10.1016/j.brainres.2023.148375] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
With the approval of s-ketamine nasal spray as a novel antidepressant, its robust antidepressant effects have been intensively examined in clinical trials. However, the therapeutic efficacy and mechanisms of repeated intermittent drug administration remain unclear. In the present study, we applied a classic chronic unpredictable mild stress (CUMS) model to induce depressive-like behaviors of mice and evaluated the role of repeated s-ketamine administration (10 mg/kg, 7 consecutive days) in ameliorating depressive-like behaviors and modulating related molecular pathways. A battery of behavioral tests were performed to assess CUMS-induced depression. The protein expressions of GluN1, GluN2A, GluN2B, GluR1, CaMKIIα, phosphorylated CaMKIIα (p-CaMKIIα), BDNF, TrkB, phosphorylated TrkB (p-TrkB), mTOR, and phosphorylated mTOR (p-mTOR) as well as modification of synaptic ultrastructure was identified in hippocampal tissues. It turned out that s-ketamine manifested evident antidepressant effects with improved synaptic plasticity. Meanwhile, the results suggested that s-ketamine could differentially modulate glutamate receptors with upregulated GluN1 and GluR1 levels and downregulated GluN2B levels. CUMS-induced elevation of CaMKIIα phosphorylation and decline of BDNF, TrkB phosphorylation and mTOR could also be reversed through s-ketamine treatment. Together, our study provided evidence that selectively modulated glutamate receptors as well as CaMKIIα and mTOR signaling were involved in repeated s-ketamine administration.
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Affiliation(s)
- Bingjie Liu
- Department of Anesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Yuxin Du
- Department of Anesthesiology, Jinling Hospital, the First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Chang Xu
- Department of Anesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Qingzhen Liu
- Department of Anesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Lidong Zhang
- Department of Anesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China.
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19
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Williamson D, Turkoz I, Wajs E, Singh JB, Borentain S, Drevets WC. Adverse Events and Measurement of Dissociation After the First Dose of Esketamine in Patients With TRD. Int J Neuropsychopharmacol 2023; 26:198-206. [PMID: 36525338 PMCID: PMC10032296 DOI: 10.1093/ijnp/pyac081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND "Dissociation" comprises distinct phenomena, some of which are associated with esketamine treatment and some may overlap with positive symptoms of psychosis. Relationships between dissociation and psychotic symptoms assessed by -clinician report vs conventional rating scales were investigated in a post hoc analysis of data from the initial treatment session in an -open-label, -long-term safety, phase 3 study of esketamine plus a newly initiated oral antidepressant in patients with treatment-resistant depression. METHODS Adverse events of dissociation or psychosis were examined via investigator report and the Clinician Administered Dissociative States Scale (CADSS) and Brief Psychiatric Rating Scale-Plus, respectively, 40 minutes post first esketamine dose. The range of CADSS total scores associated with investigator-reported severity of dissociation was determined by equipercentile linking. Logistic regression models and receiver operating curve analysis explored the CADSS cutoff point for determining presence/absence of dissociation. Frequency of response to specific CADSS items was examined to investigate qualitative differences in the pattern of symptoms reported across investigator-reported levels of adverse event severity. RESULTS Dissociation was reported as an adverse event in 14.3% (109/764) of patients. Severity of most CADSS items increased with the severity of investigator-reported dissociation. No CADSS cutoff point discriminated well between the presence and absence of dissociation events. Hallucinations were reported as adverse events in 5 patients; none reported delusions. CONCLUSIONS CADSS scores and severity of dissociation adverse events move generally in the same direction; however, there is substantial variability in this relationship. No signature profile of dissociative experiences was revealed, and psychotic symptoms were uncommon. TRIAL REGISTRATION Clinical Trials.gov identifier: NCT02497287.
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Affiliation(s)
- David Williamson
- Janssen Scientific Affairs, LLC, Titusville, New Jersey, USA
- Department of Psychiatry and Health Behavior at Augusta University, Augusta, Georgia, USA
| | - Ibrahim Turkoz
- Department of Statistics and Decision Sciences, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Ewa Wajs
- Department of Neuroscience, Janssen Research & Development Belgium, Beerse, Belgium
| | - Jaskaran B Singh
- Neurocrine Biosciences, San Diego, California, USA
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, California, USA
| | - Stephane Borentain
- Department of Global Medical Affairs, Janssen Research & Development LLC, Titusville, New Jersey, USA
| | - Wayne C Drevets
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, California, USA
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20
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Johnston JN, Kadriu B, Allen J, Gilbert JR, Henter ID, Zarate CA. Ketamine and serotonergic psychedelics: An update on the mechanisms and biosignatures underlying rapid-acting antidepressant treatment. Neuropharmacology 2023; 226:109422. [PMID: 36646310 PMCID: PMC9983360 DOI: 10.1016/j.neuropharm.2023.109422] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant spurred significant research to understand its underlying mechanisms of action and to identify other novel compounds that may act similarly. Serotonergic psychedelics (SPs) have shown initial promise in treating depression, though the challenge of conducting randomized controlled trials with SPs and the necessity of long-term clinical observation are important limitations. This review summarizes the similarities and differences between the psychoactive effects associated with both ketamine and SPs and the mechanisms of action of these compounds, with a focus on the monoaminergic, glutamatergic, gamma-aminobutyric acid (GABA)-ergic, opioid, and inflammatory systems. Both molecular and neuroimaging aspects are considered. While their main mechanisms of action differ-SPs increase serotonergic signaling while ketamine is a glutamatergic modulator-evidence suggests that the downstream mechanisms of action of both ketamine and SPs include mechanistic target of rapamycin complex 1 (mTORC1) signaling and downstream GABAA receptor activity. The similarities in downstream mechanisms may explain why ketamine, and potentially SPs, exert rapid-acting antidepressant effects. However, research on SPs is still in its infancy compared to the ongoing research that has been conducted with ketamine. For both therapeutics, issues with regulation and proper controls should be addressed before more widespread implementation. This article is part of the Special Issue on "Ketamine and its Metabolites".
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Josh Allen
- The Alfred Centre, Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.
| | - Jessica R Gilbert
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
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21
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Scott F, Hampsey E, Gnanapragasam S, Carter B, Marwood L, Taylor RW, Emre C, Korotkova L, Martín-Dombrowski J, Cleare AJ, Young AH, Strawbridge R. Systematic review and meta-analysis of augmentation and combination treatments for early-stage treatment-resistant depression. J Psychopharmacol 2023; 37:268-278. [PMID: 35861202 PMCID: PMC10076341 DOI: 10.1177/02698811221104058] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is a highly burdensome health condition, for which there are numerous accepted pharmacological and psychological interventions. Adjunctive treatment (augmentation/combination) is recommended for the ~50% of MDD patients who do not adequately respond to first-line treatment. We aimed to evaluate the current evidence for concomitant approaches for people with early-stage treatment-resistant depression (TRD; defined below). METHODS We systematically searched Medline and Institute for Scientific Information Web of Science to identify randomised controlled trials of adjunctive treatment of ⩾10 adults with MDD who had not responded to ⩾1 adequate antidepressant. The cochrane risk of bias (RoB) tool was used to assess study quality. Pre-post treatment meta-analyses were performed, allowing for comparison across heterogeneous study designs independent of comparator interventions. RESULTS In total, 115 trials investigating 48 treatments were synthesised. The mean intervention duration was 9 weeks (range 5 days to 18 months) with most studies assessed to have low (n = 57) or moderate (n = 51) RoB. The highest effect sizes (ESs) were from cognitive behavioural therapy (ES = 1.58, 95% confidence interval (CI): 1.09-2.07), (es)ketamine (ES = 1.48, 95% CI: 1.23-1.73) and risperidone (ES = 1.42, 95% CI: 1.29-1.61). Only aripiprazole and lithium were examined in ⩾10 studies. Pill placebo (ES = 0.89, 95% CI: 0.81-0.98) had a not inconsiderable ES, and only six treatments' 95% CIs did not overlap with pill placebo's (aripiprazole, (es)ketamine, mirtazapine, olanzapine, quetiapine and risperidone). We report marked heterogeneity between studies for almost all analyses. CONCLUSIONS Our findings support cautious optimism for several augmentation strategies; although considering the high prevalence of TRD, evidence remains inadequate for each treatment option.
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Affiliation(s)
- Fraser Scott
- South London and Maudsley NHS
Foundation Trust, London, UK
| | - Elliot Hampsey
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | | | - Ben Carter
- Department of Biostatistics and Health
Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College
London, London, UK
| | - Lindsey Marwood
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Rachael W Taylor
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Cansu Emre
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Lora Korotkova
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Jonatan Martín-Dombrowski
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Anthony J Cleare
- South London and Maudsley NHS
Foundation Trust, London, UK
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Allan H Young
- South London and Maudsley NHS
Foundation Trust, London, UK
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Rebecca Strawbridge
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
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22
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Quintanilla B, Medeiros GC, Greenstein D, Yuan P, Johnston JN, Park LT, Goes F, Gould TD, Zarate CA. κ-Opioid Receptor Plasma Levels Are Associated With Sex and Diagnosis of Major Depressive Disorder But Not Response to Ketamine. J Clin Psychopharmacol 2023; 43:89-96. [PMID: 36821406 PMCID: PMC9992159 DOI: 10.1097/jcp.0000000000001663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Preclinical evidence indicates that the κ-opioid receptor (KOR)/dynorphin pathway is implicated in depressive-like behaviors. Ketamine is believed to partly exert its antidepressant effects by modulating the opioid system. This post hoc study examined the following research questions: (1) at baseline, were there differences in KOR or dynorphin plasma levels between individuals with major depressive disorder (MDD) and healthy volunteers (HVs) or between men and women? (2) in individuals with MDD, did KOR or dynorphin baseline plasma levels moderate ketamine's therapeutic effects or adverse effects? and (3) in individuals with MDD, were KOR or dynorphin plasma levels affected after treatment with ketamine compared with placebo? METHODS Thirty-nine unmedicated individuals with MDD (23 women) and 25 HVs (16 women) received intravenous ketamine (0.5 mg/kg) and placebo in a randomized, crossover, double-blind trial. Blood was obtained from all participants at baseline and at 3 postinfusion time points (230 minutes, day 1, day 3). Linear mixed model regressions were used. RESULTS At baseline, participants with MDD had lower KOR plasma levels than HVs ( F1,60 = 13.16, P < 0.001), and women (MDD and HVs) had higher KOR plasma levels than men ( F1,60 = 4.98, P = 0.03). Diagnosis and sex had no significant effects on baseline dynorphin levels. Baseline KOR and dynorphin levels did not moderate ketamine's therapeutic or adverse effects. Compared with placebo, ketamine was not associated with postinfusion changes in KOR or dynorphin levels. CONCLUSIONS In humans, diagnosis of MDD and biological sex are involved with changes in components of the KOR/dynorphin pathway. Neither KOR nor dynorphin levels consistently moderated ketamine's therapeutic effects or adverse effects, nor were levels altered after ketamine infusion. TRIAL REGISTRATION NCT00088699 ( ClinicalTrials.gov ).
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Affiliation(s)
- Brandi Quintanilla
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
| | - Gustavo C. Medeiros
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dede Greenstein
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
| | - Peixiong Yuan
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
| | - Jenessa N. Johnston
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Lawrence T. Park
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
| | - Fernando Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Todd D. Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Departments of Pharmacology and Anatomy & Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - Carlos A. Zarate
- Experimental Therapeutics & Pathophysiology Branch, NIMH-NIH, Bethesda, MD, USA
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23
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Jollant F, Colle R, Nguyen TML, Corruble E, Gardier AM, Walter M, Abbar M, Wagner G. Ketamine and esketamine in suicidal thoughts and behaviors: a systematic review. Ther Adv Psychopharmacol 2023; 13:20451253231151327. [PMID: 36776623 PMCID: PMC9912570 DOI: 10.1177/20451253231151327] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/01/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND More than 2% of the general population experience suicidal ideas each year and a large number of them will attempt suicide. Evidence-based therapeutic options to manage suicidal crisis are currently limited. OBJECTIVES The aim of this study was to overview the findings on the use of ketamine and esketamine for the treatment of suicidal ideas and acts. DESIGN Systematic review. DATA SOURCES AND METHODS PubMed, article references, and Clinicaltrials.gov up to June 30, 2022. Meta-analyses published within the last 2 years were also reviewed. RESULTS We identified 12 randomized controlled trials with reduction of suicidal ideation as the primary objective and 14 trials as secondary objectives. Intravenous racemic ketamine was superior to control drugs (placebo or midazolam) within the first 72 h, in spite of large placebo effects. Adverse events were minor and transient. In contrast, intranasal esketamine did not differ from placebo in large-scale studies. Limitations, clinical considerations, and opportunities for future research include the following points: large placebo effects when studying suicidal ideation reduction; small concerns about blinding quality due to dissociative effects; no studies on the risk/prevention of suicidal acts and mortality; lack of studies beyond affective disorders; no studies in adolescents and older people; lack of knowledge of long-term side effects, notably liability for abuse; no robust predictive markers; limited understanding of the mechanisms of ketamine on suicidal ideas; need for improved assessment of suicidal ideation in clinical trials; need for studies in outpatient settings, emergency room, and liaison consultation; need for research on ketamine administration; limited knowledge on the positive and negative effects of concomitant treatments. CONCLUSION Overall, there is compelling evidence for a favorable short-term benefit-risk balance with intravenous racemic ketamine but not intranasal esketamine. The place of ketamine will have to be defined within a multimodal care strategy for suicidal patients. Caution remains necessary for clinical use, and pharmacovigilance will be essential.
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Affiliation(s)
- Fabrice Jollant
- Service de Psychiatrie, CHU Bicêtre, APHP, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.,Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,MOODS Team, Inserm 1018, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Le Kremlin-Bicêtre, France.,Department of Psychiatry, CHU Nîmes, Univ Montpellier, Nîmes, France.,Department of Psychiatry & McGill Group for Suicide Studies, McGill University, Montréal, QC, Canada
| | - Romain Colle
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Department of Psychiatry, CHU Bicêtre, APHP, Le Kremlin-Bicêtre, France.,MOODS Team, Inserm 1018, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Le Kremlin-Bicêtre, France
| | - Thi Mai Loan Nguyen
- Faculty of Pharmacy, University Paris-Saclay, Orsay, France.,MOODS Team, Inserm 1018, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Le Kremlin-Bicêtre, France
| | - Emmanuelle Corruble
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Department of Psychiatry, CHU Bicêtre, APHP, Le Kremlin-Bicêtre, France.,MOODS Team, Inserm 1018, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Le Kremlin-Bicêtre, France
| | - Alain M Gardier
- Faculty of Pharmacy, University Paris-Saclay, Orsay, France.,MOODS Team, Inserm 1018, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Le Kremlin-Bicêtre, France
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany.,Clinical Affective Neuroimaging Laboratory (CANLAB), Magdeburg, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany.,Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany.,German Center for Mental Health (DZPG), site Jena Magdeburg Halle, Germany.,Center for Intervention and Research on adaptive and maladaptive Brain Circuits underlying Mental Health (C-I-R-C), site Jena Magdeburg Halle, Germany
| | - Mocrane Abbar
- Department of Psychiatry, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Gerd Wagner
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany.,Network for Suicide Prevention in Thuringia (NeST), Jena, Germany.,Center for Intervention and Research on adaptive and maladaptive Brain Circuits underlying Mental Health (C-I-R-C), site Jena Magdeburg Halle, Germany
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24
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Impact of Repeated Doses of Subcutaneous Esketamine on Acute Dissociative Symptoms in Treatment-Resistant Depression. Pharmaceuticals (Basel) 2022; 16:ph16010031. [PMID: 36678528 PMCID: PMC9861342 DOI: 10.3390/ph16010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Esketamine has been approved by the US Food and Drug Administration (FDA) as an adjunctive treatment for use in conjunction with an oral antidepressant for patients with treatment-resistant depression (TRD), but dissociative symptoms are common adverse effects. METHODS A retrospective analysis of 394 subcutaneous esketamine injections given to 70 patients with TRD that were administered once a week during a six-week trial in conjunction with oral antidepressant therapy. Doses between 0.5 to 1.0 mg/kg were administered according to the patient's response. Dissociative symptoms were assessed using the Clinician-Administered Dissociative States Scale (CADSS) 30 and 60 min after every weekly treatment (day 1, 8, 15, 22, 29 and 36). RESULTS Seventy patients received a total of 394 subcutaneous esketamine injections over six weeks. Over time, the evolution of CADSS scores demonstrated a significant mean difference of CADSS at 60 min post-injection (p = 0.010) throughout the six infusions. The mean CADSS scores at 60 min on day 22, 29 and 36 were similar. There were no differences between mean CADSS scores 30 min after the injections, no clinical correlation between response and dissociative symptoms, no correlation between time and demographic and clinical characteristics and no interactions between time and combined medication. CONCLUSIONS Our results suggest that repeated subcutaneous esketamine doses are safe and well-tolerated regarding their acute dissociative and psychotomimetic symptoms. Symptoms usually peak at 30 min and decrease at 60 min post-injection, returning to their pretreatment levels at 120 min. Dissociative symptoms do not correlate with antidepressant response.
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25
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Antidepressant Effect of Ketamine on Inflammation-Mediated Cytokine Dysregulation in Adults with Treatment-Resistant Depression: Rapid Systematic Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:1061274. [PMID: 36160713 PMCID: PMC9507757 DOI: 10.1155/2022/1061274] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/25/2022] [Accepted: 08/23/2022] [Indexed: 11/28/2022]
Abstract
Background Major depressive disorder (MDD) and treatment-resistant depression (TRD) represent a global source of societal and health burden. To advise proper management of inflammation-related depression among TRD patients, it is important to identify therapeutic clinical treatments. A key factor is related to proinflammatory cytokines such as interleukin- (IL-) 1β, IL-6, and tumor necrosis factor- (TNF-) α which have been implicated in the pathogenesis of depressive symptoms in MDD patients. Ketamine may provide an anti-inflammatory therapeutic strategy by targeting proinflammatory pathways associated with depressive disorders, which may be exacerbated in the ageing population with TRD. Objective Despite a burgeoning body of literature demonstrating that inflammation is linked to TRD, there is still a lack of comprehensive research on the relationship between proinflammatory biomarkers and ketamine's antidepressant effect on TRD patients. Method The Cochrane Library and PubMed/MEDLINE databases were systematically searched from inception up to February 1, 2022, adopting broad inclusion criteria to assess clinical topics related to the impact of ketamine on inflammatory cytokines in TRD patients. The present work is in compliance with the World Health Organization Rapid Review Guide. Results Five out of the seven studies examined in this review show that ketamine infusion may reduce depressive symptoms with a quick start of effect on TRD patients. Based on the Montgomery-Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale (HAM-D) scores, the overall response rate for ketamine was 56%; that is, 56% of those treated with ketamine had MADRS/HAM-D scores decreased by at least 50%. Conclusions While the anti-inflammatory effects of ketamine modulate specific proinflammatory cytokines, its rapid antidepressant effect on TRD patients remains inconsistent. However, our study findings can provide a reliable basis for future research on how to improve systemic inflammatory immune disorders and mental health. We suggest that ketamine infusion may be part of a comprehensive treatment approach in TRD patients with elevated levels of depression-specific inflammatory biomarkers.
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26
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Le TT, Cordero IP, Jawad MY, Swainson J, Di Vincenzo JD, Jaberi S, Phan L, Lui LMW, Ho R, Rosenblat JD, McIntyre RS. The abuse liability of ketamine: A scoping review of preclinical and clinical studies. J Psychiatr Res 2022; 151:476-496. [PMID: 35623124 DOI: 10.1016/j.jpsychires.2022.04.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/17/2022] [Accepted: 04/25/2022] [Indexed: 12/22/2022]
Abstract
While ketamine has been used clinically over the past decades, it has only been recently shown to be a promising therapy for treatment-resistant depression (TRD). However, ketamine and related dissociative agents may also be misused recreationally, creating significant concerns for abuse liability when prescribed for depression. Although the abuse potential of ketamine is widely recognized, there is limited evidence on the differential abuse liability of ketamine enantiomers, (S)-ketamine and (R)-ketamine. The current scoping review aims to summarize the extant literature on the abuse liability of (R,S)-ketamine and the enantiomers. A systematic search was conducted on the Embase, Medline, and APA PsycInfo databases from 1947 to July 29, 2021. Clinical and preclinical studies that assessed the abuse potential of (R,S)-ketamine, (S)-ketamine, and (R)-ketamine were screened and assessed for eligibility by two independent reviewers. A total of 65 eligible studies were identified; 55 were preclinical studies and 10 were clinical studies. Only 4 preclinical studies evaluated the abuse liability of ketamine enantiomers. Available preclinical evidence suggests that (R,S)-ketamine and (S)-ketamine have greater risk for abuse compared to (R)-ketamine. (R)-ketamine, at the antidepressant-relevant doses in rodents, appears to be safe with minimal liability for abuse. Although the abuse potential of (R,S)-ketamine is well-established in animals, limited clinical studies indicate that single or repeated ketamine administrations in professionally controlled settings did not result in misuse, dependence, diversion and/or gateway activity in patients with TRD. However, most clinical studies were retrospective and did not systematically evaluate the abuse liability of ketamine via validated psychological scales/questionnaires. Future randomized controlled trials are warranted to ascertain the abuse liability of racemic, (S)- and (R)-ketamine in TRD population, especially among patients with comorbid substance use disorders.
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Affiliation(s)
- Tuyen T Le
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Isabel Pazos Cordero
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Human Biology, University of Toronto, Toronto, ON, Canada
| | - Muhammad Youshay Jawad
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada
| | | | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Saja Jaberi
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada
| | - Lee Phan
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, ON, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Alberta, Edmonton, Canada; Institute of Medical Science, University of Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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27
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Moore TJ, Alami A, Alexander GC, Mattison DR. Safety and effectiveness of
NMDA
receptor antagonists for depression: A multidisciplinary review. Pharmacotherapy 2022; 42:567-579. [PMID: 35665948 PMCID: PMC9540857 DOI: 10.1002/phar.2707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 12/18/2022]
Abstract
Ketamine, an anesthetic available since 1970, and esketamine, its newer S‐enantiomer, provide a novel approach for the treatment of depression and other psychiatric disorders. At subanesthetic doses, the two drugs, along with their older congener, phencyclidine (PCP), induce a transient, altered mental state by blocking the N‐methyl‐D‐aspartate (NMDA) receptor for glutamate, the primary excitatory neurotransmitter in the mammalian central nervous system. This multidisciplinary review examines the pharmacology/direct effects on consciousness, effectiveness in depression and acute suicidality, and safety of these fast‐acting NMDA antagonists. To capture the essence of 60 years of peer‐reviewed literature, we used a semi‐structured approach to the subtopics, each of which required a different search strategy. We review the evidence for the three primary reported benefits of the two clinical drugs when used for depression: success in difficult‐to‐treat patients, rapid onset of action within a day, and immediate effects on suicidality. Key safety issues include the evidence—and lack thereof—for the effects of repeatedly inducing this altered mental state, and whether an adequate safety margin exists to rule out the neurotoxic effects seen in animal studies. This review includes evidence from multiple sources that raise substantial questions about both safety and effectiveness of ketamine and esketamine for psychiatric disorders.
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Affiliation(s)
- Thomas J. Moore
- Center for Drug Safety and Effectiveness, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of EpidemiologyMilken Institute School of Public Health, The George Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Abdallah Alami
- McLaughlin Centre for Population Health Risk AssessmentUniversity of OttawaOttawaOntarioCanada
- School of Mathematics and StatisticsCarleton UniversityOttawaOntarioCanada
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
- Division of General Internal MedicineJohns Hopkins MedicineBaltimoreMarylandUSA
| | - Donald R. Mattison
- McLaughlin Centre for Population Health Risk AssessmentUniversity of OttawaOttawaOntarioCanada
- Department of Epidemiology and Biostatistics, Arnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
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Orsolini L, Salvi V, Volpe U. Craving and addictive potential of esketamine as side effects? Expert Opin Drug Saf 2022; 21:803-812. [PMID: 35509224 DOI: 10.1080/14740338.2022.2071422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Esketamine was approved for adults with treatment-resistant depression (TRD) in conjunction with an oral antidepressant, and for treating depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior. However, evidence of great efficacy and safety of esketamine is accompanied by a widespread concern regarding its addictive potential. AREAS COVERED A comprehensive review on the craving and addictive potential of ketamine and esketamine was carried out. In addition, a clinical case of a 34-year-old TRD woman treated with esketamine who experienced drug-seeking behaviors and craving symptomatology was described and critically discussed, with a particular focus on treatment strategies to manage craving in the short- and long term. EXPERT OPINION Esketamine showed great efficacy and safety in treating TRD and MDD with acute suicidal ideation or behavior. Our clinical experience demonstrated the presence of an additive potential, which has been favorably managed with slow esketamine de-titration and combination with bupropion. However, literature so far published is scant and shows contradictory findings. Therefore, it is crucial to promptly detect and manage craving symptomatology in esketamine-treated TRD patients. In our experience, the use of bupropion to counteract craving and addictive symptoms was proven to be effective and safe.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Virginio Salvi
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
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29
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Lengvenyte A, Strumila R, Olié E, Courtet P. Ketamine and esketamine for crisis management in patients with depression: Why, whom, and how? Eur Neuropsychopharmacol 2022; 57:88-104. [PMID: 35219097 DOI: 10.1016/j.euroneuro.2022.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
Currently, only a limited number of interventions can rapidly relieve depressive symptomatology in patients with major depressive disorder or bipolar disorder experiencing extreme distress. Such crises, especially when suicide attempt or ideation is involved, are a major risk factor of suicide. Ketamine, a N-methyl-d-aspartate glutamate receptor antagonist, and its enantiomer esketamine rapidly reduce depressive symptoms in depressed patients with current suicidal ideation. Recently, esketamine has been approved for use in patients with depression at risk of suicide and for psychiatric emergency by major medical agencies in the United States and Europe, whereas ketamine is increasingly used off-label. However, there is currently limited guidance on why, when, and how to use these drugs in patients with depression to treat a crisis. In this review article, we provide a succinct overview of the cellular and molecular mechanisms of action of ketamine and esketamine, and of the functional brain changes following their administration. We also summarize the major clinical studies on ketamine and esketamine efficacy in patients experiencing a crisis (generally, suicidal ideation), and propose a profile of patients who can benefit most from such drugs, on the basis of neurobiological and clinical observations. Finally, we describe the administration mode, the efficacy and tolerability profiles, the side effect management, possible concomitant treatments and the issue of deprescribing.
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Affiliation(s)
- Aiste Lengvenyte
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France; Psychiatric Clinic, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Robertas Strumila
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France; Psychiatric Clinic, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, France; IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
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30
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Optimized Clinical Strategies for Treatment-Resistant Depression: Integrating Ketamine Protocols with Trauma- and Attachment-Informed Psychotherapy. PSYCH 2022. [DOI: 10.3390/psych4010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Strategically timed trauma- and attachment-informed psychotherapy to address underlying emotional wounds, paired with ketamine administered in precision-calibrated doses to ensure high-entropy brain states, may be key to improving the quality and duration of ketamine’s therapeutic efficacy for treatment-resistant depression. This approach optimizes the opportunities for change created by ketamine’s known effects as a rapid antidepressant that stimulates synaptogenesis, normalizes neural connectivity and coherence, enhances neuroplasticity, reduces inflammation, and induces high-entropy brain states with associated subjective psychedelic experiences. Ketamine, a non-selective N-methyl-D-aspartate (NMDA) receptor antagonist is a safe, effective, fast-acting dissociative anesthetic that, as a standalone treatment, also exhibits rapid sustained antidepressant effects, even in many patients with treatment-resistant depression. A prior history of developmental trauma and attachment injuries are known primary factors in the etiology of treatment resistance in depression and other mental disorders. Thus, the adjunct of targeted psychotherapy attuned to trauma and attachment injuries may enhance and prolong ketamine efficacy and provide an opportunity for lasting therapeutic change. Psychotherapy engagement during repeated ketamine sessions for patient safety and integration of altered states, paired with separate individualized psychotherapy-only sessions timed 24–48 h post ketamine induction, takes advantage of peak ketamine-induced dendritic spine growth in the prefrontal cortex and limbic system, and normalized network connectivity across brain structures. This strategically timed paired-session approach also exploits the therapeutic potential created by precision-calibrated ketamine-linked high-entropy brain states and associated psychedelic experiences that are posited to disrupt overly rigid maladaptive thoughts, behaviors, and disturbing memories associated with treatment-resistant depression; paired sessions also support integration of the felt sense of happiness and connectivity associated with psychedelic experiences.
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31
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Tamman AJF, Anand A, Mathew SJ. A comparison of the safety, feasibility, and tolerability of ECT and ketamine for treatment-resistant depression. Expert Opin Drug Saf 2022; 21:745-759. [PMID: 35253555 DOI: 10.1080/14740338.2022.2049754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Treatment-resistant depression (TRD) is a problematic and prevalent public health and societal concern. Although electroconvulsive therapy (ECT) is the gold standard TRD intervention, the treatment evokes apprehension due to public perceptions, feasibility, and tolerability. Despite significant medical advancements, few medications have been approved by the U.S. Food and Drug Administration for TRD. In 2019, intranasal esketamine, the S-isomer of racemic ketamine, was approved for TRD, garnering significant excitement about the potential for the drug to act as an alternative treatment to ECT. AREAS COVERED The goal of this narrative review is to compare the safety, efficacy, and tolerability of ketamine and ECT; clarify whether ketamine is a reasonable alternative to ECT; and to facilitate improved treatment assignment for TRD. Empirical quantitative and qualitative studies and national and international guidelines these treatments are reviewed. EXPERT OPINION : The field awaits the results of two ongoing large comparative effectiveness trials of ECT and IV ketamine for TRD, which should help guide clinicians and patients as to the relative risk and benefit of these interventions. Over the next five years we anticipate further innovations in neuromodulation and in drug development which broadly aim to develop more tolerable versions of ECT and ketamine, respectively.
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Affiliation(s)
- Amanda J F Tamman
- Department of Psychology, St. John's University, Queens, NY, USA.,Mood and Anxiety Disorders Program, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Amit Anand
- Department of Psychiatry, Mass General Brigham, Harvard Medical School, Boston, MA, USA
| | - Sanjay J Mathew
- Michael E. Debakey VA Medical Center, Houston, TX, USA.,Mood and Anxiety Disorders Program, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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32
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Chen G, Chen L, Zhang Y, Li X, Lane R, Lim P, Daly EJ, Furey ML, Fedgchin M, Popova V, Singh JB, Drevets WC. Relationship Between Dissociation and Antidepressant Effects of Esketamine Nasal Spray in Patients With Treatment-Resistant Depression. Int J Neuropsychopharmacol 2022; 25:269-279. [PMID: 35022754 PMCID: PMC9017766 DOI: 10.1093/ijnp/pyab084] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/16/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In this post-hoc analysis, data from 2 positive, pivotal, phase 3 trials of esketamine nasal spray (ESK) in treatment-resistant depression (TRD)-short-term study (TRANSFORM-2) and maintenance study (SUSTAIN-1)-were analyzed to evaluate the relationship between dissociation and antidepressant effects of ESK. METHODS Analysis by responder status, correlation analysis, and mediation analysis were performed to assess the relationships between peak Clinician Administered Dissociative States Scale (CADSS) scores after first (day 1) and last (day 25) ESK dose and change in Montgomery-Åsberg Depression Rating Scale (MADRS) total scores at the first (day 2) and last assessments (day 28) in TRANSFORM-2 and peak CADSS after first maintenance ESK dose and time to relapse in SUSTAIN-1 (only for mediation analysis). RESULTS In TRANSFORM-2, the percentage of responders (>50% reduction in MADRS) at day 2 and day 28 did not significantly differ between patients who did vs did not manifest significant dissociation (peak CADSS scores >4 or ≤4, respectively) following the first ESK dose. Spearman correlation coefficients between dissociation and depression improvement were nonsignificant and close to zero. CADSS scores did not significantly mediate the reduction in MADRS at day 2 or 28 in TRANSFORM-2 or the time to depression relapse in SUSTAIN-1. The mean difference in MADRS between ESK and active-control arms persisted beyond day 2 without significant change across time, although the mean peak CADSS scores significantly decreased across consecutive doses and fewer patients experienced significant dissociation after the last ESK dose compared with the first. CONCLUSION Within the dose range tested, the dissociative and antidepressant effects of ESK were not significantly correlated. TRIAL REGISTRATION NCT02417064 (TRANSFORM-1); NCT02418585(TRANSFORM-2); NCT02493868 (SUSTAIN-1).
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Affiliation(s)
- Guang Chen
- Janssen Research and Development, San Diego, California, USA,Correspondence: Guang Chen, MD, PhD, Translational Research, Mood DAS, Neuroscience Therapeutic Area, Janssen R & D, LLC, Janssen Pharmaceutical Companies of Johnson and Johnson, 3210 Merryfield Row, Room 1908, San Diego, CA 92121 ()
| | - Li Chen
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Yun Zhang
- Janssen Research and Development, San Diego, California, USA
| | - Xiang Li
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Rosanne Lane
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Pilar Lim
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Ella J Daly
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Maura L Furey
- Janssen Research and Development, San Diego, California, USA
| | - Maggie Fedgchin
- Janssen Research and Development, Titusville, New Jersey, USA
| | | | | | - Wayne C Drevets
- Janssen Research and Development, San Diego, California, USA
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Swainson J, Klassen LJ, Brennan S, Chokka P, Katzman MA, Tanguay RL, Khullar A. Non-parenteral Ketamine for Depression: A Practical Discussion on Addiction Potential and Recommendations for Judicious Prescribing. CNS Drugs 2022; 36:239-251. [PMID: 35165841 PMCID: PMC8853036 DOI: 10.1007/s40263-022-00897-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada. .,Misericordia Community Hospital, Edmonton, AB, Canada.
| | | | - Stefan Brennan
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK Canada
| | - Pratap Chokka
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Chokka Center for Integrative Health, Edmonton, AB Canada
| | - Martin A. Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, ON Canada ,Department of Psychiatry, Northern Ontario School of Medicine, Thunder Bay, ON Canada ,Department of Psychology, Lakehead University, Thunder Bay, ON Canada ,Department of Psychology, Adler Graduate Professional School, Toronto, ON Canada
| | - Robert L. Tanguay
- Department of Psychiatry and Department of Surgery, University of Calgary, Calgary, AB Canada ,The Newly Institute, Calgary, AB Canada ,Hotchkiss Brain Institute and Mathison Centre for Mental Health, Calgary, AB Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Northern Alberta Sleep Clinic, Edmonton, AB Canada
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Kojic M, Saelens J, Kadriu B, Zarate CA, Kraus C. Ketamine for Depression: Advances in Clinical Treatment, Rapid Antidepressant Mechanisms of Action, and a Contrast with Serotonergic Psychedelics. Curr Top Behav Neurosci 2022; 56:141-167. [PMID: 35312993 PMCID: PMC10500612 DOI: 10.1007/7854_2022_313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The approval of ketamine for treatment-resistant depression has created a model for a novel class of rapid-acting glutamatergic antidepressants. Recent research into other novel rapid-acting antidepressants - most notably serotonergic psychedelics (SPs) - has also proven promising. Presently, the mechanisms of action of these substances are under investigation to improve these novel treatments, which also exhibit considerable side effects such as dissociation. This chapter lays out the historical development of ketamine as an antidepressant, outlines its efficacy and safety profile, reviews the evidence for ketamine's molecular mechanism of action, and compares it to the proposed mechanism of SPs. The evidence suggests that although ketamine and SPs act on distinct primary targets, both may lead to rapid restoration of synaptic deficits and downstream network reconfiguration. In both classes of drugs, a glutamate surge activates α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) throughput and increases in brain-derived neurotrophic factor (BDNF) levels. Taken together, these novel antidepressant mechanisms may serve as a framework to explain the rapid and sustained antidepressant effects of ketamine and may be crucial for developing new rapid-acting antidepressants with an improved side effect profile.
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Affiliation(s)
- Marina Kojic
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Johan Saelens
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Bashkim Kadriu
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, CA, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Christoph Kraus
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria.
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
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Wang J, Sun Y, Ai P, Cui V, Shi H, An D, Wu A, Wei C. The effect of intravenous ketamine on depressive symptoms after surgery: A systematic review. J Clin Anesth 2021; 77:110631. [PMID: 34971992 DOI: 10.1016/j.jclinane.2021.110631] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE The development of depressive symptoms is an important complication experienced by patients postoperatively and is associated with poor clinical outcomes. Ketamine is a feasible treatment option for depressive symptoms after surgery due to its known antidepressant effect. This meta-analysis aimed to evaluate the current body of research regarding the effects of intravenous ketamine on depressive symptoms after surgery. DESIGN A meta-analysis of randomized controlled trials. SETTING Perioperative care area. PATIENTS Adult surgical patients. MEASUREMENTS Systematic literature search was performed in the CENTRAL, MEDLINE, and EMBASE databases, for randomized controlled trials comparing the effect of intravenous ketamine versus placebo on postoperative depressive symptoms as the primary outcome, with no language restrictions. Two independent reviewers screened records for inclusion, extracted data, and assessed risk of bias. Random effects models were used to pool overall estimates. Postoperative pain intensity was also examined. The GRADE approach was used to assess the quality of evidence. MAIN RESULTS Out of 834 records screened, 9 studies met our inclusion criteria, comprising a total of 2468 patients. Compared with the control group, ketamine provided significant reduction of postoperative depression scale scores, by a standardized mean difference (SMD) of -0.89 (95% CI [-1.23, -0.73], P = 0.33, I2 = 13%; 4 studies) on postoperative day (POD) 1, SMD -0.51 (95% CI [-0.99, -0.04], P < 0.001, I2 = 93%; 4 studies) on POD 3, suggesting clinically relevant reduction in postoperative depressive symptoms. Postoperative depression scale scores on POD 7 were also reduced in patients receiving ketamine compared to the control group, with SMD -0.33 (95% CI [-0.52, -0.14], P = 0.36, I2 = 2%; 3 studies), but the minimal clinical difference of 0.5 SMD was not reached. No significant difference was observed in the postoperative depression scale over the long term at 30 days' follow-up (SMD -0.13, 95% CI [-0.25, 0.00], P = 0.07, I2 = 52%; 5 studies). A significant reduction of postoperative pain intensity on POD 1 was identified in patients following ketamine administration (SMD -1.29, 95% CI [-2.57, -0.01], P = 0.05, I2 = 98%; 5 studies). However, administration of ketamine resulted in a significantly increased risk of nausea and vomiting (RR 1.71, 95% CI [1.25, 2.33], P = 0.17, I2 = 35%; 6 studies), headache (RR 4.88, 95% CI [1.97, 12.06], P = 0.83, I2 = 0%; 4 studies), and hallucination (RR 34.94, 95% CI [8.59, 142.17], P = 0.44, I2 = 0%; 4 studies). CONCLUSIONS The current evidence supports intravenous ketamine administration for the treatment of depressive symptoms after surgery. While ketamine administration has clinically significant side effects, future studies are needed in surgical populations at high risk of complications.
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Affiliation(s)
- Jing Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, China
| | - Yi Sun
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, China
| | - Pan Ai
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, China
| | - Victoria Cui
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Hui Shi
- Department of Clinical Psychology, Beijing Chao-Yang Hospital, Capital Medical University, China
| | - Dongjiao An
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, China.
| | - Changwei Wei
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, China.
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Pearson C, Siegel J, Gold JA. Psilocybin-assisted psychotherapy for depression: Emerging research on a psychedelic compound with a rich history. J Neurol Sci 2021; 434:120096. [PMID: 34942586 DOI: 10.1016/j.jns.2021.120096] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/22/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
There is a serious need for novel therapies that treat individuals with depression, including major depressive disorder (MDD) and treatment-resistant depression (TRD). An emerging body of research has demonstrated that psychedelic drugs such as psilocybin, combined with supportive psychotherapy, exert rapid and sustained antidepressant effects. The use of psychedelics is not new: they have a rich history with evidence of their use in ritual and medical settings. However, due to political, social, and cultural pressures, their use was limited until modern clinical trials began to emerge in the 2010s. This review provides a comprehensive look at the potential use of psilocybin in the treatment of depression and TRD. It includes an overview of the history, pharmacology, and proposed mechanism of psilocybin, and describes several published studies in the last decade which have provided evidence of the efficacy and safety of psilocybin-assisted psychotherapy for individuals with depression. It also includes a discussion of the limitations and barriers of current research on psychedelics. The results of these studies are contextualized within the current treatment landscape through an overview of the pathophysiology of depression and the treatments currently in use, as well as the clinical needs these novel therapies have the promise to fulfill.
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Affiliation(s)
- Craig Pearson
- Washington University School of Medicine, St. Louis, MO 63108, United States of America
| | - Joshua Siegel
- Washington University School of Medicine, St. Louis, MO 63108, United States of America
| | - Jessica A Gold
- Washington University School of Medicine, St. Louis, MO 63108, United States of America.
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37
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Nikkheslat N. Targeting inflammation in depression: Ketamine as an anti-inflammatory antidepressant in psychiatric emergency. Brain Behav Immun Health 2021; 18:100383. [PMID: 34849492 PMCID: PMC8609146 DOI: 10.1016/j.bbih.2021.100383] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 02/02/2023] Open
Abstract
Major depressive disorder (MDD) is a common psychiatric disorder with multifactorial aetiology and complex pathophysiology. Despite availability of various pharmacological and non-pharmacological therapeutic strategies, treatment resistant depression (TRD) remains a significant challenge with specific concern for those patients with severe depressive symptoms in particular suicidal ideations who require immediate and effective intervention. Inflammation has been widely studied for its association with MDD and treatment response. Ketamine known as a dissociative anaesthetic has a novel rapid-acting antidepressant effect at lower doses. Anti-inflammatory actions of ketamine appear to play a role in mechanisms underlying its antidepressant effects. Considering the rapid antidepressant action of ketamine, this review provides a brief overview of antidepressant properties of ketamine as well as its effects on peripheral and central inflammation to better understand the mechanisms underlying the therapeutic action of ketamine as an anti-inflammatory antidepressant target in psychiatric emergency. Development of effective medications, which act rapidly with dual effect on both inflammation and MDD would be of a significant clinical importance for a successful and personalised treatment of inflammatory-induced TRD and suicidal thoughts and behaviour. Anti-inflammatory actions of ketamine play a role in mechanisms underlying its antidepressant effects. Ketamine’s dual effect on inflammation and depression is particularly important in treatment of inflammatory-induced TRD and suicidal patients. Ketamine affects CNS receptors and pathways, neurotransmitter systems, synaptogenesis, and inflammatory responses. Ketamine remains a promising target for treatment of TRD and suicidal thoughts.
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Affiliation(s)
- Naghmeh Nikkheslat
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, UK
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Riggs LM, An X, Pereira EFR, Gould TD. (R,S)-ketamine and (2R,6R)-hydroxynorketamine differentially affect memory as a function of dosing frequency. Transl Psychiatry 2021; 11:583. [PMID: 34772915 PMCID: PMC8590048 DOI: 10.1038/s41398-021-01685-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 12/14/2022] Open
Abstract
A single subanesthetic infusion of ketamine can rapidly alleviate symptoms of treatment-resistant major depression. Since repeated administration is required to sustain symptom remission, it is important to characterize the potential untoward effects of prolonged ketamine exposure. While studies suggest that ketamine can alter cognitive function, it is unclear to what extent these effects are modulated by the frequency or chronicity of treatment. To test this, male and female adolescent (postnatal day [PD] 35) and adult (PD 60) BALB/c mice were treated for four consecutive weeks, either daily or thrice-weekly, with (R,S)-ketamine (30 mg/kg, intraperitoneal) or its biologically active metabolite, (2R,6R)-hydroxynorketamine (HNK; 30 mg/kg, intraperitoneal). Following drug cessation, memory performance was assessed in three operationally distinct tasks: (1) novel object recognition to assess explicit memory, (2) Y-maze to assess working memory, and (3) passive avoidance to assess implicit memory. While drug exposure did not influence working memory performance, thrice-weekly ketamine and daily (2R,6R)-HNK led to explicit memory impairment in novel object recognition independent of sex or age of exposure. Daily (2R,6R)-HNK impaired implicit memory in the passive-avoidance task whereas thrice-weekly (2R,6R)-HNK tended to improve it. These differential effects on explicit and implicit memory possibly reflect the unique mechanisms by which ketamine and (2R,6R)-HNK alter the functional integrity of neural circuits that subserve these distinct cognitive domains, a topic of clinical and mechanistic relevance to their antidepressant actions. Our findings also provide additional support for the importance of dosing frequency in establishing the cognitive effects of repeated ketamine exposure.
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Affiliation(s)
- Lace M Riggs
- Program in Neuroscience and Training Program in Integrative Membrane Biology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Xiaoxian An
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Edna F R Pereira
- Department of Epidemiology and Public Health, Division of Translational Toxicology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA.
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Ceban F, Rosenblat JD, Kratiuk K, Lee Y, Rodrigues NB, Gill H, Subramaniapillai M, Nasri F, Lui LMW, Lipsitz O, Kumar A, Lee JG, Chau EH, Cao B, Lin K, Ho RC, Mansur RB, Swainson J, McIntyre RS. Prevention and Management of Common Adverse Effects of Ketamine and Esketamine in Patients with Mood Disorders. CNS Drugs 2021; 35:925-934. [PMID: 34363603 DOI: 10.1007/s40263-021-00846-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 01/22/2023]
Abstract
The emerging roles of ketamine and esketamine as effective rapid-acting antidepressants hold promise for patients suffering from treatment-resistant depression and/or major depressive disorder with suicidality. Practitioner familiarity with common tolerability/safety concerns along with pragmatic prevention and management strategies are needed to reduce patient burden and improve the acceptability and accessibility of these treatments. The most common treatment-emergent adverse events associated with ketamine/esketamine are dissociation, anxiety, nausea, increased blood pressure, and headache. The majority of side effects are mild, transient, dose dependent, and attenuate with subsequent treatments. Patient selection, baseline physical and psychiatric assessments, and an appropriate setting are critical first steps in the prevention and mitigation of adverse events. Patient education and supportive interventions play central roles in the prevention and management of select adverse events. Severe and/or clinically significant adverse effects may necessitate the judicious use of adjunctive medications. Moreover, practitioners must remain vigilant to the potential for abuse liability and long-term adverse events, for which there are insufficient data. This article succinctly reviews common treatment-emergent adverse events of ketamine and esketamine within the context of mood disorders, and provides practical suggestions for prevention and management at point-of-care.
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Affiliation(s)
- Felicia Ceban
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | | | - Yena Lee
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | - Mehala Subramaniapillai
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | - Flora Nasri
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Orly Lipsitz
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | | | - Jung Goo Lee
- Department of Psychiatry, College of Medicine, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea.,Paik Institute for Clinical Research, Inje University, Busan, Republic of Korea.,Department of Health Science and Technology, Graduate School, Inje University, Busan, Republic of Korea
| | | | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, People's Republic of China
| | - Kangguang Lin
- Department of Affective Disorders, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, People's Republic of China.,Laboratory of Emotion and Cognition, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Roger C Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada. .,Braxia Health, Mississauga, ON, Canada. .,Department of Psychiatry, University of Toronto, Toronto, ON, Canada. .,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.
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Boyd NL, Navathe PD. An Update to Aircrew Grounding Periods After Ketamine Use. Aerosp Med Hum Perform 2021; 92:670-675. [PMID: 34503619 DOI: 10.3357/amhp.5764.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION: Ketamine is a rapidly acting general anesthetic which is globally used in surgical analgesia, as well as in the management of pain. It is also used as a recreational drug. Because of its widespread use in surgical settings, the use of this drug presents an aeromedical problemin addition, of course, to the underlying condition for which it has been used. The literature around the mechanisms and side effects of ketamine is reasonably mature, and it is possible to make fairly dependable risk management decisions about return to flying based on the information available. Accordingly, following ketamine use it is recommended that aviators be grounded for 48 h following Aviation Medical Examiner review. If review is unavailable, the aviator should be grounded for 1 wk to allow sufficient time to identify the existence of prolonged side effects, such as psychomimetic effects or cognitive changes.Boyd NL, Navathe PD. An update to aircrew grounding periods after ketamine use. Aerosp Med Hum Perform. 2021; 92(8):670-675.
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Van Amsterdam J, Van Den Brink W. Harm related to recreational ketamine use and its relevance for the clinical use of ketamine. A systematic review and comparison study. Expert Opin Drug Saf 2021; 21:83-94. [PMID: 34176409 DOI: 10.1080/14740338.2021.1949454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUNDS Ketamine is a dissociative anesthetic that is currently considered for several new indications. AIM To deduce the safety of long-term ketamine treatment using the harm of heavy recreational (non-medical) ketamine use as a proxy for maximal possible harm of ketamine treatment. METHODS Systematic literature review according to PRISMA guidelines to identify controlled studies on ketamine-related harm in heavy recreational ketamine users. Results were compared with serious adverse events (SAEs) in patients treated with ketamine according to three systematic reviews considering dosing regimen and cumulative dose. RESULTS The systematic search yielded 25 studies. Heavy recreational ketamine use can escalate to ketamine dependency and was often dose-dependently associated with other SAEs, including cognitive and mental disorders, and gastrointestinal and urinary tract symptoms, which disappeared upon marked reduction of ketamine use. Heavy ketamine users have a much higher cumulative exposure to ketamine than ketamine treated patients (>90 times), which may explain why SAEs in the clinical context are mostly mild and reversible and why ketamine dependence was not reported in these patients. CONCLUSION Treatment of patients with ketamine is not associated with ketamine dependency or SAEs. However, caution is needed since data on long-term clinical ketamine use with a long-term follow-up is lacking.
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Affiliation(s)
- Jan Van Amsterdam
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Wim Van Den Brink
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
The efficacy of standard antidepressants is limited for many patients with mood disorders such as major depressive disorder (MDD) and bipolar depression, underscoring the urgent need to develop novel therapeutics. Both clinical and preclinical studies have implicated glutamatergic system dysfunction in the pathophysiology of mood disorders. In particular, rapid reductions in depressive symptoms have been observed in response to subanesthetic doses of the glutamatergic modulator racemic (R,S)-ketamine in individuals with mood disorders. These results have prompted investigation into other glutamatergic modulators for depression, both as monotherapy and adjunctively. Several glutamate receptor-modulating agents have been tested in proof-of-concept studies for mood disorders. This manuscript gives a brief overview of the glutamate system and its relevance to rapid antidepressant response and discusses the existing clinical evidence for glutamate receptor-modulating agents, including (1) broad glutamatergic modulators ((R,S)-ketamine, esketamine, (R)-ketamine, (2R,6R)-hydroxynorketamine [HNK], dextromethorphan, Nuedexta [a combination of dextromethorphan and quinidine], deudextromethorphan [AVP-786], axsome [AXS-05], dextromethadone [REL-1017], nitrous oxide, AZD6765, CLE100, AGN-241751); (2) glycine site modulators (D-cycloserine [DCS], NRX-101, rapastinel [GLYX-13], apimostinel [NRX-1074], sarcosine, 4-chlorokynurenine [4-Cl-KYN/AV-101]); (3) subunit (NR2B)-specific N-methyl-D-aspartate (NMDA) receptor antagonists (eliprodil [EVT-101], traxoprodil [CP-101,606], rislenemdaz [MK-0657/CERC-301]); (4) metabotropic glutamate receptor (mGluR) modulators (basimglurant, AZD2066, RG1578, TS-161); and (5) mammalian target of rapamycin complex 1 (mTORC1) activators (NV-5138). Many of these agents are still in the preliminary stages of development. Furthermore, to date, most have demonstrated relatively modest effects compared with (R,S)-ketamine and esketamine, though some have shown more favorable characteristics. Of these novel agents, the most promising, and the ones for which the most evidence exists, appear to be those targeting ionotropic glutamate receptors.
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Abstract
Over the last two decades, the dissociative anaesthetic agent ketamine, an uncompetitive N-Methyl-D-Aspartate (NMDA) receptor antagonist, has emerged as a novel therapy for treatment-resistant depression (TRD), demonstrating rapid and robust antidepressant effects within hours of administration. Ketamine is a racemic mixture composed of equal amounts of (S)-ketamine and (R)-ketamine. Although ketamine currently remains an off-label treatment for TRD, an (S)-ketamine nasal spray has been approved for use in TRD (in conjunction with an oral antidepressant) in the United States and Europe. Despite the promise of ketamine, key challenges including how to maintain response, concerns regarding short and long-term side-effects and the potential for abuse remain. This review provides an overview of the history of ketamine, its use in psychiatry and its basic pharmacology. The clinical evidence for the use of ketamine in depression and potential adverse effects associated with treatment are summarized. A synopsis of some of the putative neurobiological mechanisms underlying ketamine's rapid-acting antidepressant effects is provided before finally outlining future research directions, including the need to identify biomarkers for predicting response and treatment targets that may be used in the development of next-generation rapid-acting antidepressants that may lack ketamine's side-effects or abuse potential.
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Affiliation(s)
- Luke A Jelen
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - James M Stone
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Natoli S. The multiple faces of ketamine in anaesthesia and analgesia. Drugs Context 2021; 10:dic-2020-12-8. [PMID: 33995542 PMCID: PMC8074779 DOI: 10.7573/dic.2020-12-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/08/2021] [Indexed: 12/12/2022] Open
Abstract
Objective Ketamine is an anaesthetic agent with a unique dissociative profile and pharmacological effects ranging from the induction and maintenance of anaesthesia to analgesia and sedation, depending on the dose. This article provides information for the clinical use of ketamine in anaesthesia, in both conventional and special circumstances. Methods This is a non-systematic review of the literature, through a PubMed search up to February 2021. Results With a favourable pharmacokinetic profile, ketamine is used in hospital and prehospital settings for emergency situations. It is suitable for patients with many heart conditions and, unlike other anaesthetics, its potential for cardiorespiratory depression is low. Furthermore, it may be used when venous access is difficult as it may be administered through various routes. Ketamine is the anaesthetic of choice for patients with bronchospasm thanks to its bronchodilatory and anti-inflammatory properties. Conclusion With a favourable pharmacokinetic profile, ketamine is used in hospital and prehospital settings for emergency situations and is suitable for patients with many cardiac and respiratory conditions.
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Affiliation(s)
- Silvia Natoli
- Department of Clinical Science and Translational Medicine and Unit of Pain Therapy, Polyclinic of Tor Vergata, University of Rome, Tor Vergata, Rome, Italy
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Swainson J, McGirr A, Blier P, Brietzke E, Richard-Devantoy S, Ravindran N, Blier J, Beaulieu S, Frey BN, Kennedy SH, McIntyre RS, Milev RV, Parikh SV, Schaffer A, Taylor VH, Tourjman V, van Ameringen M, Yatham LN, Ravindran AV, Lam RW. The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder: Recommandations Du Groupe De Travail Du Réseau Canadien Pour Les Traitements De L'humeur Et De L'anxiété (Canmat) Concernant L'utilisation De La Kétamine Racémique Chez Les Adultes Souffrant De Trouble Dépressif Majeur. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:113-125. [PMID: 33174760 PMCID: PMC7918868 DOI: 10.1177/0706743720970860] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Patients with major depressive disorder often have limited response to first-line and second-line medications; hence, novel pharmacological treatments are needed for treatment-resistant depression (TRD). Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, has demonstrated rapid antidepressant effects in patients with TRD. The Canadian Network for Mood and Anxiety Treatments (CANMAT) convened a task force to review the evidence for efficacy and safety of racemic ketamine and to provide recommendations for its use in clinical practice. METHODS A systematic review was conducted with computerized search of electronic databases up to January 31, 2020 using combinations of search terms, inspection of bibliographies, and review of other ketamine guidelines and consensus statements. The level of evidence and lines of treatment were assigned according to CANMAT criteria. Recommendations were given in question-answer format. RESULTS Intravenous (IV) racemic ketamine given as a single infusion has Level 1 evidence for efficacy in adults with TRD. The evidence for multiple infusions, given as an acute series or as ongoing maintenance treatment, is limited to Level 3. Adverse events associated with ketamine infusions include behavioral (e.g., dissociative symptoms) and physiological (e.g., hypertension) events. There is only Level 3 or 4 evidence for non-IV formulations of racemic ketamine. Consensus recommendations are given for clinical administration of IV ketamine including patient selection, facility and personnel issues, monitoring, and maintaining response. CONCLUSIONS Single-dose IV racemic ketamine is a third-line recommendation for adults with TRD. The need for repeated and maintenance ketamine infusions should be carefully assessed on a case-by-case basis with consideration of potential risks and benefits. Because of limited evidence for efficacy and risk for misuse and diversion, the use of oral and other formulations of racemic ketamine should be limited to specialists with ketamine-prescribing expertise and affiliations with tertiary or specialized centers.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, 12357University of Alberta, Edmonton, Alberta, Canada
| | - Alexander McGirr
- Department of Psychiatry, 70401University of Calgary, Alberta, Canada
| | - Pierre Blier
- Department of Psychiatry, 12365University of Ottawa, Ontario, Canada
| | - Elisa Brietzke
- Department of Psychiatry, 104820Queen's University, Kingston, Ontario, Canada
| | | | - Nisha Ravindran
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Jean Blier
- Department of Anesthesiology and Pain Medicine, 12365University of Ottawa, Ontario, Canada
| | - Serge Beaulieu
- Department of Psychiatry, 12367McGill University, Montreal, Quebec, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, 62703McMaster University, Hamilton, Ontario, Canada
| | - Sidney H Kennedy
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Roger S McIntyre
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Roumen V Milev
- Department of Psychiatry, 104820Queen's University, Kingston, Ontario, Canada
| | - Sagar V Parikh
- Department of Psychiatry, 12266University of Michigan, Ann Arbor, Michigan, USA
| | - Ayal Schaffer
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Valerie H Taylor
- Department of Psychiatry, 70401University of Calgary, Alberta, Canada
| | - Valérie Tourjman
- Department of Psychiatry, 12368Université de Montréal, Québec, Canada
| | - Michael van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, 62703McMaster University, Hamilton, Ontario, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Arun V Ravindran
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Raymond W Lam
- Department of Psychiatry, 8166University of British Columbia, Vancouver, British Columbia, Canada
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Kadriu B, Greenwald M, Henter ID, Gilbert JR, Kraus C, Park LT, Zarate CA. Ketamine and Serotonergic Psychedelics: Common Mechanisms Underlying the Effects of Rapid-Acting Antidepressants. Int J Neuropsychopharmacol 2021; 24:8-21. [PMID: 33252694 PMCID: PMC7816692 DOI: 10.1093/ijnp/pyaa087] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/13/2020] [Accepted: 11/16/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The glutamatergic modulator ketamine has created a blueprint for studying novel pharmaceuticals in the field. Recent studies suggest that "classic" serotonergic psychedelics (SPs) may also have antidepressant efficacy. Both ketamine and SPs appear to produce rapid, sustained antidepressant effects after a transient psychoactive period. METHODS This review summarizes areas of overlap between SP and ketamine research and considers the possibility of a common, downstream mechanism of action. The therapeutic relevance of the psychoactive state, overlapping cellular and molecular effects, and overlapping electrophysiological and neuroimaging observations are all reviewed. RESULTS Taken together, the evidence suggests a potentially shared mechanism wherein both ketamine and SPs may engender rapid neuroplastic effects in a glutamatergic activity-dependent manner. It is postulated that, though distinct, both ketamine and SPs appear to produce acute alterations in cortical network activity that may initially produce psychoactive effects and later produce milder, sustained changes in network efficiency associated with therapeutic response. However, despite some commonalities between the psychoactive component of these pharmacologically distinct therapies-such as engagement of the downstream glutamatergic pathway-the connection between psychoactive impact and antidepressant efficacy remains unclear and requires more rigorous research. CONCLUSIONS Rapid-acting antidepressants currently under investigation may share some downstream pharmacological effects, suggesting that their antidepressant effects may come about via related mechanisms. Given the prototypic nature of ketamine research and recent progress in this area, this platform could be used to investigate entirely new classes of antidepressants with rapid and robust actions.
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Affiliation(s)
- Bashkim Kadriu
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Maximillian Greenwald
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Ioline D Henter
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Jessica R Gilbert
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Christoph Kraus
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Lawrence T Park
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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47
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Muscat SA, Hartelius G, Crouch CR, Morin KW. An Integrative Approach to Ketamine Therapy May Enhance Multiple Dimensions of Efficacy: Improving Therapeutic Outcomes With Treatment Resistant Depression. Front Psychiatry 2021; 12:710338. [PMID: 34899408 PMCID: PMC8653702 DOI: 10.3389/fpsyt.2021.710338] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
Research over the last two decades has established ketamine as a safe, effective, fast-acting, and sustained antidepressant that significantly reduces adverse symptoms associated with depression, even in patients who are treatment resistant. Much of this research has evolved within the framework of several independent branches of scientific inquiry: in addition to the study of ketamine is a non-selective NMDAR antagonist with rapid antidepressant effects, it has also been found effective as a psychoplastogen that stimulates synaptogenesis and increases neuroplasticity, as a powerful anti-inflammatory that may improve inflammation-related depressive symptoms, as a substance that induces beneficial high entropy brain states, and as a subjectively impactful psychedelic agent. Each branch of inquiry has generated independent evidence of ketamine's efficacy but has advanced without substantive coordination or communication with other lines of inquiry. Integrative research that considers these branches of research together may lead toward a better understanding of ketamine's effects and improved treatment protocols and clinical outcomes. Such an overview can inform more comprehensive patient care through: (a) informed patient psychoeducation that encompasses all of ketamine's mechanisms of action; (b) calibration of optimal dosage to ensure induction and maintenance of high entropy brain states during each ketamine session utilizing EEG measurement; (c) Improved management of emergence side effects through proper care for set and setting; (d) inclusion of pre-selected appropriate music to enhance the emotional experience; (e) increased monitoring of ketamine effects on cortical activity, inter-hemispheric imbalance, and inflammation-related levels of cytokines to further improvements in ketamine protocols; and (f) appropriate timing of any adjunctive psychotherapy sessions to coincide with peak neurogenesis at 24-48 h post ketamine treatment.
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Affiliation(s)
- Sherry-Anne Muscat
- Youth Forensic Psychiatry, Alberta Hospital, Alberta Health Services, Edmonton, AB, Canada.,Integral and Transpersonal Psychology, California Institute of Integral Studies, San Francisco, CA, United States
| | - Glenn Hartelius
- Integral and Transpersonal Psychology, California Institute of Integral Studies, San Francisco, CA, United States
| | - Courtenay Richards Crouch
- Integral and Transpersonal Psychology, California Institute of Integral Studies, San Francisco, CA, United States
| | - Kevin W Morin
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.,Acute Adult Psychiatry, Alberta Hospital, Alberta Health Services, Edmonton, AB, Canada
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Ballard ED, Zarate CA. The role of dissociation in ketamine's antidepressant effects. Nat Commun 2020; 11:6431. [PMID: 33353946 PMCID: PMC7755908 DOI: 10.1038/s41467-020-20190-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023] Open
Abstract
Ketamine produces immediate antidepressant effects and has inspired research into next-generation treatments. Ketamine also has short term dissociative effects, in which individuals report altered consciousness and perceptions of themselves and their environment. However, whether ketamine's dissociative side effects are necessary for its antidepressant effects remains unclear. This perspective examines the relationship between dissociative effects and acute and longer-lasting antidepressant response to ketamine and other N-methyl-D-aspartate (NMDA) receptor antagonists. Presently, the literature does not support the conclusion that dissociation is necessary for antidepressant response to ketamine. However, further work is needed to explore the relationship between dissociation and antidepressant response at the molecular, biomarker, and psychological levels.
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Affiliation(s)
- Elizabeth D Ballard
- Section on the Neurobiology and Treatment of Mood Disorders, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA
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Savalia NK, Shao LX, Kwan AC. A Dendrite-Focused Framework for Understanding the Actions of Ketamine and Psychedelics. Trends Neurosci 2020; 44:260-275. [PMID: 33358035 DOI: 10.1016/j.tins.2020.11.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/07/2020] [Accepted: 11/24/2020] [Indexed: 02/09/2023]
Abstract
Pilot studies have hinted that serotonergic psychedelics such as psilocybin may relieve depression, and could possibly do so by promoting neural plasticity. Intriguingly, another psychotomimetic compound, ketamine, is a fast-acting antidepressant and induces synapse formation. The similarities in behavioral and neural effects have been puzzling because the compounds target distinct molecular receptors in the brain. In this opinion article, we develop a conceptual framework that suggests the actions of ketamine and serotonergic psychedelics may converge at the dendrites, to both enhance and suppress membrane excitability. We speculate that mismatches in the opposing actions on dendritic excitability may relate to these compounds' cell-type and region selectivity, their moderate range of effects and toxicity, and their plasticity-promoting capacities.
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Affiliation(s)
- Neil K Savalia
- Medical Scientist Training Program, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Ling-Xiao Shao
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Alex C Kwan
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06511, USA; Department of Neuroscience, Yale University School of Medicine, New Haven, CT 06511, USA.
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Gill H, Gill B, Rodrigues NB, Lipsitz O, Rosenblat JD, El-Halabi S, Nasri F, Mansur RB, Lee Y, McIntyre RS. The Effects of Ketamine on Cognition in Treatment-Resistant Depression: A Systematic Review and Priority Avenues for Future Research. Neurosci Biobehav Rev 2020; 120:78-85. [PMID: 33242561 DOI: 10.1016/j.neubiorev.2020.11.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/12/2020] [Accepted: 11/12/2020] [Indexed: 12/28/2022]
Abstract
Replicated evidence has documented cognitive deficits in populations with treatment-resistant depression (TRD). Approximately 40 % of patients with MDD present with impairment of one or more cognitive domains. As such, there is an unmet need to discover treatments that have pro-cognitive effects in TRD patients. Ketamine has demonstrated efficacy as a rapid-onset intervention for the treatment of depression. The objective of the current review was to assess the effects of ketamine on cognition in TRD patients. We systematically searched PubMed, Google Scholar and PsycINFO between database inception to March 24th, 2020. We identified five studies that evaluated cognition in TRD populations following ketamine treatment. All studies included a 0.5 mg/kg subanesthetic intravenous (IV) administration of ketamine. One study found significant improvements in complex (p = .008) and simple (p = .027) working memory and one study found improvements in visual learning memory following IV ketamine infusions (p = .014). Improvements in speed of processing and verbal learning memory were observed in anxious TRD participants only. Importantly, a subanesthetic dose of IV ketamine does not worsen cognitive function.
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Affiliation(s)
- Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Barjot Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Orly Lipsitz
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Joshua Daniel Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Sabine El-Halabi
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Flora Nasri
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada.
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